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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 69-72

Presurgical intervention of bilateral cleft lip and palate using nasoalveolar molding with a microfiber head cap

1 Department of Dentistry, King Abdulaziz Medical City; King Abdullah Specialized Children's Hospital, Ministry of National Guard - Health Affairs; King Saud Bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
2 Teaching Assistant in Restorative Dental Sciences, King Saud University, Riyadh, Saudi Arabia
3 General Dentistry, Ministry of Health, Riyadh, Saudi Arabia

Date of Submission17-Aug-2020
Date of Acceptance06-Oct-2020
Date of Web Publication13-Jan-2021

Correspondence Address:
Dr. Najla S Alrejaye
King Abdulaziz Medical City-Riyadh, National Guard Health Affairs P.O. Box 22490 , Riyadh 11426
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_26_20

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Nasoalveolar molding (NAM) was introduced by Grayson et al. in 1993. NAM helps with reshaping of the maxillary arch deformity and nose before surgical lip repair. NAM involves lengthy and extensive use of taping and skin barriers to the infant's cheeks, which usually causes skin irritation and discomfort. This is a case report describing NAM, for an infant with bilateral cleft lip and palate and severely malpositioned premaxilla. In this case, a special head cap with straps was used to secure the NAM appliance instead of the conventional taping. After NAM, there was a significant improvement in the cleft deformity. The parents were very satisfied about the result and felt much more comfortable using the head cap with the special straps compared to the conventional taping because it reduced cheek irritation and was much easier to use.

Keywords: Cleft lip and palate, head cap, NAM, nasoalveolar molding, taping

How to cite this article:
Alrejaye NS, Alharbi MH, Alqahtani HM, Alharbi MS. Presurgical intervention of bilateral cleft lip and palate using nasoalveolar molding with a microfiber head cap. J Cleft Lip Palate Craniofac Anomal 2021;8:69-72

How to cite this URL:
Alrejaye NS, Alharbi MH, Alqahtani HM, Alharbi MS. Presurgical intervention of bilateral cleft lip and palate using nasoalveolar molding with a microfiber head cap. J Cleft Lip Palate Craniofac Anomal [serial online] 2021 [cited 2021 Apr 11];8:69-72. Available from: https://www.jclpca.org/text.asp?2021/8/1/69/306770

  Introduction Top

Increased cleft width and nasolabial deformity in infants with cleft lip and palate may make surgical procedures challenging to get more successful cosmetic repair. Presurgical orthopedics was developed to ease these challenges.[1] Introduction of such procedures can be traced back to the 17th century where an extra-oral anchorage was utilized to retract the premaxilla using a head cap with arms extended to the face.[2] This technique was modified later to an elastic strap placed over the prolabium and attached to a head bonnet.[3] A variety of techniques have been developed since then for alveolar molding before surgical repair.[4],[5] In 1993, Grayson et al. introduced nasoalveolar molding (NAM).[6] The idea of this technique is integrating molding of the nose to molding of the lip and alveolus in infants with cleft lip and palate.[7]

NAM procedure requires significant parent's cooperation and involves lengthy and extensive use of taping and skin barriers to the infant's cheeks, which usually causes skin irritation and nuisance to the infant and the parents. This is a case report describing NAM, for an infant with bilateral cleft lip and palate (BCLP) and severely malpositioned premaxilla, with the use of a special commercially available head cap and straps to secure the NAM appliance instead of conventional taping.

  Case Report Top

A 25-day-old male infant with BCLP was referred to the orthodontic clinic at King Abdulaziz Medical City in Riyadh, Saudi Arabia, to initiate NAM prior to lip repair surgery. Upon examination, it was noticed that the premaxilla was severely protruded, rotated counterclockwise, and deviated to the left [Figure 1].
Figure 1: Frontal photograph of the patient taken before starting unilateral taping (patient's age = 1 month and 2 days)

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Taping with a surgical strip was initiated unilaterally for 11 days [Figure 2]. The basic steps of NAM were performed following Grayson's method.[1] The molding plate was delivered and secured initially using the conventional tape-elastic system; surgical strips were secured bilaterally to the retention buttons using an orthodontic intraoral elastic at one end and adhered to a skin barrier on the cheek at the other end. During the follow-up visit, the mother reported that she started to use a special head cap with straps that is originally used to hold neonatal ventilatory mask (Dräger, Lübeck, Germany), which was in fact a suggestion by a neonatal respiratory therapist. The special ready-made straps were used bilaterally and held to the NAM buttons using intra-oral elastics at one end and self-attached to the head cap at the other end instead of the cheeks [Figure 3].
Figure 2: Frontal photograph of the patient demonstrating unilateral taping. Three separate pieces of a folded surgical tape were connected by two heavy intraoral orthodontic elastics and wrapped around the premaxilla to pull it gently toward the right side by attaching the tape to the right cheek only (patient's age = 1 month and 16 days)

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Figure 3: (a) Frontal photograph taken 3 weeks after initiation of the alveolar molding part of nasoalveolar molding, showing the microfiber head cap with easy-to-use straps to hold the molding plate and deliver forces needed for premaxilla retraction (patient age = 2 months and 9 days). (b) Frontal photograph taken 4 weeks after the initiation of alveolar molding, showing significant improvement in the premaxillary position (patient's age = 2 months and 17 days)

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After 5 weeks of alveolar plate delivery and adjustment, a nasal stent was integrated [Figure 4]. After 6½ weeks of nasal stent integration, the patient had the lip repair surgery [Figure 5].
Figure 4: Frontal (a) and side views (b) of the patient with the nasoalveolar molding appliance taken 3 weeks after nasal stent integration. (c) Frontal view of the patient without the appliance. (d) Nasoalveolar molding appliance with the easy-to-connect nonsticky straps (patient's age = 3 months and 13 days)

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Figure 5: a) Frontal and b) basal photographs of the patient taken 6 weeks after the surgical lip repair (patient's age = 5 months and 24 days)

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  Discussion Top

This is a case report that discusses NAM as a presurgical intervention for a 25-day-old male infant with BCLP. Unilateral taping was needed initially, and that was actually a simple and effective technique to partially correct the premaxilla deviation and make room for the left retention button, thus allowing proper appliance insertion. In this case, a microfiber head cap with special straps was used mainly during NAM instead of the conventional taping to the cheeks with the regular tape-elastic system. The head cap and straps are commercially available and originally made to secure and retain breathing masks for infants with respiratory problems. They were more user friendly for the mother and helped in the reduction of cheek irritation. Attaching the straps to the head cap was more convenient compared to conventional taping to the cheeks. In addition, engaging the intra-oral elastics into the straps was much easier than that of the conventional strips. The straps attach using mechanical retention, instead of using chemical adhesive, similar to the mechanism used in sew-on Velcro® tapes. The middle two-thirds of the strap that would run over the cheeks contain a side with the loop part and have a smooth nonirritating texture on both sides, however the ends of each strap have a side with the hook part needed for mechanical retention. One end of the strap was passed through an intraoral elastic and folded over it to secure it, which was much easier than folding a sticky tape through a stretched heavy elastic. The other end was just placed over the head cap, which self-attaches with mechanical retention as mentioned earlier [Figure 4]. Moreover, the cap and the straps are hygienic and can last for weeks. The head caps are flexible and are available in seven sizes. The material used to fabricate the head caps is breathable, is stretchy, is of microfiber fabric, and is comfortable to infants. The mother started to use this head cap with straps as suggested by a relative and continued to use it throughout the whole procedure. The mother reported that it was much less nuisance to use and more comfortable for the patient with less cheek irritation. Choosing the proper size of head cap is important to provide enough retention without causing discomfort. The mother reported that she had to upgrade the head cap size once during the 3 months of NAM, which can be explained by growth. The retention provided by the straps was adequate during NAM. The direction and the amount of forces were easy to control by changing the strap orientation and amount of pulling as the straps easily self-attach to any part of the head cap.

The overall result, after about 3 months of NAM although it was started relatively late, showed a significant improvement in the premaxilla position, reduction of the cleft size, and significant improvement in the shape of nostrils [Figure 6].
Figure 6: Comparison between the casts taken before nasoalveolar molding (a) and after (nasoalveolar molding)-before surgical lip repair (b), showing how the premaxilla was centered and retracted significantly with improved alveolar segments' alignments before the lip surgery (patient's age = 1 month and 2 days at the initial cast versus 4 months and 6 days at the final cast)

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  Conclusion Top

Commercially available head caps with straps that are specially made for infants are helpful and are found to make NAM procedure less nuisance to the parents and the patient compared to conventional taping to the cheeks. In addition, the NAM had a clinically significant impact on this BCLP case even though it was initiated relatively late.

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.


Special thanks to Dr. Snehlata Oberoi, Professor in Craniofacial Orthodontics at University of California, San Francisco, for her advice especially for recommending the unilateral taping.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of the lip, alveolus, and palate. Clin Plast Surg 2004;31:149-58.  Back to cited text no. 1
Millard DR. Cleft Craft: The Evolution of its Surgery. II. Bilateral and Rare Deformities. 2nd ed.. Boston: Little Brown and Company; 1977.  Back to cited text no. 2
Berkowitz S. A comparison of treatment results in complete bilateral cleft lip and palate using a conservative approach versus Millard-Latham PSOT procedure. Semin Orthod 1996;2:169-84.  Back to cited text no. 3
McNEIL CK. Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec (London) 1950;70:126-32.  Back to cited text no. 4
Georgiade NG, Latham RA. Maxillary arch alignment in the bilateral cleft lip and palate infant, using pinned coaxial screw appliance. Plast Reconstr Surg 1975;56:52-60.  Back to cited text no. 5
Grayson BH, Cutting C, Wood R. Preoperative columella lengthening in bilateral cleft lip and palate. Plast Reconstr Surg 1993;92:1422-3.  Back to cited text no. 6
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. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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