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 Table of Contents  
TECHNICAL NOTE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 129-132

The double coil molder: A modified presurgical nasoalveolar molding appliance for bilateral cleft correction


1 Consultant Orthodontist, Mangalore, Karnataka, India
2 Consultant Orthodontist, Cochin, Kerala, India
3 Department of Orthodontics, AJ Institute of Dental Sciences, Mangalore, Karnataka, India

Date of Submission08-May-2020
Date of Acceptance07-Jun-2020
Date of Web Publication31-Jul-2020

Correspondence Address:
Dr. Farhan Nadeem Farooq
#706, Classique Harmony, Kankanady, Mangalore - 575 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_11_20

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  Abstract 


A cleft formation in infants is quite disturbing for the parents as it extremely affects the esthetics of the infant. Other than esthetics, it also disturbs the normal functioning of the infant. The reduction of this deformity in bilateral cleft patients is done by bringing the deviated premaxilla medially using a technique called presurgical nasoalveolar molding (PNAM) technique. The deviated premaxilla is mainly due to the growth of the nasal septum and the effect of its growth on the vomero-premaxillary suture. We present a case of bilateral cleft lip and palate which is treated by a double coil molder which is a modified PNAM appliance, followed by surgery of the lip and the palate. A follow-up inspection is done to check the outcome of the therapy on the long term.

Keywords: Bilateral cleft lip and palate, double coil molder, presurgical orthopedics


How to cite this article:
Farooq FN, Jose AR, Mithun K, Shetty NK. The double coil molder: A modified presurgical nasoalveolar molding appliance for bilateral cleft correction. J Cleft Lip Palate Craniofac Anomal 2020;7:129-32

How to cite this URL:
Farooq FN, Jose AR, Mithun K, Shetty NK. The double coil molder: A modified presurgical nasoalveolar molding appliance for bilateral cleft correction. J Cleft Lip Palate Craniofac Anomal [serial online] 2020 [cited 2020 Aug 8];7:129-32. Available from: http://www.jclpca.org/text.asp?2020/7/2/129/291134




  Introduction Top


Orofacial clefting involves the formation of clefts in and around the oral cavity. It can be unilateral or bilateral. The Indian population has about 27,000–33,000 clefts per year.[1] One in every 781 live births is a patient with cleft lip/palate, with males being twice as common compared to females.[2]

The surgical intervention of cleft lip and palate can be traced back to AD 317, where the cleft lip was corrected by approximating and suturing the edges as one.[3]

Grayson et al. had shown a technique, in which they achieved a nonsurgical elongation of the columella in combination with the molding of the alveolar process.[4]

In a bilateral cleft, the premaxilla is left hanging and is protruded and rotated outward. The nasal septum forms the base of the premaxilla, and the septopremaxillary ligament extends from the nasal septum to the premaxillary bone. As the nasal septum grows downward and forward, it leads to a pull on the premaxilla which leads to some amount of tension on the premaxillary-vomerine suture leading to the bone deposition and hence its elongation.[5]

The main aim of presurgical nasoalveolar molding (PNAM) is the approximation of the tissues to achieve a successful surgical procedure with minimum scar formation. PNAM takes advantage of the plasticity of the cartilage in the newborn which is due to the increased amount of hyaluronic acid during the first 6–8 weeks of the infant, which is in turn due to the presence of estrogen in the infant for several weeks after birth.[6]


  Case Top


The parents of the 12-day-old neonate complained of unaesthetic appearance and difficulty in feeding. On clinical examination, the patient presented with a bilateral cleft with the cleft involving both the lip and the palate, all the way up to the soft palate. The premaxilla was deviated to the right side.

According to the Modified Indian Classification, the given case can be classified as “Gp3 R + L Pmax.”[7] According to Kernahan's Striped Y classification, we can depict the case as given in the image [Figure 1].[8]
Figure 1: Kernahan's Striped Y classification

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Objectives

Our aim is to minimize the alveolar defect as much as possible and medialize the premaxilla to the mid-sagittal plane. We must approximate the lips as close as possible before the surgery.

Appliance design

The double coil molder is a modified PNAM which has three parts [Figure 2]:
Figure 2: Appliance design

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  1. Acrylic portion encompassing the premaxilla: It has two retention buttons used for securing the extraoral traction
  2. Acrylic portion encompassing the palate: Acts as an anchorage unit and an obturator
  3. Two loops made up of 0.018 Beta Tittanium Alloy (TMA) round wire: Attaches both parts together. TMA is used because it has both the desirable properties of resilience and flexibility [Figure 3].
Figure 3: Activation of loops

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Treatment plan and progress

An impression was taken and the cast was poured [Figure 4]. The double coil molder works by two mechanics:
Figure 4: (a) Impression of the defect; (b) Plaster model; (c) Double coil molder

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  1. Activation of the loops: The loops were activated by closing the coil as shown in the image
  2. Asymmetric force for the premaxillary segment: 3M Tegaderm was adapted on the patient's cheeks onto which the micropore tape was applied. The other end of the micropore was used to attach elastics. We have used extraoral traction using blue elastic on the right side of the patient where the premaxilla was displaced. Red elastic was used on the left side to apply enough force to move the premaxilla medially.


The nasal stent was later fabricated into the same appliance to modify the shape of the nose. Within 4 months, we were successful in medializing the premaxilla to the mid-sagittal plane. This was followed by the lip repair (7 months) and the palatal repair (9 months) [Figure 5] and [Figure 6]. A substantial change can be observed at the end of the treatment which shows stability after one year post treatment. [Figure 7].
Figure 5: Extraoral photograph with the double coil molder

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Figure 6: (a) Pretreatment photographs; (b) Treatment progress (1 month postappliance insertion); (c) Treatment progress (2 months postappliance insertion); (d) Posttreatment photographs; (e) Postlip surgery; (f) Postpalatal repair

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Figure 7: (a) Pretreatment photographs; (b) Posttreatment photographs; (c) Follow up photographs (1 year posttreatment)

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  Discussion Top


In a bilateral cleft, the premaxilla is usually protruded and rotated outward. Taking the laterality into consideration, the premaxilla may be deviated to the left side (most common), right side, or in the midline (rare).[9]

The three factors which contribute to the naso-premaxillary deformity include: septomaxillary ligament, abnormal direction of alveolar growth, and the possible underdevelopment of the maxillary segment. The septomaxillary ligament pulls the premaxilla leading to the protrusion of the premaxilla. Due to the break in the continuity of the mucogingival pad, there is more of a forward growth rather than an inferior growth which leads to the abnormal direction of the alveolar growth. This is mainly due to the absence of the normal lip musculature along with the action of the tongue and the lower jaw. Finally, due to the presence of the bilateral clefts, the maxilla is deprived of the forward growth stimulus leading to premaxillary protrusion.[5]

In a bilateral cleft, there is a loss of columella due to overgrowth at the vomero-premaxillary suture.[5]

According to Melvin Moss's Functional Matrix Theory,[10] a hypothesis can be put forward regarding the laterality of the premaxilla. The fetal breathing leads to a continuous inward and outward movement of the amniotic fluid. There is more flow in the right nostril as per the lateralization in the brain. This might be one of the reasons of the vomer flexing toward the left side.[9]

Grayson et al. were among the first to bring in the new combined approach of correction of the cleft lip and palate.[4],[11],[12] The objective of the PNAM is to reduce the size of the defect so as to ease the surgical procedure with minimum relapse. The concept of presurgical orthopedics was based on a research by Matsuo and Hirose, who suggest to take advantage of the presence of hyaluronic acid in the fetal circulation few weeks after birth.[6] The results are better when the PNAM is started soon after birth to take advantage of the plasticity.[13]


  Conclusion Top


PNAM should be started soon after birth to take advantage of the plasticity of the nasal cartilage. The double coil molder successfully repositioned the premaxilla at the midline and served as an obturator aiding in feeding. It also approximated the lips and the alveolar segments before surgery of the lip and the palate which gave us a better prognosis of the treatment.

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. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mossey P, Little J. Addressing the challenges of cleft lip and palate research in India. Indian J Plast Surg 2009;42 Suppl 1:S9-18.  Back to cited text no. 1
    
2.
Raman S, Jacob M, Jacob M, Nagarajan R. Providing intervention services for communication deficits associated with cleft lip and/or palate – A retrospective analysis. Asia Pac Disabil Rehabil J 2004;15:78-85.  Back to cited text no. 2
    
3.
Yang S, Stelnicki EJ, Lee MN. Use of nasoalveolar molding appliance to direct growth in newborn patient with complete unilateral cleft lip and palate. Pediatr Dent 2003;25:253-6.  Back to cited text no. 3
    
4.
Grayson BH, Cutting C, Wood R. Preoperative columella lengthening in bilateral cleft lip and palate. Plast Reconstr Surg 1993;92:1422-3.  Back to cited text no. 4
    
5.
Latham RA. Development and structure of the premaxillary deformity in bilateral cleft lip and palate. Br J Plast Surg 1973;26:1-1.  Back to cited text no. 5
    
6.
Matsuo K, Hirose T. Nonsurgical correction of cleft lip nasal deformity in the early neonate. Ann Acad Med Singapore 1988;17:358-65.  Back to cited text no. 6
    
7.
Agrawal K. Classification of cleft lip and palate: An Indian perspective. J Cleft Lip Palate Craniofac Anomalies 2014;1:78.  Back to cited text no. 7
    
8.
Kernahan DA. The striped Y – A symbolic classification for cleft lip and palate. Plast Reconstr Surg 1971;47:469-70.  Back to cited text no. 8
    
9.
Murthy J, Manisha D. Pre-maxillary complex morphology in bilateral cleft and hypothesis on laterality of deviated pre-maxilla. Indian J Plast Surg 2016;49:336-9.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Moss ML, Salentijn L. The primary role of functional matrices in facial growth. Am J Orthod 1969;55:566-77.  Back to cited text no. 10
    
11.
Cutting C, Grayson B, Brecht L, Santiago P, Wood R, Kwoon S. Presurgical columellar elongation and primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair. Plast Reconstr Surg 1998;101:630-9.  Back to cited text no. 11
    
12.
Grayson BH, Cutting CB. Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip, and alveolus of infants born with unilateral and bilateral clefts. Cleft Palate Craniofac J 2001;38:193-8.  Back to cited text no. 12
    
13.
Attiguppe PR, Karuna YM, Yavagal C, Naik SV, Deepak BM, Maganti R, et al. Presurgical nasoalveolar molding: A boon to facilitate the surgical repair in infants with cleft lip and palate. Contemp Clin Dent 2016;7:569-73.  Back to cited text no. 13
[PUBMED]  [Full text]  


    Figures

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



 

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