|Year : 2015 | Volume
| Issue : 2 | Page : 107-112
Effects of nasoalveolar molding therapy on alveolar morphology in unilateral cleft lip and palate using two different approaches
Puneet Batra1, MV Ashith2, Shaksham Mittal1, Akhter Hussain2, Khader Mustafa2, Sudeshwar Sood3
1 Department of Orthodontics and Dentofacial Orthopedics, Institute of Dental Studies and Technologies, Meerut, Uttar Pradesh, India
2 Center for Craniofacial Surgery, Yenepoya University, Mangalore, Karnataka, India
3 Department of Plastic Surgery, Sant Parmanand Hospital, New Delhi, India
|Date of Web Publication||17-Aug-2015|
Dr. Shaksham Mittal
Department of Orthodontics and Dentofacial Orthopedics, Institute of Dental studies and Technologies, Modinagar, Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study was to evaluate the effects of presurgical nasoalveolar molding (PNAM) therapy by standard Grayson technique (G1) and Yen Modification single step NAM technique (G2) on alveolar tissues in patients with unilateral cleft lip and palate (UCLP) using three-dimensional digital models. Materials and Methods: Totally, 10 patients with a mean age of 20 ± 16.07 days, having complete UCLP, were included in this prospective study. The maxillary plaster models were scanned. The study sample was divided into two group of 5 UCLP patients (G1 treated by standard Grayson technique and G2 treated by Yen Modification) for linear, angular, and area measurements before and after PNAM therapy. The distances between the identified landmarks were measured on the maxillary casts, and the distance and area measurements were performed using software Poly works (IIT Delhi). All subjects had undergone PNAM therapy for 3 months, the alveolar segments should have been approximated (≤5 mm), and the cleft width after PNAM should be reduced. Results: The decrease of the cleft width and arch length on the cleft side were significantly altered on the affected side (P < 0.005). No significant changes were observed when comparing both the groups using standard Grayson technique and Yen Modification single step NAM technique (G1 and G2). Conclusion: PNAM therapy effects mainly in the anterior alveolar segment and reduction of palatal and alveolar cleft width in patients with unilateral clefts of lip, alveolus, and palate in both Grayson and Yen Modification single step NAM technique. Both the Groups G1 and G2 suggested same treatment outcome in term of alveolar molding, but single step technique reduces patient's visits.
Keywords: Grayson technique, presurgical nasoalveolar molding, presurgical nasoalveolar molding therapy
|How to cite this article:|
Batra P, Ashith M V, Mittal S, Hussain A, Mustafa K, Sood S. Effects of nasoalveolar molding therapy on alveolar morphology in unilateral cleft lip and palate using two different approaches. J Cleft Lip Palate Craniofac Anomal 2015;2:107-12
|How to cite this URL:|
Batra P, Ashith M V, Mittal S, Hussain A, Mustafa K, Sood S. Effects of nasoalveolar molding therapy on alveolar morphology in unilateral cleft lip and palate using two different approaches. J Cleft Lip Palate Craniofac Anomal [serial online] 2015 [cited 2019 Mar 18];2:107-12. Available from: http://www.jclpca.org/text.asp?2015/2/2/107/162964
| Introduction|| |
Cleft lip and palate can arise with considerable variation in severity and form. Wider and extensive clefts are associated with significant nasolabial deformity. The unilateral cleft lip deformity is characterized by a wide nostril base and separated lip segments on the side of the cleft. The lower lateral nasal cartilage which is affected is displaced laterally and inferiorly resulting in a depressed dome, an oblique columella, the appearance of increased alar rim, and an overhanging nostril apex. If associated with cleft palate, the nasal septum deviates to the non-cleft side with a shift of the nasal base.  The basic goal of any approach to cleft lip, alveolus, and palate repair is to restore its normal anatomy. Ideally, expansion of deficient tissues and repositioning of malpositioned structures should be done before surgical correction that will provide the foundation for a less-invasive surgical repair. 
Presurgical nasoalveolar molding (PNAM) was first described by Grayson et al.  which involved active molding and repositioning of the deformed nasal cartilages and alveolar processes, followed by the lengthening of the deficient columella. The alveolar molding is done first followed by nasal molding appliance. The alveolar process is molded into a predetermined position by selective trimming and adding of soft reliner [Figure 1].
|Figure 1: Removal of the clear hard acrylic resin (yellow arrow) and sequential addition of the soft denture lining material (blue arrow)|
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The NAM technique has been claimed to improve significantly the surgical outcome of the primary repair of cleft lip and palate compared with traditional approaches of presurgical orthopedic techniques.  The advantages of nasoalveolar presurgical infant orthopedics may be considered from a soft tissue perspective as well as from the usual osseous perspective. The presurgical reduction in soft tissue and cartilaginous deformity facilitates surgical soft tissue repair as a result of minimal tension and optimal conditions for scar formation.  In contrast, the disadvantage associated with the nasoalveolar presurgical infant orthopedics is that the patient has to visit a number of times during the procedure, which is quiet unaffordable by many of the patients in India due to low socioeconomic status. Thus, several modifications have been made in the PNAM procedure so that it can be successful and burden of care is reduced.
The present study was designed to analyze the alveolar molding changes after PNAM therapy by standard Grayson technique using alveolar molding first followed by nasal molding and Yen Modification single step NAM technique in which weekly modification of the appliance for alveolar molding is not required. The study was done using three-dimensional (3D) digital models.
| Materials and Methods|| |
The study sample includes 10 unilateral cleft lip and palate (UCLP) infants (6 males and 4 female) divided into two groups of five patents each with mean age at pretreatment 20 ± 16.07 days and post treatment 113 ± 11.51 days who were treated with the PNAM by Grayson technique (G1) and Yen Modification single step NAM technique (G2) [Figure 2] and [Figure 3]. Pre- and post-treatment maxillary impressions were made with elastomeric impression material [Figure 4] and poured in dental stone. The 3D models [Figure 5] were constructed using a laser scanning machine (Comet Plus, IIT Delhi) and 3D software (Polyworks, IIT Delhi). Reference points and lines, which were based on the anatomic structures, were identified and digitized on the 3D model [Table 1] with a point accuracy of 0.040 mm and a resolution (point-to-point distance) of 0.130 mm in X and Y and 0.005 mm in Z according to the manufacturer.
|Figure 2: One case representing presurgical nasoalveolar molding procedure with Grayson technique|
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|Figure 3: One case representing presurgical nasoalveolar molding procedure with Yen Modification a single step technique|
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The linear, angular, midline deviation, distance, and area variables were defined according to reference used in the study by Baek and Son  [Table 2] and [Table 3]. Same reference points were marked on the cast, and the linear value was calculated [Figure 6], [Figure 7], [Figure 8] for point linear and angular].
Magnification error was removed in calculated linear and angular values by using the formula: measured value/actual value ×100.
Wilcoxon Rank Sum test was applied for statistical analysis using SPSS software (IBM) version 16 and the results were tabulated.
| Results|| |
The pre-treatment and post-treatment changes after PNAM therapy were recorded and compared under the linear and angular variable. The digital superimposition of pre- and post-PNAM cast was done and the changes were recorded.
Statistically no significance changes seen in the width between the most posterior ends of larger segment (LS) and smaller segment (SS) as well as in the widths between the middle parts of LS and SS (B L -B S ) and sagittal length between M S in the SS and P L -P S (M S -(P L -P S )). The widths of the cleft gap (A L -A S , transverse A L -A S ) showed continuous and significant decrease with P < 0.05 during the PNAM treatment. The sagittal length of LS and SS from the P L -P S line (M L -(P L -P S )) was decreased by 13.75 mm in G1 with P = 0.02 and 14.29 mm in G2 with P = 0.02 during the PNAM treatment [Figure 7] and [Table 2] and [Table 4].
On comparing the linear variable of both the groups there were no significant changes seen in the treatment outcome.
Presurgical nasoalveolar molding treatment significantly reduced the angle between the anterior parts of LS to the P L -P S line (A L -P L )-(P L -P S ) by 7.8° in G1 with P = 0.02 and 11.05° in G2 with P = 0.03. No significant reduction is seen in the angle between A L -B L and P L in the LS [A L -B L -P L ] and the angle between A L , B L , and P L in the SS [A S -B S -P S ]. No significant reduction is seen in the angle between A S -P S in the SS and P L -P S [(A S -P S )-(P L -P S )]. Angle between the anterior part of LS and SS shows significant increase after PNAM therapy [(B L -A L )-(B S -A S )] by 21° in G1 with P = 0.01 and 19.85° in G2 with P = 0.02 [Figure 8] and [Table 3] and [Table 5].
On comparing the angular variable of both the groups there were no significant changes seen in the treatment outcome.
Three-dimensional models of 2 consecutive (pre- and post-treatment) casts of each patient were oriented in a coordinate system using the Y-axis (P L -P S ), X-axis (sagittal line), and Z-axis and were superimposed with each other using the midpoint in P L -P S line . It was found that the closure of the cleft gap during PNAM treatment was mainly due to the inward bending of the whole part of LS [Figure 9].
|Figure 9: Superimposition of pre- and post-treatment three-dimensional mode|
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| Discussion|| |
Historically, the use of presurgical infant orthopedic appliances, or molding therapy, has aided significantly in reducing the cleft size of the alveolus and palate before surgery.  Various techniques for molding intraoral alveolar segments closer together in unilateral and bilateral cleft situations have been described. , All these orthopedic appliances move only alveolar segments together but do not reposition the deformed surrounding soft tissues such as the nasal dome and columella-philtrum region. PNAM includes not only the reduction in size of the intraoral alveolar cleft through the molding of the bony segments, but also the active molding and positioning of the surrounding soft tissues affected by the cleft, including the deformed soft tissue and cartilage in the cleft nose. This is accomplished through the use of a nasal stent that enters the nasal aperture.
In Grayson technique, first molding of the alveolar segment happens with reduction and addition of soft liner by 1 mm. Nasal molding started when the alveolar gap reduces to 5 mm. However, in the Yen Modification single step technique the arch form is recreated before the appliance is made.
Acceptance for the NAM has been slow in the Indian scenario. Reason for it is two-fold. There is a lack of sufficient resources and poor background of the parents further limits the efficacy of the cleft team.
The literature ,,, also suggest that PNAM is an effective procedure to reduce alveolar defect before elective surgery [Table 5].
The cleft gap in patients with UCLP is much exaggerated than in patients with bilateral cleft lip and palate due to contraction of the perioral muscle, orbicularis oris, and lateral displacement of alveolar segments. Moreover, the pressure of tongue anteriorly fitting into the cleft gap does not allow the alveolar gap between the two segments to close (A L -A S and Trans A L -A S ).
Use of the presurgical orthopedics in cleft lip and palate has been controversial since its inception in 1950s. Recent prospective studies have clearly shown the questionable benefit of conventional presurgical orthopedics in the UCLP patients. , PNAM was described in the last decade, which conceptualized the combination of nasal cartilage molding along with the conventional form of alveolar orthopedics.  However, the critiques of the presurgical treatment have described it as unnecessary, tedious and costly procedure. 
Presurgical nasoalveolar molding either carried out by Grayson technique or by prearch alignment technique did not contribute to any significant differences in the end result of the treatment. Thus, both the techniques are suitable for treatment. However, in Grayson technique for aligning the arch, the soft liner is added at weekly interval. In contrast, the pre-alignment arch technique involves the fabrication of an ideal arch form in the appliance due to which the number of visits of the patient is decreased in this technique. However, the drawback related to this latter technique is the uncertainty whether the patient is using the appliance or not, as patient enters to the clinic after a relatively longer period of time.
Linear, angular variable and superimposition of pre- and post-treatment cast suggest that the width of the cleft gap decrease in both the groups and the remolding of the greater segment is more as compared to the lesser segment. Both the Groups G1 and G2 suggested same treatment outcome in term of alveolar molding.
Though the sample size is small, the following conclusion can be drawn from this study. However, larger sample size may be required to confirm the results of the present study.
| Conclusions|| |
- The study suggests that alveolar molding effects mainly in the anterior alveolar segment during PNAM treatment.
- Presurgical nasoalveolar molding can effect a marked reduction of palatal and alveolar cleft width while evaluating alveolar molding in patients with unilateral clefts of lip, alveolus, and palate in both Grayson and Yen Modification single step NAM technique.
- Presurgical nasoalveolar molding can be done by either of the two techniques, as both the techniques shows no significant differences on the treatment outcome in terms of alveolar molding. Yen Modification single step technique may have the advantage of less patient visits.
| Acknowledgment|| |
The authors wish to thank Dr. P. M. Pandey, Professor, Department of Mechanical Engineering, IIT Delhi, for guiding us during this study.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]