CASE REPORT |
https://doi.org/10.5005/jp-journals-10005-2916 |
Enhancing Surgical Outcomes: Presurgical Nasoalveolar Molding for Unilateral Cleft Lip, Alveolus, and Palate in Infants—A Progressive Clinical Report
1,2Department of Orthodontics and Dentofacial Orthopedics, Lady Hardinge Medical College, Delhi, India
3,4Department of Oral and Maxillofacial Surgery, Lady Hardinge Medical College, Delhi, India
Corresponding Author: Lucky Yadav, Department of Orthodontics and Dentofacial Orthopedics, Lady Hardinge Medical College, Delhi, India, Phone: +91 9975546896, e-mail: drluckyyadav4170@gmail.com
ABSTRACT
This case report describes the successful application of presurgical nasoalveolar molding (PNAM) in the treatment of a neonate with Veau’s class III cleft lip and palate of the left side. PNAM, a noninvasive method, effectively reduced the cleft deformity (from 10 mm pretreatment to 1 mm post-NAM), improved nasal esthetics, and minimized the need for extensive surgical interventions and better surgical outcomes. The treatment involved precise impression procedures, custom-made appliances, and weekly modifications to achieve optimal results. The comprehensive approach resulted in favorable esthetic outcomes, reduced scar formation, and improved lip symmetry, demonstrating the potential of PNAM as a valuable adjunctive therapy in cleft lip and palate management.
Keywords: Alveolar cleft segments, Bilateral cleft lip and palate, Case report, Cleft lip, Infant feeding, Nasoalveolar molding
How to cite this article: Yadav L, Mattu N, Yadav N, et al. Enhancing Surgical Outcomes: Presurgical Nasoalveolar Molding for Unilateral Cleft Lip, Alveolus, and Palate in Infants—A Progressive Clinical Report. Int J Clin Pediatr Dent 2024;17(8):951–954.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.
INTRODUCTION
Since the 1950s, presurgical infant orthopedics has been used as an additional treatment for correcting cleft lip and palate. However, traditional methods often fall short in addressing nasal cartilage deformities in cases of Veau’s type III and Veau’s type IV, as well as deficiencies in columella tissue among infants with bilateral clefts. The nasoalveolar molding (NAM) technique, pioneered by Grayson and Shetye, introduces a fresh approach by reducing the severity of initial cleft alveolar and nasal deformities.1
This technique utilizes a NAM, which includes an intraoral molding plate along with nasal stents. Its purpose is to concurrently shape the alveolar ridge and nasal cartilage. The main objective of presurgical NAM is to minimize the severity of the initial cleft deformity, enabling surgeons to achieve a more effective and esthetically pleasing repair of the alveolus, lip, and nose.2 Research has shown that nasoalveolar molding significantly improves surgical outcomes for primary repair in patients with cleft lip and palate compared to other presurgical orthopedic approaches.1
CASE DESCRIPTION
A 2-day-old neonate female child was referred to the orthodontics wing of the Department of Dental and Oral Surgery at Lady Hardinge Medical College, Delhi, India with the chief complaint of regurgitation of milk while feeding. Her medical and family histories did not provide relevant information. After a comprehensive examination, a diagnosis of Veau’s class III with the presence of a Simonart’s band on the left side was made (Figs 1A and B). The treatment plan included presurgical nasoalveolar molding (PNAM), followed by the scheduled primary surgical repair, which proceeded as intended.
Figs 1A to F: (A and B) Pre-NAM extraoral and intraoral photographs of the patient showing cleft lip and palate with Simonart’s band; (C) PNAM appliance; (D) NAM appliance without nasal stent; (E and F) PNAM appliance with nasal stent
Following the acquisition of informed consent from the parents, which included a comprehensive explanation of the potential risks and benefits of PNAM, the case was scheduled for the impression procedure. A custom-made tray, pretrimmed to eliminate sharp edges, was crafted based on a primary cast made from the primary impression taken with impression compound. The final impression was made using putty (Reprosil, Dentsply) with careful consideration to prevent any airway obstruction in the presence of a surgeon. Subsequently, a dental stone cast was prepared and carefully trimmed. Accurate measurements were taken using calipers and a ruler, meticulously documented for future reference (Figs 2A2C).
Figs 2A to I: (A, B, C) Pre-NAM record; (D to G) Postnasoalveolar molding; (H and I) Postsurgery records
Modeling wax was employed to conceal the gap in the alveolus and other recessed areas on the physical model. Subsequently, a 2 mm thick, autopolymerizing transparent acrylic resin NAM plate was crafted. To ensure the NAM plate fit securely and stayed in place, red orthodontic elastics measuring 0.25 inches in diameter were applied to its handle. Upon insertion and once the appliance achieved stability, 3M Tegaderm was applied to both sides of the cheeks. Later, Steri-Strips™ were extended and attached to the base tapes on the infant’s cheeks. Regular replacement of these elastics was carried out to uphold the effectiveness of the appliance by sustaining the necessary tension (Fig. 1D). The appliance was left in place for 24 hours, with removal only for cleaning purposes.
Weekly follow-up was done to evaluate the need for modifications to the NAM appliance. The working principle of nasoalveolar molding (negative sculpting and passive molding) involved selective modifications in the NAM appliance with the help of soft tissue liners for directing the growth of alveolar segments in the desired direction. After a presurgical NAM period of around 7 weeks, and when the alveolar cleft was <5 mm, a nasal stent was added to improve nasal symmetry with continuous modifications to obtain the desired results (Figs 1C11F).
Around 5 months after the initiation of PNAM, the alveolar segments were approximated to 1 mm from the pre-PNAM measurement of 10 mm (Figs 2D22G), the cleft team evaluated the NAM outcomes, and surgical repair was done using Millard’s rotation-advancement technique (Figs 2H and I).
The patient is on constant follow-up with the interdisciplinary cleft team for further management in the hospital (Figs 3A3333F).
Figs 3A to F: (A) Follow-up records, Pre-NAM; (B and C) Post-NAM; (D) Postsurgery- day 3; (E) 1-week postsurgery; (F) 6 months postsurgery
DISCUSSION
In 1950, McNeil was the first to introduce the concept of presurgical maxillary orthopedics, utilizing serial appliances to bring together alveolar cleft segments.3 The elevated levels of maternal estrogen circulating in the fetal system during the initial 6 weeks of life lead to an increase in hyaluronic acid levels. This elevation in hyaluronic acid plays a crucial role in molding cartilage, ligaments, and connective tissues, contributing to the desired permanent outcomes of tissue molding. Matsuo and Hirose later applied this concept to address nasal deformities in individuals with cleft lip.4
Nasoalveolar molding represents a noninvasive, passive approach to bringing the gums and lips into alignment by harnessing natural growth forces. This method contributes to correcting a flattened nose before surgery and facilitates concurrent nose repair during lip repair. PNAM incorporates the principles of both “negative sculpturing” and “passive molding” to address the alveolus and soft tissues in the surrounding area.5
In cases of Veau’s type III, using a presurgical appliance helps create a more unified cleft and a well-formed alveolar arch. This reduces tension during the primary surgery, thereby minimizing scar formation. Proper alignment of the alveolar segments is crucial for achieving balanced lip symmetry, promoting improved bone formation by narrowing the cleft gap. In the present case, there was significant alveolar cleft reduction from around 10 to 1 mm post-NAM. Moreover, a notable reduction in alveolar cleft size correlates with a decreased necessity for alveolar bone grafting during the mixed dentition stage and better outcomes.6,7
CONCLUSION
Presurgical nasoalveolar molding has shown promising outcomes, notably in diminishing the extent of cleft deformities affecting the lip, palate, and alveolus while enhancing nasal esthetics. Prior to the surgical intervention, PNAM served as a valuable adjunctive therapy in the case, effectively reducing the cleft deformity from 10 mm to 1 mm. This not only improved esthetic outcomes but also resulted in a reduction in the number of required surgical treatments. Beyond the physical changes, there were additional psychological benefits as satisfaction with facial appearance improved before the primary surgical lip repair.
ORCID
Lucky Yadav https://orcid.org/0000-0003-4731-8940
Navraj Mattu https://orcid.org/0000-0003-0651-0872
Jaspreet Kaur Deo https://orcid.org/0000-0003-1131-3582
REFERENCES
1. Grayson BH, Shetye PR. Presurgical nasoalveolar moulding treatment in cleft lip and palate patients. Indian J Plast Surg 2009;42(Suppl):S56–S61. DOI: 10.4103/0970-0358.57188
2. Grayson BH, Cutting C, Wood R. Preoperative columella lengthening in bilateral cleft-lip and palate. Plast Reconstr Surg 1993;92(7):1422–1423.
3. McNeil CK. Oral and facial deformity. Sir Isaac Pitman and Sons: London; 1954. pp. 81–89.
4. Matsuo K, Hirose T. Preoperative non-surgical over-correction of cleft lip nasal deformity. Br J Plast Surg 1991;44(1):5–11. DOI: 10.1016/0007-1226(91)90168-j
5. Shaik N, Eggula A, Pudi S, et al. Presurgical orthopedic nasoalveolar molding in cleft lip and cleft palate: case report. Int J Clin Pediatr Dent 2023;16(4):659–662. DOI: 10.5005/jp-journals-10005-2487
6. Yadav L, Bamal R, Jaswal A, et al. Secondary alveolar bone moulding in cleft lip and cleft palate: a review. Int J Appl Dent Sci 2022;8(1):471–477. DOI: 10.22271/oral.2022.v8.i1g.1465
7. Hegde RJ, Kharkar VR, Kamath S. Presurgical nasoalveolar molding in unilateral cleft lip and palate. Contemp Clin Dent 2015;6(4):567–569. DOI: 10.4103/0976-237X.169865
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