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| CASE REPORT |
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| Year : 2023 | Volume
: 10
| Issue : 1 | Page : 40-44 |
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A novel modification of nasoalveolar molding procedure to enhance ease of use
Gaurav Pratap Singh, Gaurav Vohra
Department of Orthodontics and Dentofacial Orthopedics, Military Dental Centre, Gwalior, Madhya Pradesh, India
| Date of Submission | 30-Sep-2022 |
| Date of Acceptance | 15-Nov-2022 |
| Date of Web Publication | 14-Mar-2023 |
Correspondence Address:
Dr. Gaurav Pratap Singh
Department of Orthodontics and Dentofacial Orthopedics, Military Dental Centre, Gwalior, Madhya Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jclpca.jclpca_22_22
Cleft lip and palate (CLP) is one of the most common craniofacial birth defects. Its incidence varies according to race, sex and region. As ubiquitous as the condition may be, when it comes to clinical presentation, CLP manifests in a myriad of forms and varieties. The most common clinical presentation is that of a unilateral cleft lip and palate (UCLP). Management of CLP is a challenging proposition but in recent times, the results have become better owing to standardization of treatment protocol and the availability of multidisciplinary teams at specialized cleft centers worldwide. Management of CLP is initiated right from birth with parental counselling followed by presurgical infant orthopedics (PSIO). Nasoalveolar moulding (NAM) is on of the most widely accepted modalities of PSIO and is used to achieve alignment of the cleft alveolar segments into a more ideal relationship prior to the primary lip repair surgery. In its bare essence, NAM uses an acrylic molding plate with selective addition and removal of soft liner to mould the segments into a more ideal position. The molding plate is held in place with elastics which are retained by the use of adherent tapes on the cheek. The use of these tapes on a young infant often leads to tissue irritation and results in reduced compliance and treatment effect. Herein this case report we aim to highlight a novel approach of retaining the molding plate which dispenses with the need of adherent tapes. This technique has the benefit of no tissue irritation, easier application and improved compliance.
Keywords: Cleft lip and palate, nasoalveolar molding, orthodontics, presurgical infant orthopedics
How to cite this article:
Singh GP, Vohra G. A novel modification of nasoalveolar molding procedure to enhance ease of use. J Cleft Lip Palate Craniofac Anomal 2023;10:40-4 |
How to cite this URL:
Singh GP, Vohra G. A novel modification of nasoalveolar molding procedure to enhance ease of use. J Cleft Lip Palate Craniofac Anomal [serial online] 2023 [cited 2023 Mar 30];10:40-4. Available from: https://www.jclpca.org/text.asp?2023/10/1/40/371642 |
| Introduction | |  |
Cleft lip and palate (CLP) is one of the most common congenital birth defects that affects approximately 1 in 700 births worldwide. The numbers vary for sex and region and show wide geographical and racial variation.[1]
The management of CLP is unlike any other condition as it necessitates repeated and timely interventions by a specialized team throughout the growth period of the individual. The treatment aspect starts soon after birth and continues till the cessation of growth which brings the patient into young adulthood. The team of health-care providers for the CLP patient incorporates many specialists including ENT specialists, geneticists, plastic and reconstructive surgeons, pediatricians, speech pathologists, oral and maxillofacial surgeons, and orthodontists among others. The orthodontist in the team is well placed to act as a coordinator as his/her interventions are interspersed throughout the growth period of the patient.
Orthodontic management of the case of CLP starts with presurgical infant orthopedics (PSIO). The basic goal of all forms of infant orthopedics remains to align the cleft segments into a correct anatomical position, i.e., where they would lie had the cleft not been there. This facilitates lip repair surgery. Nasoalveolar molding (NAM) protocol also helps in the reduction of nasal soft-tissue deformity before the lip and palate reconstruction. This allegedly reduces/obviates the need for secondary revision rhinoplasty surgical procedures.[2]
The most common problem associated with NAM therapy is irritation to oral mucosa, gingival tissue, and cheeks.[3] Extreme care has to be taken while removing the cheek tapes to avoid irritation to the skin. Infant skin is delicate and in our experience, even with the utmost care, repeated removal and fixation of cheek tapes is associated with irritation, erythema, and on rare occasions, allergic rashes. This frequently leads to noncompliance with therapy as parents are hesitant to see the infant go through the perceived trauma of tape removal on a regular basis.
This case report is about a 10-day-old girl with unilateral CLP who was referred to our dental center for the fabrication of a feeding plate. After the initial examination, we decided to proceed with the NAM protocol for the patient. To avoid frequent cheek irritation, we devised a novel technique for the retention of the molding plate using fabric elastic bands from an N95 mask. This technique made it much easier to remove and replace the molding plate and also avoided tissue irritation leading to improved compliance and predictable treatment results.
| Case Report | | |
A 10-day-old girl child was referred to us from the pediatric facility of the collocated hospital. The child was diagnosed case of unilateral CLP of the right side [Figure 1]. The initial medical examination did not reveal the presence of any other associated symptoms hence ruling out a syndrome. The parents were healthy and of nonconsanguineous marriage. There was no relevant family history of CLP in the immediate family. The child appeared healthy and free of any infirmity. | Figure 1: Pretreatment photograph showing the presence of unilateral cleft lip and palate
Click here to view |
We consulted with the pediatrician and plastic and reconstructive surgeon to establish a tentative timeline of treatment for the patient and communicated the same to the parents. Then, we started with the NAM protocol for the patient according to the technique promulgated by Grayson.[4]
Initial impression of the child was taken with heavy-bodied silicone impression material (Dentsply) [Figure 2]. The impression was obtained in the hospital setting with the pediatrician and anesthetist in attendance to handle any unforeseen airway emergency. The impression was then removed and poured with dental stone to obtain an accurate cast.
Before the fabrication of the molding plate, the cast was blocked off for all undercuts and the integrity of the cleft region was restored with wax to obtain a contiguous zone for the alignment of the cleft segments [Figure 3]. Then, the plate was fabricated with clear self-cure acrylic with a thickness of approximately 2–3 mm. The retention button was fabricated and positioned centrally in the cleft region and at an angle of 40° to the molding plate. A small opening measuring about 5 mm in diameter was created in the palatal region of the molding plate to provide an airway if the plate drops down posteriorly. Then, the plate was finished and polished to remove any sharp points or areas of irritation [Figure 4]. Finally, before the insertion, the plate was kept in water for 24 h to allow for the leaching of any residual monomer. | Figure 3: Cast poured with dental stone and prepared for fabrication of molding plate
Click here to view |
For insertion, skin barrier tapes were applied on the cheek, and on top of them, the surgical tape was applied. The end of the surgical tape was looped, and an orthodontic elastic (Koden, internal diameter 0.25 inch) was secured to this end. The elastic was stretched to approximately twice its resting diameter and looped over the retention button to help secure the molding plate in the infant's mouth. The force approximated 100 g. The parents were instructed on the insertion and removal of the plate and were recalled the following day for review.
The next day we found that the patient was not wearing the plate and presented with tissue irritation and erythema bilaterally on the cheeks. The pediatrician recommended to avoid the use of skin barrier tapes or any adherent tapes for a few days. This posed a problem as with the NAM protocol, time is of vital importance. The earlier the regime is started, the better are the results.
We went back to the drawing board and came up with a novel idea to secure the molding plate without the use of any adherent tapes. We removed the fabric elastic loops off of an N95 mask and tied them to each other to create a rudimentary head strap. Then, at both ends of the straps, we looped a surgical tape with an orthodontic elastic. The presence of an adjuster allowed us to change the diameter of the head strap so as to allow for a snug fit [Figure 5]. | Figure 5: Stepwise fabrication of the adjustable head strap from an N95 mask:- (a) Start with an N-95 mask with adjustable loops, (b) Remove the loops from the N-95 mask, (c) Tie the two ends of the loop together as shown above, (d) Use the adjuster to customise the size according to the head dimensions. Then apply the tape for attachment of the orthodontic elastics
Click here to view |
The patient was recalled the following day, and the appliance was inserted with the modified head strap [Figure 6]. The parents were very receptive to the new method as it made the removal and insertion of the plate much easier. After 1 week, we started with the selective removal of acrylic and the addition of soft liner I the molding plate so as to move the cleft segments into their desired positions. The weekly modification continued for the next 6 weeks and we were able to reduce the cleft gap from an initial 18 mm to approximately 5 mm [Figure 7] and [Figure 8]. Unfortunately, at the time of insertion of the nasal stent, the child contracted a prolonged upper respiratory tract infection which precluded the continuation of therapy. Retention of results was achieved using lip taping [Figure 9], and the patient underwent definitive lip repair at 3 months of age [Figure 10].
| Discussion | | |
The present era of PSIO treatment for CLP cases owes its beginnings to McNeil, a prosthodontist, who used a series of acrylic plates to bring the cleft segments together.[5] Most of the subsequent developments were active or passive techniques all developed with the main purpose of bringing the cleft segments into a more ideal relationship. The proponents of PSIO proposed many benefits to the therapy in addition to the alignment of cleft segments. These include a more normalized pattern of deglutition, improvement of arch form and position of alar base, facilitation of feeding, better speech development, better nasal respiration, less need of complex orthodontic treatment at a later date, and a positive psychological effect on parents.[6] Conversely, the naysayers held the increased cost of therapy, restriction in maxillary growth, and burden of compliance against the regime.[7]
A prospective randomized clinical trial to investigate the effects of PSIO in children with UCLP was begun in 1993. The results showed that PSIO has a negligible positive effect on feeding, parents' satisfaction, or future orthodontic need. A positive but limited effect was observed in the speech which regardless remained far behind the noncleft peers. The trial also stressed upon the need for higher quality research in the future with standardized protocols of intervention.[8],[9],[10],[11]
Nevertheless, the molding of the segments achieved by these appliances does make definitive lip repair easier for the surgeon.[12]
With this background, we come to the advent of presurgical NAM proposed by Grayson.[4] The principal objective of NAM remains to reduce the severity of the initial cleft deformity so as to facilitate lip repair surgery. In addition, NAM proposes to address the nasal cartilage deformity with the use of a nasal stent to reshape the nasal cartilage, lengthen the columella, and achieve projection of the flattened nasal tip. This correction of the nasal cartilage is predicated upon the work done by Matsuo in 1984 to correct auricular deformities. According to Matsuo, there are elevated levels of maternal estrogen in the infant's bloodstream which increases the plasticity of cartilage and allows us to modify its shape with positive long-term effects.[13] This same principle is applied to nasal cartilage which too can be amenable to correction in CLP patients.
Although data from long-term prospective trials are lacking, retrospective studies on the NAM protocol have demonstrated improved nasolabial esthetics and fewer revision surgeries as compared to non-NAM-treated patients.[14],[15]
The most common complication associated with the NAM protocol is irritation of the oral mucosa and gingival tissue. The most common area of tissue irritation is the cheeks. It is advised to wet the tape before removal and also periodic application of aloe vera gel to ameliorate the symptoms of tissue irritation.[4] However, in spite of these measures, tissue irritation is a significant deterrent for compliance by the parents.
To mitigate the above disadvantage, we fabricated a custom-based looped headwear for the anchorage of the molding plate. This modification of the technique led to several benefits which are enumerated below:
- Ease of use. It is easy to remove and reapply the molding plate without the additional hassle of sticking and removing tapes
- This reduces the initial difficulty barrier for the parents and results in improved compliance
- The presence of adjustable loops allows to titrate the force applied by the elastics
- No tissue irritation.
Objective analysis of the true potential of this modification will require a prospective study comparing the modified technique with the original in terms of compliance and parent acceptance. In this case report, we found the benefits to be highly significant; enough to warrant a change in our own treatment protocol.
A trial comparing the caregiver's response to both techniques will give us a more objective insight into the compliance and also delve deeper into the comparative efficacy of this modification as well as report on side effects if any.
| Conclusion | | |
In this case, we report on a modification to the NAM procedure. By doing away with the use of surgical tapes and replacing them with customized loop-based headgear, we circumvent the biggest drawback of NAM, that is tissue irritation of the cheeks. This in turn led to improved compliance from the parents and helped us to achieve the desired results. Incorporating this modification into our regular treatment protocol will enable us to get a better insight into its advantages vis-à-vis the original technique.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the father has given her consent for images and other clinical information to be reported in the journal. The father understands that names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Graber LW, Vanarsdall RL, Vig KW, Huang GJ, editors. Orthodontics: Current Principles and Techniques. 6 th ed. Philadelphia, PA: Elsevier/Mosby; 2017. p. 343.  |
| 2. | Maull DJ, Grayson BH, Cutting CB, Brecht LL, Bookstein FL, Khorrambadi D, et al. Long-term effects of nasoalveolar molding on three-dimensional nasal shape in unilateral clefts. Cleft Palate Craniofac J 1999;36:391-7. |
| 3. | Grayson BH, Shetye PR. Presurgical nasoalveolar moulding treatment in cleft lip and palate patients. Indian J Plast Surg 2009;42:S56-61. [ PUBMED] [Full text] |
| 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. |
| 5. | Mcneil CK. Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec (London) 1950;70:126-32. |
| 6. | Prahl C, Kuijpers-Jagtman AM, van't Hof MA, Prahl-Andersen B. A randomised prospective clinical trial into the effect of infant orthopaedics on maxillary arch dimensions in unilateral cleft lip and palate (Dutchcleft). Eur J Oral Sci 2001;109:297-305. |
| 7. | Pruzansky S. Pre-surgical orthopedics and bone grafting for infants with cleft lip and palate: A dissent. Cleft Palate J 1964;1:164-86. |
| 8. | Prahl C, Kuijpers-Jagtman AM, Van 't Hof MA, Prahl-Andersen B. Infant orthopedics in UCLP: Effect on feeding, weight, and length: A randomized clinical trial (Dutchcleft). Cleft Palate Craniofac J 2005;42:171-7. |
| 9. | Konst EM, Prahl C, Weersink-Braks H, De Boo T, Prahl-Andersen B, Kuijpers-Jagtman AM, et al. Cost-effectiveness of infant orthopedic treatment regarding speech in patients with complete unilateral cleft lip and palate: A randomized three-center trial in the Netherlands (Dutchcleft). Cleft Palate Craniofac J 2004;41:71-7. |
| 10. | Bongaarts CA, van 't Hof MA, Prahl-Andersen B, Dirks IV, Kuijpers-Jagtman AM. Infant orthopedics has no effect on maxillary arch dimensions in the deciduous dentition of children with complete unilateral cleft lip and palate (Dutchcleft). Cleft Palate Craniofac J 2006;43:665-72. |
| 11. | Bongaarts CA, Kuijpers-Jagtman AM, van 't Hof MA, Prahl-Andersen B. The effect of infant orthopedics on the occlusion of the deciduous dentition in children with complete unilateral cleft lip and palate (Dutchcleft). Cleft Palate Craniofac J 2004;41:633-41. |
| 12. | Vig KW, Turvey TA. Orthodontic-surgical interaction in the management of cleft lip and palate. Clin Plast Surg 1985;12:735-48. |
| 13. | Matsuo K, Hirose T, Tomono T, Iwasawa M, Katohda S, Takahashi N, et al. Nonsurgical correction of congenital auricular deformities in the early neonate: A preliminary report. Plast Reconstr Surg 1984;73:38-51. |
| 14. | Nayak T, Bonanthaya K, Parmar R, Shetty PN. Long-term comparison of the aesthetic outcomes between nasoalveolar molding and non-nasoalveolar molding-treated patients with unilateral cleft lip and palate. Plast Reconstr Surg 2021;148:775e-784e. |
| 15. | Yarholar LM, Shen C, Wangsrimongkol B, Cutting CB, Grayson BH, Staffenberg DA, et al. The nasoalveolar molding cleft protocol: Long-term treatment outcomes from birth to facial maturity. Plast Reconstr Surg 2021;147:787e-794e. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
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