|Year : 2015 | Volume
| Issue : 5 | Page : 208-214
Presurgical nasoalveolar molding therapy in cleft lip and palate individuals: Case series and review
Narayan H Gandedkar, Chng Chai Kiat, Palaniselvam Kanesan, Wen Cong Lee, Por Yong Chen, Vincent Kok Leng Yeow
Department of Plastic, Reconstructive, and Aesthetic Surgery, Cleft and Craniofacial Center and Dental Service, KK Women's and Children's Hospital, Bukit Timah - 229 899, Singapore
|Date of Web Publication||24-Aug-2015|
Narayan H Gandedkar
Department of Plastic, Reconstructive, and Aesthetic Surgery, Cleft and Craniofacial Center and Dental Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Bukit Timah, 229 899
Source of Support: None, Conflict of Interest: None
The nasoalveolar molding (NAM) therapy is advocated to reduce the severity of alveolar cleft and nasal deformity. NAM therapy has demonstrated to be an effective method for reducing cleft and improve nose anatomy. This paper presents a case report of three cleft lip and palate individuals treated with NAM therapy. Furthermore, the paper highlights the advantages of NAM therapy along with an enumeration of literature suggesting in favor of NAM therapy and otherwise. Regardless of controversies and divergent views involved with NAM therapy, the immediate success of NAM therapy facilitating primary lip repair surgery cannot be under-emphasized.
Keywords: Cleft lip and palate, nasoalveolar molding, presurgical treatment
|How to cite this article:|
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
|How to cite this URL:|
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 [serial online] 2015 [cited 2018 Aug 15];5:208-14. Available from: http://www.apospublications.com/text.asp?2015/5/5/208/163424
| Introduction|| |
Cleft lip and palate (CLP) is one of the most common congenital birth defects with the greatest incidence among Asians (2.1 cases/1000 live births). CLP is a multi-factorial birth disorder that can be associated with hereditary factors and environmental factors; folic acid deficiency, maternal smoking, alcohol consumption, and medications. 
Nasoalveolar molding (NAM) is a presurgical infant orthopedics technique that reduces the severity of the cleft and nasal deformity before the lip and palate surgery.  The principle of NAM is based on the breakdown of the intercellular matrix of nasal cartilage due to the abundance of hyaluronic acid during infant's first 6-8 weeks. During this period, there are high levels of maternal estrogen in fetal circulation, which triggers an increase in hyaluronic acid.  Furthermore, according to Hamrik's chondral modeling hypothesis, NAM is thought to simulate immature nasal chondorblasts producing the interstitial expansion, which in turn improve nasal morphology.  Various devices such as a palatal obturator, nasal conformers, articulation development prosthesis, palatopharyngeal obturator, and palatal lift are used as non-surgical therapies to improve cleft deformity.
Three cases of CLP infants treated with NAM therapy are presented with following primary objectives;
- On alveolar segments, ,
- Reduction of severity of cleft of alveolar segments.
- Alignment of lesser and greater alveolar segments.
- Approximation of alveolar cleft without maxillary arch constriction.
- On lips, ,
- Nonsurgical columella lengthening.
- Approximation of lip segments prior to surgery to reduce tension in the lip tissues and hence minimize lip scar.
- Medialization of the premaxilla (in bilateral cleft lip [BCLP]) along the midsagittal plane and hence aide surgeon to form uniform Cupid's bow.
- On nose,
- Reduction of nasal tip width.
- Improve nasal tip projection.
- Decrease nasal alar base width.
- Improve nostril shape.
| Case reports|| |
Cases 1 and 2 are isolated unilateral CLP (UCLP) and case three is BCLP.
Cases 1 and 2
Two infants, a female child, the age of 21 days, and a male child of 24 days were referred to Cleft and Craniofacial Centre, KK Women's and Children's Hospital, Singapore. On clinical examination, the patient's showed complete UCLP. On the first visit, lip taping (1/4 inches) (3M Steri-Strip™, Neuss, Germany) was done and instructions were given to parents about lip taping, and advised to continue lip taping for 2 weeks. On the second visit, palate impression was made with alginate impression material (Jeltrate°, Dentsply, DeTrey GmbH, Konstanz, Germany). The impression was poured using Type IV dental stone, and the cast was made ready of fabrication of NAM plate. The acrylic plate of 2 mm thickness was constructed with polymerizing resin (self-cure) and 0.036'' TMA wire extension arm having a nasal stent. NAM plate was inserted into the patient's mouth with nasal stent gently resting beneath the nasal dome. The oral cavity was carefully examined for sore points and soft tissues blanching. Sufficient relief was provided for frenal attachment. For retention purpose, adhesive cream (Polident, GalxoSmithKline) was applied onto the NAM plate and held in place for about 50-60 sec for the cream to form a protective layer around the plate. The two active ingredients in the cream; gantrez salt, which holds the dentures firmly to the gums, and sodium carboxymethyl cellulose, which seals off the area, and prevents food from getting in between the gums and NAM plate.
Parents were demonstrated regarding the insertion and removal of NAM plate and were told to apply the fresh cream once daily. The appliance was activated once in 2 weeks and during every activation schedule, the nasal stent's extension arm was activated for the correction of nasal projection, and also, nasal bulb or stent was increased in size for correction of nostril size. Furthermore, any trauma or sore points were evaluated along with evaluation of patient's compliance and parents' co-operation. The activation schedule continued until the time of primary lip repair, which is about 4 months.
Results achieved after NAM therapy were narrower lip gap, an approximation of lesser and greater alveolar segments, and correction of the droopy nostril. This aforementioned correction not only enabled better esthetic results after surgery but also reduced tissues tension and scar formation postsurgery [Figure 1] [Figure 2] [Figure 3] [Figure 4] [Figure 5] [Figure 6] [Figure 7] [Figure 8].
|Figure 1: Pretreatment extra- and intra-oral photos of unilateral cleft lip and palate individual|
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|Figure 2: Photos showing nasoalveolar molding plate along with lip taping|
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|Figure 3: Photos showing post nasoalveolar molding therapy with approximation of lip width and improved nasal shape|
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|Figure 5: Pretreatment extra- and intra-oral photos of unilateral cleft lip and palate individual|
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|Figure 6: Photos showing nasoalveolar molding plate along with lip taping|
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|Figure 7: Photos showing post nasoalveolar molding therapy with approximation of lip width and improved nasal shape|
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A male child, aged 18 days, with BCLP, was reported to the above-mentioned institution. On examination, he showed complete BCLP with procumbency of the premaxilla. On the first visit, the parents were instructed to apply tape across the cheek such that premaxilla is pushed backward. Six weeks was the time taken by the premaxilla to move backward, once it was ascertained that premaxilla had moved sufficiently, the impression of the maxilla was made for the fabrication of NAM plate. The NAM plate was fitted, and a nasal stent was adjusted such that nostrils were molded. After 5 months, the promulgated objectives of NAM plate were achieved. The patient was subjected to primary lip repair, and post-surgical results were pleasing [Figure 9] [Figure 10] [Figure 11] [Figure 12].
|Figure 9: Pretreatment extra- and intra-oral photos of bilateral cleft lip and palate individual|
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|Figure 10: Photos are showing nasoalveolar molding plate along with lip taping|
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|Figure 11: Photos showing post nasoalveolar molding therapy with approximation of lip width and improved nasal shape|
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| Discussion|| |
Through this case report series, emphasizes is laid on the fact that NAM therapy is advantageous in both UCLP and BCLP individuals. Our technique of NAM therapy is simple, efficient, quick, and precise without burdening the parents and the child. The plate is devoid of any retentive arms and additional retention elastics. This modification of removing the additional arms simplifies the plate and also makes the plate less bulky. However, the retention of the plate is obtained from the adhesive cream that is applied over NAM plate.
Skin irritation, especially on cheeks, can be reduced by applying skin barrier tapes (DuoDERM Extra Thin ® , Convatec, Bristol-Myers Squibb Company, USA). It is also recommended to apply the dermal cream (ABC Derm, Perioral Cream, Bioderma Laboratoire Dermatologique, Lyon, France) to reduce skin irritation. We recommend over correction of nostril as nostril shape relapse is anticipated (width, 10%; height, 20%; and angle of columella, 4.7%) at one year of age,  moreover nasal conformers (Nostril Retainer ® , Koken Co. Ltd., Tokyo, Japan) are recommended for at least 6-month posttreatment. 
Presurgical orthopedic devices and their application are controversial as two schools of thoughts predominate on the application of NAM therapy. One school, proponents of NAM therapy believe that NAM is effective and makes a significant difference in the management of CLP individuals. However, the second school of thought does not associate with all the objectives of NAM. We have enumerated studies in relation to the benefit of NAM and also, those studies which reveal otherwise [Table 1] and [Table 2].
| Conclusion|| |
NAM therapy has been demonstrated to be an effective method for reducing cleft and improve nose anatomy. Regardless of controversies and divergent views involved with NAM therapy, the immediate success of NAM therapy facilitating primary lip repair surgery cannot be under-emphasized.
Financial support and sponsorship
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], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2]