263© 2021 Journal of Natural Science, Biology and Medicine | Published by Wolters Kluwer - Medknow 263

Abstract

Case Report

IntroductIon

The presurgical orthopedic treatment in the cleft lip and palate was initiated by McNeil in 1950.[1] Nasoalveolar molding (NAM) appliance is a recent infant orthopedic appliance used in cleft lip and palate patients under 3–4 months of age. It is constructed under 3–4 months of age because the moldability of primary cartilage is very high due to high estrogen content in infants at this age.[2] The NAM consists of an intraoral appliance with molding plate attached with nasal stents to mould the lip, alveolus, and nasal cartilages to reduce the severity of cleft deformity and enabling surgeon to achieve better repair of alveolus, lip, and nose.[3]

In cleft lip and palate patients, the ala on the cleft side flattens and stretches toward noncleft side, which results into asymmetry of nasal apertures, the surgical intervention without NAM therapy causes undue pressure and tension on lip and alveolar segments and it adversely impacts on anteroposterior growth of the maxilla.[4]

NAM focuses on maxillary alveolar alignments, nasal septum up righting, encourages unrestricted maxillary growth, improves curvature of alar cartilages, and approximates lip segments into desired positions.[5]

This article presents about successful NAM therapy carried out below 4 months of age in unilateral cleft lip and palate baby reported to our institution.

case report

The cleft lip and palate infant aged 15 days (3 weeks) reported to the department of pedodontics and preventive dentistry. Upon clinical examination, we observed unilateral cleft on the left side extending from nasal floor, lip, alveolus, hard palate anterior to incisive foramen which is classified as block 5, 6, 7, and 8 as per the Millard’s modification of Kernahan’s stripped Y classification.[6] We referred this patient to pediatrician for physical and general examination, patient reported back with the report which indicated that this patient had no systemic problems except cleft deformities which did

Nasoalveolar molding (NAM) is a recent infant orthopedic appliance constructed in cleft lip and palate patients below 3–4 months of age because the moldability of primary cartilage is very high due to high estrogen content in infants below 4 months of age. We started NAM therapy in this case at 3 weeks of age and continued till 4 months of age, the cleft lip gap decreased from 19 mm to 9 mm and palate (alveolar) gap reduced from 9 mm to 3 mm, there was also improvement in nasal anatomy. This is an important case report in which we have successfully completed NAM therapy and also followed the case after lip surgery for 6 months which resulted in better surgical outcome in terms of function and esthetics. In conclusion, we suggest that presurgical NAM improves esthetics, decreases cleft deformities, and prepares the patients for less surgical procedures with better results.

Keywords: Cleft lip, cleft palate, nasoalveolar molding

Address for correspondence: Dr. Vinod Kumar, Department of Pedodontics and Preventive Dentistry, Navodaya Dental

College and Hospital, Raichur ‑ 584 102, Karnataka, India. E‑mail: dr.vinod990@gmail.com

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DOI: 10.4103/jnsbm.JNSBM_99_20

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How to cite this article: Kumar V, Shakir MK, Koppalkar RR, Nanda A, Karthika B, Babu A, et al. Presurgical nasoalveolar molding therapy in cleft lip palate infant: A successful case report. J Nat Sc Biol Med 2021;12:263‑7.

Presurgical Nasoalveolar Molding Therapy in Cleft Lip Palate Infant: A Successful Case Report

Vinod Kumar, M. K. Shakir, Rohith R. Koppalkar, Anisha Nanda, B. Karthika, Aleena Babu, Khandelwal Ankita Pravin

Department of Pedodontics and Preventive Dentistry, Navodaya Dental College and Hospital, Raichur, Karnataka, India

Submitted: 16‑May‑2020Accepted: 06‑Dec‑2020

Revised: 26‑Sep‑2020Published: 15‑Jul‑2021

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Journal of Natural Science, Biology and Medicine ¦ Volume 12 ¦ Issue 2 ¦ July-December 2021264

not interfere with feeding. We proceeded with NAM therapy at 3 weeks of age after obtaining parents’ consent. The gap between cleft lip segments was measured with the Vernier caliper [Figure 1a]. The child was posted to the neonatal intensive care unit (NICU) maintained with adequate airway management team for impression of the cleft palate. The previously available cleft palate patient’s tray was selected for obtaining the primary impression and rubber base silicone putty impression material was selected for impression. Master cast was prepared. The cleft palate segments were measured using the Vernier caliper [Figure 1b]. Later, the cleft gaps were blocked using modelling wax, and acrylic plate was prepared with self‑cure acrylic, with creation of a hole of 3–4 mm diameter in the middle to prevent obstructive apnea [Figure 1c] and a retention button using self‑cure acrylic was prepared in cylindrical form with diameter of 6 mm and length of 1–1.5 cm with creation of a circumferential depression of 2 mm on midway to engage elastics.

Next retention button to acrylic plate was attached using self‑cure acrylic on the anterior region labially at 45° angulation to the horizontal of acrylic plate [Figure 1d]. Now this whole unit is known as basic NAM appliance.

NAM appliance insertion should succeed the lip taping. Lip taping is done to approximate cleft lip segments and also brings philtrum on to the midline. In our case report, first the micropore tape was stuck on the uncleft side of the lip and pulled towards cleft side, to bring philtrum and columella in midline [Figure 2a]. After lip taping, the NAM appliance was inserted inside the mouth was engaged using 3/16 inch (3.5 oz) red elastics and tapes to attach to the cheeks. One end of the 1st elastic was engaged to retention button, it is stretched double

Figure 1: (a) Prenasoalveolar molding measurement of gap between cleft lip segments at 3 weeks. (b) Prenasoalveolar molding measurement of gap between cleft palate (alveolus) segments at 3 weeks. (c) Acrylic plate prepared with hole in middle to prevent obstructive apnoea. (d) Attachment of acrylic retention button to acrylic plate on the middle of cleft alveolar gap 45° to horizontal (nasoalveolar molding appliance without nasal stent)

a b

dc

the lumen and another end of 1st elastic attached with micropore tape which was fixed on the cheeks on one side, similarly, 2nd elastic attached with micropore tape was fixed on another side of cheeks [Figure 2b]. The NAM appliance was fixed with two elastics with micropore tape on either side of the cheek diagonally along the angle of mouth till midway between the ear and corner of the eye. In this way, the two stretched elastics with force of 50–100 g on either side will apply downward and forward pressure on nasomaxillary complex bringing the cleft segments together, and they also retain the NAM appliance.

The parents of the patient were advised to clean the NAM appliance daily once in the morning hours using warm water, later disinfect and clean with cloth and insert into the mouth by double stretching the elastic lumen after lip taping procedure.

Feeding of cleft baby with NAM is through bottle. The advent of new bottles with one way valves that use compression (positive pressure) and suction (negative pressure) such as Haberman and Pigeon nipples can be used for feeding. Squeezable bottles have also offered improved way of feeding infants with cleft lip and palate.

For remodeling, the inner side of acrylic plate of NAM appliance should be modified every week by addition of 1–2 mm soft liner in the certain areas of excess bony alveolar ridge to encourage bone resorption and 1–2 mm of acrylic should be removed in certain areas of deficient bony alveolar ridge for bone deposition. On repeated remodeling, the palatal shelves were moved toward then midline in a symmetric pattern moulding the arch. In the present case, the patient was recalled every week for selective remodeling [Figure 2c], until the cleft alveolus gap was reduced to 6 mm, which was achieved by the end of 2 months.

Figure 2: (a) Lip taping procedure. (b) Nasoalveolar molding appliance without nasal stent inserted inside the mouth and for retention elastics and micropore tapes used to attach to cheeks on either side. (c) Nasoalveolar moulding remodeling marking on cast (black color areas indicated for acrylic removal for bone deposition and yellow color areas indicated for soft liner addition for bone resorption)

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Kumar, et al.: Presurgical nasoalveolar molding therapy in cleft lip palate

Journal of Natural Science, Biology and Medicine ¦ Volume 12 ¦ Issue 2 ¦ July-December 2021 265

Then, nasal stent was incorporated to NAM appliance. For the nasal stent construction, around fore finger length of 20–21 gauge wire was cut, the wire was straightened, and 3–4 mm of one end was bent into right angle using Adams plier which gives L shape, later using universal plier, long end of L‑shaped wire was bent back side and curved it to form Swan neck shape, now the nasal stent has wing, head, and tail [Figure 3a]. The head was having superior and inferior loop, both loops were acrylized and soft liner was added over acrylic [Figure 3b]. Nasal stent was attached to the NAM appliance with self‑cure acrylic labial to retention button near the affected nose [Figure 3c]. NAM appliance with nasal stent is inserted in the mouth and attached with elastics and micropore tape in such a way that the superior lobe of the head of nasal stent should be inside the nose (touching alar rim) and inferior lobe of the head outside the nose [Figure 3d]. Nasal stent activation and remodeling of NAM appliance should be carried out every week. Nasal stent was regularly activated using three prong plier. It done by compression of the convex side of wing of nasal stent backward in such a way that the superior lobe of nasal stent head pushes alar rim of nose upward and forward [Figure 3e].

In our case report, we started the NAM treatment at 3 weeks of age, the measurements of the cleft gaps between two lip segments, pre‑NAM was 19 mm and post‑NAM at 4 months of age was 9 mm [Figure 4a], similarly pre‑NAM cleft palate (alveolus) gap at 3 weeks of age was 9 mm, at 8 weeks of age (2 months) was 6 mm and after NAM therapy at 4 months of age, it was 3 mm [Figure 4b], post‑NAM both right and left palatal segments were symmetrical. The post‑NAM measurements indicate improvement in terms of cleft deformity and also nasal structures have aligned with improvement of

nose, in terms of esthetics and function [Figure 5a]. After the completion of NAM therapy by 4 months immediately, we have referred for lip surgery, soon after lip surgery the surgical repair was appreciable in terms of better lip anatomy and well aligned nasal structure [Figure 5b] and after 6 months follow‑up postlip surgery the surgical repair had healed up with minimal scar tissue formation and with less surgical revisions [Figure 5c].

dIscussIon

The success of NAM depends upon the accuracy of treatment procedure and age limit. The success is good if NAM therapy is undertaken within 4 months of infancy because, at this time the chondroitin sulfate is high in children which is due to high estrogen which allows moldability of tissues, once chondroitin sulfate reduces, the cartilages loses its flexibility. It is shown that the estrogen‑induced, osteoanabolic effects were mediated through enhanced production of chondroitin sulfate, which could act as an osteogenic stimulant in our cell‑based system. Once chondroitin sulfate reduces, the cartilages lose its flexibility.

NAM appliance with retention tapes applies forward and downward force which brings cleft segments into proper alignment, the basic appliance NAM with lip taping allows moldability of alveolar segments, stent allows molding of nose and liptaping reduces gap between two separated lips. Lip taping offers a constant tension load on lip segments which lengthens them and brings them together (tissue creep) and lip taping also allows limited manipulation of both alveolar

Figure 3: (a) Nasal sent (swan shaped), with having kidney‑shaped two heads, wing, and tail. (b) Nasal sent superior and inferior head acrylized and soft liner added on the top of acrylized head. (c) Nasal stent added to nasoalveolar molding appliance with self‑cure acrylic labial to retention button near the affected nose. (d) Nasoalveolar molding appliance with nasal stent inserted in mouth and fixed on either side of cheeks using elastics and micropore tapes. (e) Nasal sent activation procedure

a b c

d e

Figure 4: (a) Prenasoalveolar molding at 3 weeks with lip gap 19 mm and postnasoalveolar moulding at 4 months with lip gap of 9 mm. (b) Pre‑ and post‑nasoalveolar molding changes in palatal (alveolar) gaps; at 3 weeks prenasoalveolar molding was 9 mm, at 2 months postnasoalveolar molding was 6 mm, at 4 months postnasoalveolar molding was 3 mm. Right and left palatal segments remodeled and were symmetrical at 4 months postnasoalveolar molding

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b

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segments and nasal cartilage. Lip taping is easy to perform, less expensive, and not interferes with feeding, it’s continued until lip repair. DuoDerm can be applied on cheek and lip before taping to prevent skin irritation. Lip taping should be combined with NAM to achieve better results. Movement of palatal (alveolar) segments during NAM therapy has secondary effect on closer approximation of lip segments.

Addition of nasal stent is helpful to the NAM appliance because it allows maintaining nasal anatomy. Grayson and Maull[7] suggests that nasal stent should not be constructed till alveolar gap reduces to 4–6 mm. In our case report, we have constructed the nasal stent when alveolar gap was reduced to 6 mm; this brings lip segments closer and decreases nasal base width which brings laxity of the alar rim of nose. In our case report, prior to the NAM therapy, on the left side the roof of nose was collapsed, nasal dome has flattened and opening of nasal aperture was restricted. Post‑NAM therapy, on the left side, nasal dome has risen with adequate opening of nasal aperture and columella length has increased with even alar base.

We have used routinely available materials such as rubber base silicone putty impression material, acrylic, soft liner, elastics, and micropore tapes. In our case report after 4 months of NAM treatment, the cleft gaps reduced and nasal anatomy was also improved which reduced many surgical treatment burdens on the patient.

We have referred the case after NAM therapy for primary lip surgery after 4 months. Primary closure of lip is indicated around 3–5 months of age, or rule of 10s; at least 10 pounds,

10 weeks of age, 10 g hemoglobin level.[8] The result of surgical lip repair in our case is appreciable in terms of no scar formation and well alignment of lips with pleasing esthetics [Figure 5b].

According to Sato et al., the anatomic improvement in nose, lip, and alveolar segments after NAM therapy decreases the number of surgical revisions for excessive scar tissue formations, oronasalfistula, nasal, and labial defects.[9] Studies also indicated that after NAM therapy nasal form and lip approximation is stable with less scar tissue formation following surgery.[10]

With NAM therapy, surgeons can modify the techniques taking advantage of well‑aligned cleft segments. The approximated lip and alveolus allow the surgeon to perform surgery with less scar tissue formation and also gingivoperiosplasty can also be performed. With the NAM therapy, the reshaped alar cartilages of nose and stretched nasal mucosa increase the chances of surgeons’ ability to achieve good surgical results.

Following successful NAM therapy with better aligned alveolar segments, the deciduous and permanent teeth have high chances of eruption in the proper position with adequate periodontal support.[11] Studies have demonstrated that 60% of patients who had undergone NAM and gingivoperiosteoplasty did not require secondary bone grafting.[12]

Lee et al.[13] proved that in cleft lip and palate patient, the midfacial growth is not impaired after successful NAM therapy. NAM therapy can be routinely taken up at any clinic, it does not require special equipment and materials. Only operator skill is required and also the parent’s compliance is very important. In our case report, after 4 months of NAM treatment, the cleft gaps reduced with improvement in nasal anatomy, and after lip surgery, there was minimal scar formation with less surgical revisions. Post 6 months follow‑up after lip surgery, there were no wide scars with vermillion match, good mucosal contour, and no shortened lip segments. This is one of the important case report in which we have successfully completed NAM therapy in unilateral cleft lip and palate infant and also followed the case for 1 year after lip surgery which resulted in better surgical outcome in terms of function and esthetics.

conclusIon

In conclusion, we suggest that presurgical NAM therapy is an important treatment modality in cleft lip and palate patient, indicated below 4 months of age, this treatment modality improves esthetics, decreases cleft deformities, and prepares the patients for less surgical procedures with better results.

Declaration of patient consentThe authors authenticate that we have obtained appropriate patient parent consent form for publishing child’s images and other clinical information in the journal. The parents understood that child’s name and parents’ name will not be

Figure 5: (a) PRE‑NAM 3 weeks old baby and POST‑NAM 4 months old baby. At 4 months after NAM the cleft lip gap reduced and left side nasal anatomy improved. (b) Patient after successful lip surgery at 4 months succeeding NAM therapy showing good lip anatomy with least surgical scar (c) 6 months follow up after lip surgery showing improved esthetics without any scar

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b c

Kumar, et al.: Presurgical nasoalveolar molding therapy in cleft lip palate

Journal of Natural Science, Biology and Medicine ¦ Volume 12 ¦ Issue 2 ¦ July-December 2021 267

published and all steps will be undertaken to conceal their identity, but anonymity cannot be guaranteed.

AcknowledgmentDuring the cleft palate impression procedure at NICU, we acknowledge the assistance and cooperation provided by the staff and postgraduates of Department of Pediatrics, Navodaya Medical College and Hospital, Raichur, India

Financial support and sponsorshipNil.

Conflicts of interestThere are no conflicts of interest.

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12. Santiago PE, Grayson BH, Cutting CB, Gianoutsos MP, Brecht LE, Kwon SM. Reduced need for alveolar bone grafting by presurgical orthopedics and primary gingivoperiosteoplasty. Cleft Palate Craniofac J 1998;35:77‑80.

13. Lee CT, Grayson BH, Cutting CB, Brecht LE, Lin WY. Prepubertal midface growth in unilateral cleft lip and palate following alveolar molding and gingivoperiosteoplasty. Cleft Palate Craniofac J 2004;41:375‑80.