|Year : 2015 | Volume
| Issue : 2 | Page : 143-146
Nasoalveolar molding: Use of reverse expansion screw in retraction of cleft premaxilla in a case of bilateral cleft lip and palate
Neha1, Tulika Tripathi1, Priyank Rai1, Padam Singh Bhandari2
1 Department of Orthodontics and Dentofacial Orthopedics, Maulana Azad Institute of Dental Sciences, New Delhi, India
2 Department of Burns and Plastic Surgery, Lok Nayak Jai Prakash Hospital, New Delhi, India
|Date of Web Publication||17-Aug-2015|
Department of Orthodontics, Maulana Azad Institute of Dental Sciences, AK-30, Shalimar Bagh, New Delhi - 110 088
Source of Support: None, Conflict of Interest: None
The projecting premaxilla in case of bilateral cleft lip and palate presents a great challenge to the surgical repair of the cleft lip due to difficulty in suturing the large defect. Furthermore, the short columella and nasal dysmorphology result in compromised esthetics even with repeated surgeries. The current case report describes the use of an expansion screw for retraction of cleft premaxilla prior to surgical repair along with nasal molding in a 5-month-old infant.
Keywords: Cleft premaxilla, nasoalveolar molding, retraction cleft premaxilla
|How to cite this article:|
Neha, Tripathi T, Rai P, Bhandari PS. Nasoalveolar molding: Use of reverse expansion screw in retraction of cleft premaxilla in a case of bilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal 2015;2:143-6
|How to cite this URL:|
Neha, Tripathi T, Rai P, Bhandari PS. Nasoalveolar molding: Use of reverse expansion screw in retraction of cleft premaxilla in a case of bilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal [serial online] 2015 [cited 2021 Sep 17];2:143-6. Available from: https://www.jclpca.org/text.asp?2015/2/2/143/162979
| Introduction|| |
In complete bilateral clefts, the premaxilla invariably extends in front of the maxillary elements, and the projection can vary from insignificant to almost insurmountable protrusion often associated with deviation. The earliest practice involved removal of the projecting and malpositioned premaxilla in cases of "hare mouth" so as to permit suturing of the bilateral cleft lip (Pierre Franco, 1556 Dupuytren, Sims). But this resulted in central deformity of the face. Following dissatisfaction with primary excision, ingenious methods of external compression were devised because wide complete cleft lips, if repaired under tension, resulted in a tight lip with inadequate lip elements, often with a thin vermilion and a whistle deformity. 
One of the earliest methods was given in 1686 by Hoffman, who used head cap with cheek extensions laced with tension to press on the premaxilla.  Hullihen in 1844 used adhesive tape binding to retract the maxilla before surgical repair.  The first pre surgical nasoalveolar molding (PNAM) appliance was described by Grayson et. al.  Berggren (2001) and Berggren et al. used an adhesive paper tape and a nasal elevator to improve the morphology of the nose before the surgery.  Thus, the reduction in the volume of defects can facilitate surgical repair with ease by approximation of the cleft segments, resulting in lesser scarring and better surgical repair. Furthermore, the nasal deformities can be addressed in a more natural way by means of molding procedures. The current report describes the retraction of cleft premaxilla with a reverse expansion screw prior to the surgical repair of cleft lip and anterior palate.
| Case Report|| |
A male child, 4 months 22 days old, was referred to the Department of Orthodontics, Maulana Azad Institute of Dental Sciences for retraction of the cleft premaxilla to facilitate surgical repair of the cleft of lip and anterior maxilla. The premaxillary segment was protruding with a large gap between the lip segments which made the surgical repair extremely difficult [Figure 1]. The segment was so protrusive that it completely obscured the nasal tip projection in the bird's eye view with slight rotation to the right side. Alar domes were depressed with a short columella.
|Figure 1: Pretreatment photographs of the patient showing the protruding cleft premaxilla|
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In order to unite the cleft lip segments with minimal scarring for better esthetics, the prolabium required retraction. Also, for the closure of the anterior palatal cleft, the protruding premaxillary segment necessitated alveolar molding to minimize the distance between the cleft segments. The nasal morphology could be improved by nasal molding for columellar lengthening and lifting of the depressed alar domes.
An impression was made with putty in the Pediatric Intensive Care Unit as a precaution to manage any airway emergency [Figure 2]. The patient was held in a mother's lap with the face at a lower level than the rest of the body. The impression was made after waiting for 1½ hours of feeding. As the patient was older than 4 months, it was decided to apply an active retractive force rather than a passive molding plate. An expansion screw was incorporated in the active molding appliance after fully opening the screw [Figure 3], and the appliance was retained in the mouth with the help of extra-oral tapes and elastics [Figure 4].
|Figure 3: The appliance with an open expansion screw for retraction of the premaxilla and retentive stents|
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To save the patient's skin from any ulceration due to repeated placement and removal of the surgical tapes, a protective layer of Tegaderm (3M) was placed over which the active taping was done. The parents were then advised to close the screw by half a turn every 3 rd day to bring the cleft segments into alignment. After 21 days, when the intercleft distance was reduced to nearly half the pretreatment gap, nasal molding was started [Figure 5]. For this, two stents made of wire bent in a swan shape with acrylic covering the ends for lifting the nasal domes were added [Figure 6]. A horizontal bar of acrylic was added below in the region of columella uniting the two acrylic ends of the nasal stent to provide the stretching force for columellar lengthening. The stretching force on the other end was provided by the surgical tape placed on the median part of the cleft lip. The horizontal tape was added on top of this arrangement after holding in approximation the cleft segments of the lips bilaterally. This tape exerted a compressive force as well on the protruding prolabium. The NAM therapy continued for 2 months and 10 days and alveolar continuity and columellar length improved [Figure 7] and [Figure 8]. Since the patient was nearly 7 months, compliance had become difficult. Hence, the surgical repair was planned for the lip. The postoperative photographs show a good nasal tip projection and columella [Figure 9]. The treatment progress was evaluated on the patients models and is given in [Table 1].
|Figure 5: Treatment progress — reduction in cleft defect prior to nasal molding|
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|Figure 6: Addition of nasal stents along with horizontal and vertical taping|
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| Discussion|| |
The cleft deformity is significantly reduced in size with the NAM therapy before surgery, making primary repair of the lip, alveolus, and the nose an effortless procedure.  It also forces the protruded premaxillary segment into alignment with the dental alveolar segments, improving the shape of the maxillary arch. In addition to the ease of surgical repair, with the alveolar segments in a better position and increased bony bridges across the cleft, the permanent teeth have a better chance of eruption in a good position with adequate periodontal support. 
In the current case, the patient reported beyond the age generally recommended for NAM procedures. However, as stated by Grayson, the plasticity of the cartilage fades over the first 6 months of age, a state of elasticity eventually sets in, maintaining the shape of the nasal cartilage at that point.  Hence, we still had 1½ month before complete loss of tissue elasticity.
Mishra et al. have reported of NAM carried out on 23 patients with age ranging from 10 to 360 days in which the molding procedure was performed for an average of 2 months 10 days.  They reported significant changes in gain of columellar height and reduction in the alveolar gap in the sample. On dividing the sample according to age at the beginning of NAM, they found that collumelar length increased by 26%, while the change in alveolar gap was 33.3% in the age range of the 4-6 months in which the current patient falls. Thus, their study shows that the NAM, though is less effective as the age progresses, improvement does occur even when the patient is in the age range of 4-6 months. Furthermore, the retraction of the cleft premaxilla definitely facilitates the surgical repair by reducing the extent of defect and ease of approximation of the cleft lip segments. Considering all these factors, it was decided to take up the case for molding procedures. In order to start the nasal molding, the cleft premaxilla had to be retracted. To hasten the process of premaxillary retraction, in place of a passive molding appliance, an active retractive force was given with the help of an expansion screw. This reduced the distance between the cleft segments considerably within a short span of 21 days after which nasal molding could be performed. The rate of expansion was regulated so as to prevent any bending of the premaxillary segment towards the maxillary halves. As shown in the table, the cleft distance on the right side reduced from 3 mm to nearly complete contact while on the left side from 4 mm to 1 mm. The net reduction in cleft defect on both sides was 3 mm thus reducing the amount of bony defect minimizing the need for future bone grafting.
Preoperative NAM in combination with primary gingivoperiosteoplasty reduces the need for secondary alveolar bone grafting by 60% in patients with unilateral cleft lip and palate.  The lesser number of surgeries required also reduce the overall costs in cleft care. 
| Conclusion|| |
The use of expansion screw successfully retracted the cleft premaxillary segment into contact with two maxillary halves.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]