Presurgical Nasoalveolar Molding in Infants with Cleft Lip and Palate

Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. In this paper, we present a paradigm shift from the traditional methods of presurgical infant orthopedics. Some of the problems that the traditional approach falled to address include the deformity of the nasal cartilages in unilateral as well as bilateral clefts of the lip and palate and the deficiency of columella tissue in infants with bilateral clefts. The nasoalveolar molding (NAM) technique we describe uses acrylic nasal stents attached to the vestibular shield of an oral molding plate to mold the nasal alar cartilages into normal form and position during the neonatal period. This technique takes advantage of the malleability of immature cartilage and its ability to maintain a permanent correction of its form. In addition, we demonstrate the ability to nonsurgically construct the columella through the application of tissue expansion principles. This construction is performed by gradual elongation of the nasal stents and the application of tissue-expanding elastic forces that are applied to the prolabium. Use of the NAM technique has eliminated surgical columella reconstruction and the resultant scar tissue from the standard of care in this cleft palate center.



A heavy-bodied silicone impression material is used to take the initial impression as soon after birth as possible, when the cartilage is plastic and moldable. In case of an airway emergency, the surgeon is always present to help with the impression. The infant is held upside down by the surgeon, and the impression tray is inserted into the oral cavity. The tray is seated until impression material is observed just beginning to extrude past its posterior border. The infant is kept in the inverted position to keep the tongue forward and to allow fluids to drain out of the oral cavity. Once the impression material is set, the tray is removed, and the mouth is examined for residual impression material that may be left behind. A cast or model of the alveolar anatomy is made by filling the impression with a dense plaster material (dental stone). The molding plate is fabricated on the dental stone model. It is made of hard clear acrylic and is lined with a thin layer of soft denture material. Care is taken to reduce the border of the plate in the area of the labial frenum attachments and other areas that may be likely to ulcerate. Parents are instructed to keep the plate in full time and to take it out for cleaning as needed, at least once a day. Initially, it may take longer to feed the infant with the plate in place, but the child quickly adjusts and parents report that the infant soon will not eat without it. The appliance is secured extraorally to the cheeks and bilaterally by surgical tapes, which have an orthodontic elastic band at one end. The elastics loop over a retention arm extending from the anterior flange of the plate. The retention arm is positioned approximately 40 degrees down from the horizontal to achieve proper activation and to prevent unseating of the appliance from the palate. The tapes are changed once a day.

The benefits of NAM are numerous. In the short term, the tissues are well aligned before primary lip and nose repair, which enables the surgeon to achieve a better and more predictable outcome with less scar tissue formation. In the long term, studies indicate that the change in nasal shape is stable with less scar tissue and better lip and nasal form. This improvement reduces the number of surgical revisions for excessive scar tissue, oronasal fistulas, and nasal and labial deformities. With the alveolar segments in a better position and increased bone bridges across the cleft, the adult teeth have a better chance of erupting in a good position with adequate periodontal support.

Santiago et al found that 60% of patients who underwent NAM and GPP did not require secondary bone grafting. Sato et al found that, in the remaining 40% who did need a bone graft, there was more bone remaining in the graft site than in patients who did not previously undergo GPP. This was explained by the presence of bone bridges in the graft site resulting from the primary GPP. Henkel and Gundlach found that, in 68% to 73% of patients in whom a Millard-type GPP was performed, a secondary bone graft was not required. Fewer surgeries result in substantial cost savings for families




and insurance companies.Another important benefit of NAM is the opportunity for the parents to take part actively in the habilitation of their child.




NAM has evolved over the past decade into its present form through contributions made by practicing clinicians and parents. This method of treatment requires attention to detail with appliance adjustments that are at times less than a millimeter in dimension.




Clinical skills in NAM develop over time. Efficiency in treating patients increases as these clinical skills improve, and these skills may be advanced by the training of a dental assistant or laboratory technician to make adjustments to the molding plate under direct supervision of the practicing clinician. Since the initiation of NAM and the associated surgical technique, there has been a significant difference in the outcome of primary surgical cleft repair.

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