Long-term effects of nasoalveolar molding on three-dimensional nasal shape in unilateral clefts

A multi-centric, single-blinded, randomized, parallel-group study to evaluate the effectiveness of nasoalveolar moulding treatment in non-syndromic patients with complete unilateral cleft lip, alveolus and palate (NAMUC study): a study protocol for a randomized controlled trial

BACKGROUND

Cleft lip and palate (CLP) are among the most common congenital anomaly that affects up to 33,000 newborns in India every year. Nasoalveolar moulding (NAM) is a non-surgical treatment performed between 0 and 6 months of age to reduce the cleft and improve nasal aesthetics prior to lip surgery. The NAM treatment has been a controversial treatment option with 51% of the cleft teams in Europe, 37% of teams in the USA and 25 of cleft teams in India adopting this methodology. This treatment adds to the already existing high burden of care for these patients. Furthermore, the supporting evidence for this technique is limited with no high-quality long-term clinical trials available on the effectiveness of this treatment.

METHOD

The NAMUC study is an investigator-initiated, multi-centre, single-blinded randomized controlled trial with a parallel group design. The study will compare the effectiveness of NAM treatment provided prior to lip surgery against the no-treatment control group in 274 patients with non-syndromic unilateral complete cleft lip and palate. The primary endpoint of the trial is the nasolabial aesthetics measured using the Asher McDade index at 5 years of age. The secondary outcomes include dentofacial development, speech, hearing, cost-effectiveness, quality of life, patient perception, feeding and intangible benefits. Randomization will be carried out via central online system and stratified based on cleft width, birth weight and clinical trial site.

DISCUSSION

We expect the results from this study on the effectiveness of treatment with NAM appliance in the long term along with the cost-effectiveness evaluation can eliminate the dilemma and differences in clinical care across the globe.

TRIAL REGISTRATION

ClinicalTrials.gov CTRI/2022/11/047426 (Clinical Trials Registry India). Registered on 18 November 2022. The first patient was recruited on 11 December 2022. CTR India does not pick up on Google search with just the trial number. The following steps have to be carried out to pick up. How to search: ( https://ctri.nic.in/Clinicaltrials/advsearch.php -use the search boxes by entering the following details: Interventional trial > November 2022 > NAMUC).

Use it or Lose it: Predictors of Compliance and Satisfaction With Postoperative Nasal Stent Therapy After Primary Cleft Lip Repair

OBJECTIVE

Postoperative nasal stents (NSs) are used to improve esthetic outcomes after primary or secondary cleft lip repair (CLR). Prior studies have utilized anthropometric measurements or physician assessment to determine the efficacy of NS, but data on caregiver-reported outcomes is limited. This study aims to assess caregiver compliance and satisfaction with postoperative NS.

METHODS

The authors designed a survey to collect parent-reported postoperative NS usage outcomes. Parents of infants with cleft lip (CL) who used postoperative NS after primary CLR were approached through social media to complete the survey. Data were analyzed to determine factors impacting compliance, satisfaction, and parent-reported outcomes.

RESULTS

Eighty-five parents completed the questionnaire, and 60% reported noncompliance with NS. Parents with male children (odds ratio: 5.08, P = 0.019) and patients with incomplete CL (odds ratio: 5.72, P = 0.006) were more likely to be non-compliant with NS for over a week. Complete CL and use of presurgical molding therapy were each associated with better overall experience with postoperative NS ( P = 0.002 and P = 0.037), higher appearance ratings ( P = 0.005 and P = 0.0008), and greater satisfaction with nostril shape after surgery ( P = 0.016 and P = 0.001).

CONCLUSIONS

Despite limited literature related to caregiver-reported outcomes after postoperative NS for primary CLR, the authors' results align with what has been published regarding this topic. These results can help guide surgeons in counseling patients preoperatively. Larger, multi-institutional studies are needed to better delineate and address factors associated with compliance and satisfaction after NS therapy.

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.

Presurgical management trends and nasoalveolar molding usage for infants with cleft lip and palate in the capital of a developing country

BACKGROUNDS

Nasoalveolar molding (NAM) application is among presurgical management (PSM) techniques used for infants with cleft lip and palate (CLP). It helps to approximate the palatal cleft and to reshape the nasoalveolar complex prior to primary lip repair. This study aimed to explore types of PSM and the dental speciality provision for infants with CLP in Baghdad. The status of NAM usage and surgeons' perceptions toward NAM usage were assessed.

MATERIALS AND METHODS

This is a cross-sectional paper-based questionnaire study that collected responses of surgeons perform primary lip and nose repair regarding PSM. The questionnaire was distributed amongst public and private hospitals in Baghdad. Twenty surgeons were enrolled (only those surgeons who perform primary repair for infants with CLP); two females and eighteen males.

RESULTS

The majority of participants' responses suggested that the majority of infants with CLP were provided with baby feeding plates and lip straps. Six surgeons reported that a percentage of their patients who have been provided with NAM. PSM in Baghdad was mostly supplied by orthodontists and plastic surgeons, and the next most likely providers were prosthodontists. 82.35% of the surgeons found that primary surgical repair procedures were easier with NAM than for the other infants. The rest have not perceived any differences.

CONCLUSIONS

Orthodontists, surgeons and prosthodontists were involved in providing PSM. Baby feeding plates and lip straps were the most common PSM in Baghdad, although NAM is not uncommon. Most surgeons believe that using NAM made surgical procedures easier and permitted the prediction of surgical outcomes.

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.

Defining the Treatment Gap in Nasoalveolar Molding: Factors Affecting the Utilization of NAM in an Urban Cleft Center

BACKGROUND

Many cleft centers incorporate NasoAlveolar Molding (NAM) into their presurgical treatment protocols. However, there are limited data on eligible patients who do not receive or complete NAM. This study characterizes the demographics associated with non-utilization or completion of NAM.

METHODS

A single-institution retrospective review was performed of all patients with cleft lip and alveolus undergoing primary unilateral and bilateral cleft lip repair from 2012-2020. Patients were grouped based on utilization or non-utilization of NAM. Demographic and treatment data were collected, including documented reasons for not pursuing or completing NAM.

RESULTS

Of 230 eligible patients, 61 patients (27%) did not undergo or complete NAM (no-NAM). In this group, 37 (60.7%) received no presurgical intervention, 12 (19.7%) received presurgical nostril retainers, 3 (4.9%) received lip taping, 1 (1.6%) received a combination of taping/nostril retainers, and 8 (13.1%) discontinued NAM. The most common reasons for not receiving NAM were sufficiently aligned cleft alveolus (21.3%), medical complexity (16.4%), late presentation (16.4%), and alveolar notching (18%). Compared to the NAM group, the no-NAM group had significantly lower rates of prenatal cleft diagnosis/consult, and significantly higher proportion of non-married and non-English speaking caregivers. Multivariable analysis controlling for insurance type, primary language, prenatal consult, marital status, and age at first appointment found that age at first appointment is the only statistically significant predictor of NAM utilization (P < .001).

CONCLUSIONS

Common reasons for non-utilization of NAM include well-aligned cleft alveolus, medical complexity, and late presentation. Early presentation is an important modifiable factor affecting rates of NAM utilization.

Comparison of Facial Growth between Two Nasoalveolar Molding Techniques in Patients with Unilateral Complete Cleft Lip

BACKGROUND

Nasoalveolar molding (NAM) has become standard treatment in the authors' craniofacial center. There are two types of presurgical NAM: the Grayson and Figueroa techniques. The Grayson method involves active alveolar molding, and the Figueroa method involves passive alveolar molding. The authors previously found no differences in number of clinic visits, costs, or 6-month postoperative outcome between the two techniques. The authors extended the previous study to evaluate facial growth between these two groups.

METHODS

In this randomized single-blind study, conducted between May of 2010 and March of 2013, the authors recruited 30 patients with unilateral complete cleft lip and palate and randomized them for Grayson or Figueroa presurgical NAM. Standard lateral cephalometric measurements at 5 years were used to determine facial growth.

RESULTS

Twenty-nine patients completed 5 years of follow-up. There were no statistically significant differences in facial cephalometric measurements between the two groups.

CONCLUSION

Presurgical NAM using either a passive or active NAM technique produced similar facial growth patterns after unilateral cleft lip and palate repair.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

The Effects of NAM on the Symmetry of the Face and Maxillary Arch in Babies With Unilateral Cleft

The study aimed to evaluate the effect of nasoalveolar molding (NAM) therapy through reverse engineering, or its absence, to obtain symmetry of the face and maxillary arch. Twenty-six babies with unilateral cleft lip and palate received treatment with NAM, and 12 babies with unilateral cleft lip and palate without presurgical orthopedics (control group). Patients were molded and photographed in 2-stages: the first month of life (T1/pre) and after the use of NAM/before the cheiloplasty (T2/post). In the digital models, the analyses performed were arch perimeter, arch length, and labial frenulum angle. The photographs allowed us to analyze nasal width, mouth width, columella angle, and nostril area. The results demonstrated that there was an increase in arch perimeter and arch length in control and NAM groups in the T2 period in comparison to T1. Labial frenulum angle was reduced in the NAM group compared to the NAM-T1 and control-T2 periods. Treatment with NAM yielded a reduction in nasal width in the period of T2 compared with T1. Columella angle was enhanced after NAM use in T2 and, was different from control group. The nostril area was reduced in the NAM group in T2 compared with control group. Nasoalveolar molding therapy reduced the labial frenulum angle, contributing to a reduction in the extension of the cleft. The NAM protocol improved facial symmetry, mainly through nasal effects, whereas the absence of orthopedic therapy yielded a commitment to the face and maxillary arch symmetry.

Presurgical Orthopedic Nasoalveolar Molding in Cleft Lip and Cleft Palate: Case Report

Aim and objective

The present clinical report describes management of complete unilateral cleft lip and palate with presurgical nasoalveolar molding (NAM) therapy for infants.

Background

Orofacial clefts have a negative impact on the health and social integration of individuals affected. Patients undergo numerous procedures until they reach adolescence. The ultimate focus of surgical intervention is to improve the esthetic appearance of the lip and nose by improving the lip scar, nasal tip projection, and symmetry of the nasolabial complex.

Case description

This paper discusses a situation in which the parents of a three days old baby with the chief complaint of regurgitation of milk while feeding. On examination, baby had complete left-sided cleft lip and cleft palate (CL+CP).

Conclusion

Before surgery, nasoalveolar molding has been shown to be a useful adjunctive therapy for reducing hard and soft tissue cleft deformity.

Clinical significance

Passive preoperative intervention of the lip and alveolar segments helps to reduce tissue tension and is thought to improve surgical outcomes by minimizing wound healing disturbances and scarring.

How to cite this article

Shaik N, Eggula A, Pudi S, et al. Presurgical Orthopedic Nasoalveolar Molding in Cleft Lip and Cleft Palate: Case Report. Int J Clin Pediatr Dent 2023;16(4):659-662.

Rehabilitation of an Orofacial Cleft through Presurgical Nasoalveolar Molding with a 1-year Follow-up

Aim

To highlight the effectiveness of Presurgical Nasoalveolar Molding (PNAM) technique and the appliance used prior to the surgical reconstruction of cleft lip and palate in newborns.

Background

In underdeveloped and developing countries, babies born with oral clefts, are generally anemic with low birth weight and may be unfit for surgery immediately. Feeding these babies is also difficult as the air leaks through the cleft and they cannot create the suction needed for suckling.

Case description

Two newborn babies, presented with unilateral midfacial clefts involving the lip, alveolus and palate.

Conclusion

The PNAM appliance enabled breast Feeding while lessening the soft tissue and cartilaginous deformity and allowing surgical soft tissue repair with minor scar formations.

Clinical significance

PNAM can reduce the surgical burden and reduce the number of surgical revisions when initiated early.

How to cite this article

Ferreira AN, Eswaramurthy P, Aras MA, et al. Rehabilitation of an Orofacial Cleft through Presurgical Nasoalveolar Molding with a 1-year follow-up. Int J Clin Pediatr Dent 2023;16(1):162-165.

Long-Term Results of the Murawski Unilateral Cleft Lip Repair

BACKGROUND

In 1968, Ralph Millard published his "Millard II" method for repair of wide, complete unilateral cleft lip and nose deformity. In 1979, Murawski published a major modification of the Millard II procedure in Polish. This motif was taken up 8 years later by Mohler and 22 years later by Cutting. The Murawski variation on the Millard II procedure has become a dominant motif in unilateral cleft lip repair worldwide. This brief report intends to introduce the method to the English language literature and present long-term results.

METHODS

The Murawski method alters the Millard II procedure by changing the upper medial curve into a point in the columellar base. This creates a broad C flap used to fill the entire defect produced by downward rotation of the medial lip. Millard's lateral advancement flap becomes unnecessary. A lateral approach to primary nasal reconstruction allows the lateral C flap to be used to construct the nasal floor and sill. The method is described using a physics-based surgical simulator.

RESULTS

Long-term results of the method are demonstrated with four patients with 15 to 25-year follow-up. None of these patients had any revisions to the lip or nose.

CONCLUSIONS

The Murawski repair was the first to modify the Millard II repair by sharpening the medial columellar incision, eliminating the need for a lateral advancement flap. This motif was put forth in the years to follow by Mohler and Cutting. Long-term results of the method are presented.

A Comparative Assessment of Nasal Appearance following Nasoalveolar Molding and Primary Surgical Repair for Treatment of Unilateral Cleft Lip and Palate

BACKGROUND

Although many cleft teams have adopted nasoalveolar molding to improve nasal form, few comparative studies have assessed the postoperative benefits of this treatment. Given that reported outcomes have been contradictory and that treatment involves considerable burden to families, the purpose of this study was to assess objective and subjective changes from nasoalveolar molding at approximately 5 years of age.

METHODS

All patients with complete unilateral cleft lip and palate who underwent primary cheiloplasty performed by a single surgeon over a 7-year period were reviewed. Patient results were grouped into nasoalveolar molding or no-nasoalveolar molding. Cleft severity and aesthetic outcomes were assessed by panels of raters who independently ranked subject images at presentation, immediately preoperative (after molding), and at 5-year follow-up. Objective symmetry was measured using standard anthropometric analysis on three-dimensional images.

RESULTS

Among 41 patients included, 16 successfully completed nasoalveolar molding. Both groups were similar at presentation; however, the nasoalveolar molding group had improved appearance following molding (p < 0.05). After surgery, at 5 years of age, the nasoalveolar molding group had better rank scores for overall appearance (p < 0.05), cleft nostril height, and cleft medial lip height (p < 0.05). Regression analysis revealed that nasoalveolar molding treatment was the most significant predictor of overall nasal appearance at 5 years, but that treatment team experience and initial severity were also significant predictors (p < 0.05). Qualitative audit following analysis identified favorable and unfavorable features of nasoalveolar molding.

CONCLUSION

In children with complete unilateral cleft lip and palate, nasoalveolar molding was associated with better overall nasal aesthetics and improved cleft nostril height and cleft medial lip height at approximately 5 years of age.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

SMaRT Assessment Tool: An Innovative Approach for Objective Assessment of Flap Designs

SUMMARY

The teaching and assessment of ideal surgical markings for local flaps required for optimal aesthetic and functional outcomes remain a challenge in the present era of competency-based surgical education. The authors utilized the bilobed flap for nasal reconstruction as a proof of concept for the development of an innovative objective assessment tool based on statistical shape analysis, with a focus on providing automated, evidence-based, objective, specific, and practical feedback to the learner. The proposed tool is based on Procrustes statistical shape analysis, previously used for the assessment of facial asymmetry in plastic surgery. For performance boundary testing, a series of optimal and suboptimal designs generated in deliberate violation of the established ideals of optimal bilobed flap design were evaluated, and a four-component feedback score of Scale, Mismatch, Rotation, and Translation (SMaRT) was generated. The SMaRT assessment tool demonstrated the capacity to proportionally score a spectrum of designs (n = 36) ranging from subtle to significant variations of optimal, with excellent computational and clinically reasonable performance boundaries. In terms of shape mismatch, changes in SMaRT score also correlated with intended violations in designs away from the ideal flap design. This innovative educational approach could aid in incorporating objective feedback in simulation-based platforms in order to facilitate deliberate practice in flap design, with the potential for adoption in other fields of plastic surgery to automate assessment processes.

Three-Dimensional Evaluation of Deformed Noses in Patients With Unilateral Cleft Lip and Palate: A Meta-Analysis

ABSTRACT

Multiple surgeries for patients with cleft lip and palate may be required to repair secondary deformities after the completion of cleft repair. This meta-analysis aimed to evaluate the three-dimensional nasal morphology in patients with unilateral cleft palate who underwent cleft lip and palate repair but did not undergo terminal nasal repair. PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Data, and SINOMED databases were searched from inception until December 2020. Studies involving patients ages ≥6 years with cleft lip and palate who did not undergo terminal nasal repair were included. Quantitative data were obtained through three-dimensional evaluation. Mean weighted effect sizes with 95% confidence intervals, heterogeneities, and publication biases were assessed using raw data obtained from 13 studies. In general, patients with unilateral cleft lip and palate had a significantly wider nose; shorter bridge length and nasal height; larger forehead-nose angle, nasal tip angle, and alar slope angle; and smaller nasolabial angle. The number of studies that included patients with unilateral cleft lip, unilateral cleft lip and alveolus, and unclassified deformities was limited, and their results were similar to those involving patients with unilateral cleft lip and palate. Patients with unilateral cleft tend to have short, flat, and wide noses. Nasal tip elevation and alar base adduction should be prioritized during terminal nasal repair to achieve more normalized cleft-side nostrils.

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.

Effect of Cleft Width on the Outcome of Presurgical Nasoalveolar Molding in Patients With Unilateral Cleft Lip and Palate

ABSTRACT

The purpose of this study was to investigate the short-term effects of presurgical nasoalveolar molding (PNAM) according to cleft width (CW) in patients with unilateral cleft lip and palate (UCLP). In this retrospective study, 32 newborns with nonsyndromic UCLP treated with PNAM were allocated to 2 groups based on CW (group A, CW ≤5 mm; and group B, CW >5 mm). The following measurements were carried out using standardized photographs taken before and after PNAM therapy (before primary lip surgery): nostril axis inclination of healthy (NAI-NC) and cleft sides (NAI-C), columellar angle (CA), nasal base inclination (NBI), nasal floor width ratio (NFWR), alar base height ratio (ABHR), and columellar length ratio. Before PNAM therapy, there were significant differences between the 2 groups with respect to NAI-C, NBI, NFWR, and ABHR, indicating greater deformation of the nose in group B. After PNAM therapy, CA, NAI-C, NAI-NC, NFWR, and columellar length ratio were significantly improved in both the groups, whereas NBI and ABHR significantly worsened in group B. The improvement in CA, NAI-C, and NFWR was significantly greater in group B. Although a larger CW had some negative effects on the outcome of PNAM, it was found to be advantageous for nasal symmetry, if initiated as early as possible. Nevertheless, it is important to consider those aspects of the nasolabial area that are involved in the perception of symmetry when evaluating the effect of CW on PNAM outcomes in UCLP.

Effectiveness of Presurgical Nasoalveolar Molding Appliance in Infants With Complete Unilateral Cleft Lip and Palate

OBJECTIVE

To assess the effectiveness of the presurgical nasoalveolar molding appliance among infants with unilateral cleft lip and palate.

METHODS

In this prospective study, 95 pairs of casts of infants with unilateral cleft lip and palate treated by presurgical nasoalveolar molding were selected at the Children's Hospital 1 at Ho Chi Minh City, Vietnam. The average time of treatment was 3 months. All casts were scanned and measured using 3-dimensional technology before and after treatment. Paired t tests were applied for comparisons.

RESULTS

There was a statistically significant increase in the nostril height in cleft side (P < .001), decrease in the nostril width and columella angle (P < .001), and decrease in cleft width and midline deviation (P < .001) after treatment with presurgical nasoalveolar molding appliance.

CONCLUSIONS

Nasoalveolar molding appliance is effective in improving the morphology of nostril and maxillary alveolar. Understanding this helps orthodontists and surgeons in treatment outcome expectations.

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.

Current Trends in Unilateral Cleft Lip Care: A 10-Year Update on Practice Patterns

BACKGROUND

The care of unilateral cleft lip (UCL) patients is extremely variable. Historical benchmarks for perioperative and intraoperative choices by cleft surgeons were produced by Sitzman et al (Plast Reconstr Surg. 2008;121:261e-270e) in 2005. However, emerging data and cleft lip repair methods around this period were not captured by this study. The aim of this study was to update the current practice patterns of cleft lip surgeons.

METHODS

An electronic survey was distributed to surgeons in the American Cleft Palate Association. Demographic data about the surgeon were collected as well as their choices regarding perioperative and intraoperative cleft lip care.

RESULTS

Eighty-six surgeons responded to the survey. Nearly 40% of surgeons have changed their technique for UCL repair with Fisher anatomical subunit repair gaining significant popularity. Nasoalveolar molding is also being used more frequently (41% vs 22%). At the time of the cleft lip repair, closure of the nasal floor is occurring in 83.1% of patients and primary cleft rhinoplasty is being performed routinely 57% of the time.

CONCLUSIONS

Over the last 10 years, there has been an increase in the use of modified rotation advancement repairs and Fisher anatomic subunit approximation technique for treatment of UCL. There continues to be a lack of evidence regarding superiority of specific repair techniques or the benefits of adjunct procedures, which results in varying practice patterns. Educating all cleft surgeons on practices that are well supported is important to improve care to cleft patients.

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.

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.

A Quantitative Analysis of Facial Asymmetry in Torticollis Using 3-Dimensional Photogrammetry

OBJECTIVE

To assess whether children with torticollis have quantifiably greater facial asymmetry than their age-matched controls using 3-dimensional (3D) photogrammetry.

DESIGN

We retrospectively analyzed patients diagnosed with torticollis and age-matched volunteers who underwent 3D photogrammetry of their faces. We calculated the root mean square deviation (RMSD) between native and reflected facial images, as a measure of asymmetry. Two observers independently measured RMSD values for all study participants. The Spearman correlation coefficient evaluated interobserver reliability. The Wilcoxon rank-sum test with Bonferroni adjusted P values for multiple comparisons.

SETTING

Institutional.

PARTICIPANTS

Twenty patients diagnosed with torticollis and 12 age-matched volunteers. Patients were analyzed on a computer database and volunteers were selected and consented in the hospital. We excluded patients with a history of facial trauma, facial operations, or other craniofacial diagnoses.

INTERVENTIONS

Facial surface scans were obtained using the Canfield Vectra stereophotogrammetry system. The technology captures surface anatomy without radiation.

MAIN OUTCOME MEASURES

RMSD comparisons between patients with torticollis and age-matched controls.

RESULTS

Compared to controls, patients with torticollis had statistically significant greater full face, upper third, and middle third facial asymmetry. There was a trend toward greater asymmetry of the lower facial third.

CONCLUSIONS

We used 3D photogrammetry to quantitate facial asymmetry from torticollis. We found greater asymmetry in patients with torticollis than in their unaffected peers. All areas of the face appeared to be affected, though the asymmetry in the lower facial third just failed to reach significance.

Does Infant Orthopedics and Neonate Lip Surgery Influence the Occlusal Relationship in Patients With Unilateral Cleft Lip and Palate (UCLP)?

OBJECTIVE

To compare occlusal relationship in patients undergoing neonate versus conventional lip surgery (LS) with and without infant orthopedics (IO) by assessment of dental arch relationship in individuals with complete unilateral cleft lip and palate.

MATERIAL AND METHODS

Three groups treated by different protocols; Group I: neonate LS (1-15 days) + IO and palatoplasty (13-31 months); Group II: LS (3-12 months) + IO and palatoplasty (15-35 months); and Group III: LS (3-6 months) without IO and palatoplasty (12-18 months). The 112 intraoral photographs of individuals of all groups, obtained between 6 and 12 years of age, were assessed by the occlusal index for intraoral photograph rating. The groups were compared by the χ² test. The correlation between surgical timing and the scores was tested by the Spearman test (P < .05).

RESULTS

Group I presented the highest percentage of score 5, group II exhibited highest percentage of score 1, and group III presented the lowest percentage of score 5 according to the χ² test (P = .029). The Spearman correlation test revealed statistically significant difference between timing of LS and the occlusal index. The earlier the surgical timing, the higher the occlusal index (P = .019).

CONCLUSIONS

Infant orthopedics has demonstrated the possibility of postponing primary plastic surgeries. Patients submitted to late lip and palate repair had the best prognosis, while patients undergoing lip repair from 1 to 15 days of life, even operating the palate later, had the worst prognosis. Neonate LS negatively influenced the occlusal relationships.

Facial Asymmetry in Unilateral Condylar Hyperplasia: Comparing Treatment for Active versus Burnt-Out Disease

BACKGROUND

Facial asymmetry caused by unilateral condylar hyperplasia requires treatment to address facial and occlusal imbalances. There is no definitive evidence to suggest that a single intervention strategy (during either active condylar overgrowth or the burnt-out phase) results in better/more symmetric correction. This study sought to quantify preoperative and postoperative facial asymmetry in unilateral condylar hyperplasia patients comparing treatment for active versus burnt-out disease.

METHODS

Preoperative and postoperative three-dimensional photographs were obtained. Images were compared to those of unaffected controls as a standard for normal facial symmetry. Facial asymmetry was assessed using root-mean-square deviation. Paired t tests were performed to compare the root-mean-square deviations of preoperative and postoperative images between the unilateral condylar hyperplasia groups and against controls.

RESULTS

Forty patients were included (11 active, nine burnt-out, and 20 controls) and 60 three-dimensional images were evaluated. Preoperatively, patients in the burnt-out group had worse asymmetry than those with active unilateral condylar hyperplasia (p = 0.011). Both groups demonstrated significantly improved symmetry postoperatively (active, p = 0.0069; burnt-out, p = 1.74E-4). However, burnt-out patients remained with some residual asymmetry (p = 4.75E-4), whereas their active counterparts showed no significant difference compared to unaffected controls (p = 0.089).

CONCLUSIONS

Patients with end-stage unilateral condylar hyperplasia have more severe facial asymmetry that is more difficult to normalize compared to earlier intervention during active unilateral condylar hyperplasia. These findings suggest that, if possible, corrective intervention is preferable during active unilateral condylar hyperplasia.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

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.

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.

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.

Dynamic changes in nasal symmetry after presurgical nasoalveolar molding in infants with complete unilateral cleft lip and palate

BACKGROUND

Presurgical nasoalveolar molding (PNAM) technique gave a new perspective to presurgical infant orthopedics. Nasal reconstruction presents a challenge for the plastic surgeons in case of patients with unilateral cleft lip and palate (UCLP). PNAM facilitates the reshaping of the nasal cartilage and molding of maxillary arch preoperatively. This therapy not only aids the surgical repair of lip but also enhances the overall postsurgical results with negligible postoperative scar.

AIM

The aim of the study was to analyze nasal changes before and after PNAM in patients with complete UCLP.

MATERIALS AND METHODS

This was a retrospective review of 22 ULCP patients who underwent PNAM before lip surgeries. A series of standard basilar view photographs in 1:1 ratio were taken, and linear measurements were done directly on the photographs.

RESULTS

After PNAM therapy, there was highly significant increase in the nostril height, nostril dome height, and columella length (P < 0.001*) and highly significant reduction in the nostril width and nasal basal width (P < 0.001*).

CONCLUSION

Significant improvement in the nasal symmetry was found after PNAM therapy in patients with complete UCLP.

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.

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.

The Impact of Presurgical Infant Orthopedics on Oronasal Fistula Rates Following Cleft Repair: A Meta-Analysis

Background:

Presurgical infant orthopedics (PSIO) techniques were introduced to improve the outcomes achieved when treating children with complete cleft lip and palate. The effect of PSIO on the incidence of postoperative fistulae has never been reliably demonstrated. We conducted a meta-analysis to assess the effectiveness of PSIO in reducing postoperative fistulas in patients with complete cleft lip and palate.

Methods:

A search of the PubMed and Embase databases was performed to identify relevant articles that included primary palate repairs of patients with unilateral or bilateral complete clefts, reported the incidence of postoperative fistulae, and explicitly stated if PSIO was used. Details including author, number of subjects, use of PSIO, and fistula rate were cataloged.

Results:

A review of the PubMed database yielded 1135 unique citations, and Embase yielded 507 articles. Review of these yielded 15 studies, comprising 1241 children, which met inclusion criteria. The overall rate of oronasal fistula development was 7.09%. The average fistula rate for studies using PSIO was 5.93% versus 9.71% in the non-PSIO group. This difference was not statistically significant ( P = .34).

Conclusions:

The use of PSIO prior to cleft lip and palate repair provides multiple benefits related to facial and nasal form and is supported by a body of literature. The effect of PSIO on the incidence of postoperative fistulae has received less attention in the literature. Our meta-analysis of the available literature does not provide evidence to support the premise that the use of PSIO affects the incidence of fistulae after cleft palate repair.

Achievement in Nasal Symmetry after Cheiloplasty in Unilateral Cleft Lip and Palate Infants Treated with Presurgical Nasoalveolar Molding

Background:

The presurgical nasoalveolar molding (PNAM) technique gave a new perspective to presurgical infant orthopedics. Nasal reconstruction presents a challenge for the treating surgeons in case of patients with unilateral cleft lip and palate (UCLP). PNAM facilitates the reshaping of the nasal cartilage and molding of maxillary arch preoperatively.

Aims and Objective:

The aim and objective of the present retrospective study was to analyze two-dimensional nasal changes before and after PNAM in patients with complete UCLP.

Materials and Method:

Twenty-two ULCP patients who underwent PNAM before lip surgery were considered in this study. A series of standard basilar view photographs in 1:1 ratio were taken and linear measurements were done digitally.

Results:

After PNAM therapy, there was a significant increase in nostril height (P = 0.003) and highly significant increase in columella length (P = 0.001). There was also a highly significant decrease in nostril width (P = 0.001) and a significant decrease in nasal basal width (P = 0.02).

Conclusion:

There was a significant increase in nostril height and columella length and a significant decrease in nostril width and nasal basal width on the cleft side when treated with PNAM therapy in patients with complete UCLP. Hence, this therapy helps in improving the nasal symmetry in such patients and also aids in surgical procedures.

Facilitating CAD/CAM nasoalveolar molding therapy with a novel click-in system for nasal stents ensuring a quick and user-friendly chairside nasal stent exchange

Nasoalveolar molding (NAM) aims to improve nasal symmetry with a nasal stent in cleft lip and palate (CLP) patients. When plates have to be exchanged because of dentoalveolar growth or cleft reduction, the nasal stent has to be mounted onto a new plate. This procedure elongates visiting hours for patients and parents or requires second treatment sessions. This study introduces a quick-lock additive manufacturing solution for chairside nasal stent exchange called RapidNAM. A novel taping retention pin has been designed that enables nasal stent insertion. Patients with unilateral CLP were included in this study. Plaster models were digitalized and measured by two independent observers. Two methods of CAD/CAM-molding therapies were compared: (i) conventional adhesion of a nasal stent (CAD/CAM NAM); (ii) quick-lock system in which the nasal stent was transferred to another plate (RapidNAM). CAD/CAM NAM and its refinement RapidNAM significantly increased the cleft-side nasal height and tilted the nose towards symmetry. The quick-lock system minimizes wire adaptations, since the pre-existing stent can be reused. The new nasal stent development seems a feasible solution to minimize visiting hours but with clinically satisfactory results. This new nasal stent system combines traditional elements of NAM with CAD/CAM-technology.

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.

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.

Use of Nasal Conformer After Birth Effectively Improves Nostril Symmetry in Patients With Unilateral Incomplete Cleft Lip

PURPOSE

To investigate the clinical effects of preoperative nasoalveolar molding (NAM) and nasal conformer use in patients with unilateral incomplete cleft lip on the basis of their medical records and images.

PATIENTS AND METHODS

Data and images of 16 patients born with unilateral incomplete cleft lip who were hospitalized between January 2015 and August 2017 were retrieved from the medical records. The primary outcome was the extent of improvement in columella height (CH) before cheiloplasty. Other outcome measurements included the CH, nostril width, and nostril height, which were measured by ImageJ image processing software (version 1.4; National Institutes of Health, Bethesda, MD) and presented as ratios. Mann-Whitney U tests were used to compare the non-normally distributed data.

RESULTS

Patients in the NAM group and those in the nasal conformer group showed significantly improved (P < .05) preoperative cleft-side CH-to-normal-side CH ratios compared with the corresponding ratios at birth. There was no significant difference in terms of the extent of improvement in CH between the groups.

CONCLUSIONS

Preoperative use of nasal conformers in patients with unilateral incomplete cleft lip not only corrects the deformed nasal cartilage but also increases the CH and improves the overall preoperative nasal symmetry. In addition, compared with NAM, this method costs less, is more straightforward, and requires fewer outpatient clinic visits.

Presurgical Nasal Molding With a Nasal Spring in Patients With Mild-to-Moderate Nasal Deformity With Incomplete Unilateral Cleft Lip With or Without Cleft Palate

OBJECTIVE

Traditional nasoalveolar molding (NAM) requires steep learning curve for clinicians and significant compliance from parents. Nasal springs have been developed by the author to simplify presurgical nasal molding. This article presents the design, construction, and application of the spring. The treatment goal is to improve nasal deformity prior to primary repair in infants born with incomplete unilateral cleft lip with or without cleft palate.

METHOD

The design, fabrication, and utility of the nasal spring are described. The spring has a simpler design and construction compared to a traditional NAM appliance.

PARTICIPANTS

Two patients with incomplete unilateral cleft lip with and without cleft palate are presented.

INTERVENTIONS

The spring is constructed and delivered. The active arm of the spring can be 3-dimensionally (3-D) adjusted to mold the alar cartilage of the affected nostril. The spring does not require an oral plate for adherence as a traditional NAM appliance does, hence an oral impression is not needed. The spring is easy for clinicians to adjust. It also requires less compliance by parents.

MAIN OUTCOME MEASURES/RESULTS

The presurgical molding achieved by the use of a nasal spring improved surgical nasolabial aesthetic outcomes.

CONCLUSION

The nasal springs are effective in reducing the initial cleft nasal deformity. This facilitates primary surgical cleft lip and nose correction and improves surgical outcomes in patients with incomplete unilateral cleft lip with or without cleft palate.

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.

Nasal Obstruction in Children With Cleft Lip and Palate: Results of a Cross-Sectional Study Utilizing the NOSE Scale

OBJECTIVE

To characterize the epidemiology and risk factors for nasal obstruction among subjects with cleft lip and/or cleft palate (CL/P) utilizing the well-validated Nasal Obstruction Symptom Evaluation (NOSE) survey.

DESIGN

Retrospective cross-sectional study.

SETTING

Cleft Lip and Palate Program, Children's Hospital of Philadelphia.

PATIENTS, SUBJECTS

One thousand twenty-eight surveys obtained from 456 subjects (mean age: 10.10 (4.48) years) with CL/P evaluated between January 2015 and August 2017 with at least 1 completed NOSE survey.

INTERVENTIONS

Nasal Obstruction Symptom Evaluation surveys completed at each annual visit.

MAIN OUTCOME MEASURES

Composite NOSE and individual symptom scores.

RESULTS

Sixty-seven percent of subjects had nasal obstruction at some point during the study period, with 49% reporting nasal obstruction at latest follow-up. subjects aged 14 years and older reported the most severe symptoms ( P = .002). Subjects with cleft lip and alveolus (CL+A) and unilateral cleft lip and palate (CLP) reported more severe nasal blockage than other phenotypes ( P = .021). subjects with a history of either posterior pharyngeal flap (PPF) or sphincter pharyngoplasty (SP) had significantly higher NOSE scores than subjects with no history of speech surgery ( P = .006). There was no significant difference ( P > .050) in NOSE scores with regard to history of primary tip rhinoplasty, nasal stent use, or nasoalveolar molding.

CONCLUSIONS

There are more severe nasal obstructive symptoms among subjects older than 14 years of age, with CL+A or unilateral CLP, and with a history of PPF or SP. Future studies utilizing the NOSE are needed to evaluate and address this prevalent morbidity in the CLP population.

Burden of Care of Various Infant Orthopedic Protocols for Improvement of Nasolabial Esthetics in Patients With CUCLP

OBJECTIVES

1. To evaluate the orthodontic burden of care of nasoalveolar molding (NAM) and modified McNeil for the treatment of patients with complete unilateral cleft lip and palate (CUCLP). 2. To compare the esthetic outcomes of each with those of centers not utilizing infant orthopedics (IO).

DESIGN

Retrospective cohort study.

SETTING

Institutional.

PARTICIPANTS

Four cohorts with repaired CUCLP (n = 149) from 3 centers.

INTERVENTIONS

Two cohorts were treated in the same center and had either traditional infant orthopedics (TIO) or NAM and 2 were treated in centers not employing IO.

MAIN OUTCOME MEASURES

Burden of care data for the IO groups were compared using t tests. Frontal and profile photographs at approximately age 5 were collected for ratings of nasolabial esthetics, using a modification of the Asher-McDade method. Intrarater and interrater reliabilities were determined using weighted κ statistics. Median ratings were compared using a Kruskal-Wallis test.

RESULTS

The burden of care of NAM was significantly greater than TIO for both the number of visits (9.9 vs 6.6, [ P < .001]); and treatment duration (127 vs 112 days, [ P < .05]). Significant differences in nasolabial esthetic ratings were noted among the 3 centers. No significant differences were observed in the nasolabial esthetic outcomes between the NAM and TIO groups.

CONCLUSIONS

1. NAM required more visits and longer overall duration compared with TIO. 2. The center employing IO showed favorable nasolabial esthetics compared to those not utilizing IO. 3. No significant differences were found in the nasolabial esthetics of patients who have received NAM compared with TIO.

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.

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.

An Intercenter Comparison of Dental Arch Relationships and Craniofacial Form Including a Center Using Nasoalveolar Molding

Objective:

To compare dental arch relationship and craniofacial morphology of patients with CUCLP in pre-adolescence from five cleft centers including a center using NAM.

Design:

Retrospective cohort study.

Setting:

Five cleft centers in North America.

Patients:

One hundred eighty-two subjects with repaired CUCLP from the five cleft centers participated in the craniofacial form study. One hundred forty-eight subjects from four of the five centers participated in the dental arch relationship study.

Methods:

Digital dental models were assessed using the GOSLON Yardstick. Eighteen cephalometric measurements were performed. Measurement means, by center, were compared. Analysis of variance and Tukey-Kramer analysis were used to compare GOSLON scores and cephalometric measurements.

Results:

The center that performed neither PSOT (including NAM) nor primary bone grafting exhibited the most favorable mean GOSLON score. The same center also showed the highest mean SNA, ANB, and ANS-N-Pg angles. However, the mean ANB and ANS-N-Pg angles were not significantly different from those of the center using NAM. No statistically significant differences were seen for mandibular prominence, vertical dimensions, or dental inclinations. The center with NAM also showed a significantly smaller nasoform angle than two of the four other centers.

Conclusion:

The centers that used NAM and other forms of PSOT did not have better dental arch relationships or craniofacial morphology compared with the centers that performed only primary lip repair. However, this study was not designed to investigate the cause-and-effect relationship between specific outcomes and particular features of those protocols.