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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 195-197

Presurgical nasoalveolar molding therapy in patients with bilateral cleft lip and palate


Department of Odontology, Orthodontics and Maxillary Orthopedics Service, Unit of Cleft Lip Palate, National Institute of Child Health, Breña, Lima, Peru

Date of Web Publication21-Nov-2017

Correspondence Address:
Lourdes Martínez Motta
Jr. Ernesto Lopez Mindreau N ° 107, Groove, Surco, Lima
Peru
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_80_17

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  Abstract 

Infants with bilateral cleft lip and palate have an esthetic and functional involvement of the face. To obtain esthetic results, such as reducing the cleft gap and mediating premaxilla, various treatments are performed, such as presurgical orthopedics with extraoral traction headgear and nasoalveolar molding. Nasoalveolar molding (NAM) therapy has proven to be an effective method for reducing the cleft, improving the anatomy of the nose and remodeling the alveolar and nasal segments before surgical repair. This article presents two clinical cases with bilateral cleft lip and palate; case 1 treated with presurgical orthopedics with extraoral traction headgear and case 2 treated with NAM therapy.

Keywords: Cleft lip and palate, presurgical nasoalveolar molding, presurgical nasoalveolar molding therapy


How to cite this article:
Motta LM, Huanca JS. Presurgical nasoalveolar molding therapy in patients with bilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:195-7

How to cite this URL:
Motta LM, Huanca JS. Presurgical nasoalveolar molding therapy in patients with bilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2021 Mar 3];4, Suppl S1:195-7. Available from: https://www.jclpca.org/text.asp?2017/4/3/195/218894


  Introduction Top


The cleft lip and palate is one of the most frequent alterations of head and neck. The alterations in the nasal, labial, and dental area produce serious functional problems.

Grayson and Cutting[1] were among the first to combine the concepts of presurgical orthopedics and preoperative treatment of cleft lip nose deformity.

They developed the concept of nasoalveolar molding, which combined a nasal molding stent with a passive preoperative molding apparatus in the treatment of patients with cleft palate.

Nasoalveolar molding (NAM) therapy is a presurgical infant orthopedic technique that reduces the severity of the cleft nasal and deformity before lip and palate surgery.[2]

The principle of NAM is based on the breakdown of the intercellular matrix of nasal cartilage due to the abundance of hyaluronic acid during the first 6–8 weeks of the infant. During this period, there are high levels of maternal estrogen in fetal circulation, which triggers an increase in hyaluronic acid.[3]

Objectives

  • Approximation of lip segments before surgery
  • Medialization and retrusion of the premaxilla in the midsagittal plane
  • Reduction of severity of cleft of alveolar segments.



  Case Reports Top


Patients with bilateral cleft lip and palate, nonsyndromic, and collaborating parents.

Case 1

A 6-day-old female infant was treated at the National Institute of Child Health (Instituto Nacional de Salud del Niño: INSN) in February 2014. In the first visit, after the clinical evaluation, a headgear was made. Parents were given directions. During the second visit, after 4 days, the correct use of the headgear was evaluated. On the third visit, another new headgear was made due to the growth of the infant. A headgear of unilateral traction was used for 1 month, till medialization of premaxilla at the same level of the midsagittal plane then the headgear of bilateral traction was used until a lip surgery.

The results found were approximation of the lip segments, the premaxilla medialized and slightly retruded [Figure 1]a,[Figure 1]b,[Figure 1]c.
Figure 1: (a) Pretreatment extraoral photos of bilateral cleft lip and palate individual. (b) Posttreatment extraoral photos of bilateral cleft lip and palate individual. (c) Photos are showing therapy

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Case 2

A 19-day-old male infant was treated at INSN in March 2015. At the first visit, after the clinical evaluation, the palate was imprinted with heavy silicone, cast in Type IV plaster, and the NAM plaque was made. The acrylic of the plate is 2 mm thick. In the second visit, the patient with 21 days, the plaque was installed without nasal stent. On the third visit, a resilient acrylic was added. On the fourth and fifth check-ups, the wear was performed in areas to promote the bone's growth then acrylic was added in areas where alveolar processes will be redirected. On the sixth check-up, a nasal stent, made of 0.32 steel wire, was placed. Five more controls were performed before surgery, with 7 day interval [Figure 2]c.
Figure 2: (a) Pretreatment extraoral photos of bilateral cleft lip and palate individual. (b) Posttreatment extraoral photos of bilateral cleft lip and palate individual. (c) Photos are showing nasoalveolar molding plate along with lip taping. (d) Pretreatment dental model. (e) Posttreatment dental model

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The results were approximation of the lip segments, the premaxilla was medialized in the sagittal and retruded in the median plane, transverse growth of the alveolar processes, and the prolabium elongation [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d,[Figure 2]e.


  Discussion Top


Grayson et al.[4] described the first presurgical NAM device. The use of the presurgical apparatus helps in providing a more coalescing slit and a ideally alveolar arch shape.[2] This in turn reduces stress during primary surgery, reducing scar formation. This alignment of the alveolar segments provides the basis for a good lip symmetry that produces more favorable bone formation by reducing the cleft gap.

In this case, when a reduction of 2–3 mm of the alveolar fissure is observed, we placed the nasal stent, with weekly activations.

We observed reduction of the protrusion and deviation of the premaxilla similar to Spengler et al.[5]

Positive effects are observed in infants with bilateral cleft palate alveolus, also described by other authors, Rau et al.,[6] Gandedkar et al.[7]


  Conclusion Top


The NAM therapy is a method which approximates the labial and alveolar segments by the redirection of natural growth forces, offers preoperative reduction of the alveolar cleft, approximation of the lip segments before surgery, which reduces lip tension. It is observed medialization and retrusion of the premaxilla unlike the headgear of traction that only medialized the premaxilla and obtained a slight retrusion.

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.
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. 1
[PUBMED]    
2.
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. 2
[PUBMED]    
3.
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. 3
[PUBMED]    
4.
Grayson BH, Santiago PE, Brecht LE, Cutting CB. Presurgical nasoalveolar molding in infants with cleft lip and palate. Cleft Palate Craniofac J 1999;36:486-98.  Back to cited text no. 4
[PUBMED]    
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
[PUBMED]    
6.
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. 6
    
7.
Gandedkar NH, Kiat CC, Kanesan P, Lee WC, Chen PY, Yeow VK. Presurgical nasoalveolar molding therapy in cleft lip and palate individuals: Case series and review. APOS Trends Orthod 2015;5:208-14.  Back to cited text no. 7
  [Full text]  


    Figures

  [Figure 1], [Figure 2]


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