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 Table of Contents  
CASE SERIES
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 119-123

Figueroa modified presurgical nasoalveolar molding for cleft patients: A case series of three cases


1 Department of Pedodontics and Preventive Dentistry, Index Institutes of Dental Sciences, Indore, Madhya Pradesh, India
2 Department of Pedodontics, Himachal Pradesh Government Dental College, Shimla, Himachal Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, Government Duty Officer, Kullu, Himachal Pradesh, India
4 Private Practitioner, New Delhi, India

Date of Web Publication26-Jul-2018

Correspondence Address:
Dr. Divya Doneria
Room No 301, Department of Pedodontics, Himachal Pradesh Government Dental College, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_1_18

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  Abstract 


Presurgical nasoalveolar molding (PNAM) is a modified approach of presurgical infant orthopedics for cleft lip and palate (CLP) patients. PNAM provides the advantage of reduction in the nasal deformity along with reduction in the severity of the alveolar defect before surgery. Nonsurgical nasal correction, achieved by nasoalveolar molding, helps the surgeon to achieve better postoperative finer surgical scar, good nasal tip projection, and more symmetrical nasolabial complex. This clinical case report presents a series of three cases of a child with CLP, two with complete unilateral, and one with incomplete bilateral. These cases were treated with Figueroa modified PNAM technique before primary lip repair surgery.

Keywords: Cleft lip and palate, Figueroa modified presurgical nasoalveolar molding therapy ,presurgical infant orthopedics


How to cite this article:
Doneria D, Thakur S, Uppal A, Chauhan A. Figueroa modified presurgical nasoalveolar molding for cleft patients: A case series of three cases. J Cleft Lip Palate Craniofac Anomal 2018;5:119-23

How to cite this URL:
Doneria D, Thakur S, Uppal A, Chauhan A. Figueroa modified presurgical nasoalveolar molding for cleft patients: A case series of three cases. J Cleft Lip Palate Craniofac Anomal [serial online] 2018 [cited 2019 Aug 21];5:119-23. Available from: http://www.jclpca.org/text.asp?2018/5/2/119/237629




  Introduction Top


Cleft lip and palate (CLP) is present with nasal deformity as a secondary defect that arises in the fetal period. It was suggested that this nasal deformity can be reshaped by nonsurgical means by virtue of its plasticity within 3–4 months after birth.[1]

Grayson introduced a concept of combining presurgical nasal molding with alveolar molding as presurgical nasoalveolar molding (PNAM) for CLP patients. PNAM technique is a nonsurgical passive method of approximating lips and gingiva together by redirecting the forces of natural growth. It enables the clinician to align discrete and asymmetric alveolar segments in more symmetrical form. It also helps to correct malpositioning of cartilage, to raise columella and nasal dome, and to narrow flared nasal base at cleft side.[2] In bilateral CLP cases, PNAM helps in retracting premaxilla and in lengthening as well as raising columella.[3]

In PNAM technique by Grayson, weekly visits for 3–5 months are required for adjustments, so Figueroa modified PNAM technique to reduce the number of adjustments till cheiloplasty. In this case series of three CLP patients, Figueroa modified PNAM technique is used to correct their nasal deformity and alveolar segments' alignment at the same time before lip repair. The patients are followed up to 1 year after lip repair surgery for any relapse in nasal correction.


  Case Series Top


All three cases were referred to our department for needful. For these patients, pediatrician and plastic surgeon were consulted to rule out any medical/systemic condition. Then, after thorough evaluation of the cases, PNAM was planned for these patients. The treatment was explained to parents in details for procedure, duration, and prognosis. Their active involvement was also emphasized for the success of the treatment. Parental consent was obtained. Steps which were followed for PNAM for the three cases as follows:

Impression making

Impression of intraoral cleft defect, in each case, was made with condensation silicone impression material [Figure 1] in custom-made acrylic impression tray in the presence of anesthetist with OT setting to manage any emergency. The position of the infant was upside down in the mother's lap which enhanced proper visualization and reduced the chances of aspiration.
Figure 1: Impression with silicone material

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Fabrication of occlusal plate, retentive arm, and nasal stent

  • The cleft space was obliterated with the modeling wax [Figure 2] to prevent any extensions of the plate into the alveolar or palatal cleft space. This modification eliminated the need for weekly trimming of the occlusal plate
  • A molding plate made up of hard clear acrylic of 2–3 mm was fabricated with smooth borders and proper relief at frenum. One retention arm was attached to the appliance [Figure 3]. In this retentive arm, serrations were made at equal distance to engage orthodontic elastics
  • The nasal stent (0.9 mm round SS wire) was extended as a projection from the labial flange of the molding plate. Hard acrylic was added to the nasal end of the stent in shape of kidney over which a layer of the soft acrylic liner was added [Figure 4]. The free end of the nasal stent was extended into the nostril in such a way that it supported the deformed nasal alar cartilage adequately after the lip segments were approximated by the lip taping.
Figure 2: Dental stone cast with blocking of undercuts

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Figure 3: Presurgical nasoalveolar molding appliance showing occlusal plate, nasal stent, and retentive arm with serrations

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Figure 4: Nasal stent – swan neck-shaped wire component with bilobed acrylic at distal end

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Taping and insertion of plate

  • Tegaderm™ was placed over the cheeks which minimized tissue irritation and then micropore tape was applied [Figure 5]. This taping was advised at the first visit itself for approximation of the lip segments
  • Now, the appliance was secured extraorally to the cheeks, bilaterally by the adhesive tapes that have orthodontic elastic bands (inner diameter – 0.25 inch, wall thickness – heavy) at one end. The elastic band on the retentive tape was looped on the retention arm of the molding plate and the tapes were secured to the cheek bilaterally [Figure 6]
  • The elastics were pulled approximately twice their resting diameter to achieve an activation force of approximately 100 g. At the same time, cleft lip segments were approximated with the lip tapes to achieve a nonsurgical lip adhesion. Lip taping was also helpful in stabilizing the plate in wider clefts. Nasal stent was kept passive at the visit of plate insertion
  • Parents were trained for the taping, insertion, and removal of plate. They were advised for full-time wear of plate to infant, especially at the time of feeding and to maintain cleanliness of infant mouth and plate.
Figure 5: Tegaderm and base tape over cheeks

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Figure 6: Appliance inserted and secured by adhesive tapes bilaterally

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Follow-ups

  • First follow-up was preferred after 2–3 days to check for acceptance of plate by infant or for any ulceration. Nasal stent was also activated in this visit. Parents were advised to report in case of ulceration in infant mouth or rashes over cheeks
  • Next follow-up visits were planned after 3–4 weeks. Molding of the plate was done by the addition of soft acrylic liner at the labial side of the major segment. Alveolar molding and approximation was achieved only through the addition of soft acrylic (<1 mm thickness) at every follow-up visit. The amount of the soft acrylic added varied according to the desired movement of segments
  • Nasal stent was activated by serial addition and subtraction of soft acrylic liner in accordance of required nostril shape and ala form.



  Case Series Top


Case 1

This infant, with incomplete bilateral CLP, was of 10 days when brought to the department. Modified PNAM therapy was done as described step by step below. [Figure 7] showing photographs before and after PNAM therapy and lip repair. In this patient, after modified PNAM therapy, lip approximation, increase in nostril height, columella lengthening, premaxilla retraction, and decrease in intersegmental distance were observed.
Figure 7: Case 1 (a) before presurgical nasoalveolar molding therapy at 15 days (b) after presurgical nasoalveolar molding therapy at 5 months showing lip approximation and retraction of premaxilla (c) nasal view before molding (d) nasal view after molding (e) after lip repair

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Cases 2 and 3

These two infants presented with unilateral CLP of the right side. [Figure 8] and [Figure 9] show photographs before and after PNAM therapy and lip repair. In these patients, PNAM outcomes were lip approximation, increase in nostril height, nasal symmetry, and decrease in nostril width at cleft side, intersegmental distance.
Figure 8: Case 2 (a) before presurgical nasoalveolar molding therapy at 10 days (b) after presurgical nasoalveolar molding therapy at 3 months showing lip approximation (c) nasal view before molding (d) nasal view after molding (e) after lip repair

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Figure 9: Case 3 (a) before presurgical nasoalveolar molding therapy at 40 days (b) after presurgical nasoalveolar molding therapy at 4 months showing lip approximation (c) nasal view before molding (d) nasal view after molding (e) after lip repair

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  Discussion Top


In Figueroa modified PNAM technique, adjustments are made every 3–4 weeks. Nasal stents are added to PNAM appliance at the time of plate insertion itself. It helps in molding the nasal cartilage and improves nasal symmetry from the beginning. In our cases, we used Figueroa modified PNAM technique and observed lip approximation, increase in nostril height, collumelar height and angle, and decrease in intersegmental distance, bialar width and nostril width. These observations were similar to Liao et al., who found Figueroa modified PNAM technique more efficient comparatively.[4] This modified technique also provides the advantage of reducing the frequency of patient's visits and treatment cost.

In case with incomplete bilateral cleft, we observed retraction of premaxilla with PNAM appliance is similar to Spengler et al[5] and Motta and Huanca.[6] We also observed that if appliance is given early, the infant accepts it more easily. One of our patients [case 3], who was 40 days old at the time of plate insertion, resisted the plate and took longer to accept it. Even at 1 year followup after lip repair, no relapse in nostril height was observed in these cases. The literature also supports the positive effect of PNAM therapy.[7],[8]


  Conclusion Top


Figueroa modified PNAM technique is an effective method for reduction of cleft deformity and improvement in nose anatomy. It appears to be promising technique that requires further research and evaluation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Matsuo K, Hirose T, Tomono T, Iwasawa M, Katohda S, Takahashi N, et al. Nonsurgical correction of congenital auricular deformities in the early neonate: A preliminary report. Plast Reconstr Surg 1984;73:38-51.  Back to cited text no. 1
    
2.
Grayson BH, Santiago PE, Brecht LL, Cutting CB. Presurgicalnasoalveolar molding in infants with cleft lip and palate. Cleft Palate Craniofac J 1999;36:486.  Back to cited text no. 2
    
3.
Ozer T, Kama J. Presurgical infant orthopaedics in bilateral cleft lip and palate patients (Part 2). Dicle Tıp Derg 2007;34:140-3.  Back to cited text no. 3
    
4.
Liao YF, Hseich YJ, Chen IJ, Ko WC, Chen PK. Comparative outcomes of two nasoalveolar moulding techniques for bilateral cleft nose deformity. Plast Reconstr Surg 2013;130:1289-95.  Back to cited text no. 4
    
5.
Spengler AL, Chavarria C, Teichgraeber JF, Gateno J, Xia JJ. Presurgical nasoalveolar molding therapy for the treatment of bilateral cleft lip and palate: A preliminary study. Cleft Palate Craniofac J 2006;43:321-8.  Back to cited text no. 5
    
6.
Motta LM, Huanca JS. Presurgical nasoalveolar molding therapy in patients with bilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal 2017;4:S195-7.  Back to cited text no. 6
    
7.
Mishra B, Singh AK, Zaidi J, Singh GK, Agrawal R, Kumar V, et al. Presurgical nasoalveolar molding for correction of cleft lip nasal deformity: Experience from Northern India. Eplasty 2010;10. pii: e55.  Back to cited text no. 7
    
8.
Rau A, Ritschl LM, Mücke T, Wolff KD, Loeffelbein DJ. Nasoalveolar molding in cleft care – Experience in 40 patients from a single centre in Germany. PLoS One 2015;10:e0118103.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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Abstract
Introduction
Case Series
Case Series
Discussion
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