The progressive changes of nasal symmetry and growth after nasoalveolar molding: a three-year follow-up study

Effective retropulsion and centralization of the severely malpositioned premaxilla in patients with bilateral cleft lip and palate: a novel modified presurgical nasoalveolar molding device with retraction screw

PURPOSE

A novel, modified presurgical nasoalveolar molding (MPNAM) device with retraction screw was designed and used in patients with bilateral complete cleft lip and palate (BCCLP) to rapidly retract and centralize the protuberant and malpositioned premaxilla and correct the nasolabial and palatal deformities. The orthopedic effects and possible complications were evaluated.

PATIENTS AND METHODS

Nine patients with BCCLP who met the inclusion criteria were selected. After the maxillary model was obtained, the new MPNAM device with retraction screw was designed and worn until cheilorrhaphy. Changes in local deformities and complications were observed continuously, and the orthopedic effect was evaluated.

RESULTS

All patients quickly adapted to the MPNAM appliance, and the treatment was finished after 5-8 return visits. The columella was significantly prolonged, the nasal tip was elevated, and the collapsed nasal dome was obviously improved. Simultaneously, the premaxilla was rapidly retracted and rotated, and gradually centralized; the clefts were gradually reduced and closed, and a nearly normal dental arch was formed. Although there were some complications, the orthopedic treatment was continued until cheiloplasty.

CONCLUSIONS

The MPNAM device with retraction screw can simultaneously correct nasolabial and palatal deformities and also rapidly retract and centralize the premaxilla.

O que ocorre com o ângulo columelar após cirurgia de correção da fissura labial?

Objetivo avaliar a mudança do ângulo columelar que ocorre após cirurgia de correção para fissura labial. Métodos o estudo foi observacional de caráter descritivo e de corte transversal. Foram avaliadas crianças no primeiro e segundo ano de vida, portadoras de fissura labial unilateral de ambos os sexos, que foram submetidas a cirurgia para correção da fissura. A pesquisa teve um total de 11 crianças participantes. Foi examinada a região nasal e lábio superior da criança e identificados os pontos antropométricos pronasal, subnasal e glabela. Em seguida, foi realizada fotografia para análise fotogramétrica. Foram realizadas fotos no preoperatório e cerca de 4 meses após a cirurgia. As imagens obtidas por fotogrametria foram avaliadas com o programa gráfico Image J,por meio de ferramentas de estudo angular. Resultados a média da medida dos ângulos no pré-operatório foi de 55,41 graus; a média no pós foi de 78,80 graus, percebendo-se uma aproximação ao plano vertical (p<0,0001). Pacientes com fissura lábio-palatina apresentaram variação de 32 graus quando comparadas as medidas pré e pós-operatórias, enquanto que nos pacientes com fissura pré-foramen incompleta e pré-foramen completa foram menores (0,75 e 25 graus respectivamente). Conclusão ocorre verticalização do ângulo columelar após cirurgia de correção da fissura labial. Os pacientes que apresentam maior modificação do ângulo são, justamente, aquelas que apresentam diagnóstico relacionado a deformidades mais complexas.

Evidence-based medicine: The cleft lip nasal deformity

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Describe the components of unilateral and bilateral secondary cleft lip nasal deformity. (2) Discuss current methods of assessing the deformity and outcomes. (3) Discuss primary treatment options including the use of preoperative orthopedics, nasal molding techniques, and the primary cleft rhinoplasty. (4) Design a treatment plan for cleft patients that will optimize the outcome of nasal appearance and function. (5) Discuss the evidence regarding outcomes of current practices, and describe areas where more research is needed.

SUMMARY

This is the third Maintenance of Certification article on the secondary cleft lip nose deformity. In the first article, Guyuron defined the deformities and described techniques for the definitive (adult) rhinoplasty. The second article, by Zbar and Canady, presented evidence regarding the assessment, surgical treatment, and outcomes from the literature published between 1999 and 2009. In this article, the authors summarize important points from the first two articles and then concentrate on the evidence for the following topics: (1) methods currently used in evaluating the severity of the deformities; (2) methods used in evaluating outcomes of different treatments; (3) benefits of rhinoplasty performed at the time of the lip repair and evidence for the effect of rhinoplasties performed after infancy but before maturity; (4) presurgical orthopedics and nasoalveolar molding; (5) common surgical techniques used in primary cleft rhinoplasties; and (6) impact of the nasal deformity on quality of life. Overall, there is little high-level evidence regarding the outcomes of cleft nasal deformity treatment, leaving much room for future study.

Pre-surgical Alveolar Molding in A Newborn Patient with Complete Unilateral Cleft Lip and Palate-A Report

Clefts of the lip, alveolus and palate (CLAP) are the most common congenital malformations seen in the head and neck region. Children with CLAP face a vast variety of problems like feeding difficulties, hearing loss (ear infections), missing or malformed teeth and speech defects, along with psychosocial stigma which influences the social development and rehabilitation of such patients. Management of CLAP has been recognized as a unique challenge for parents as well as medical team. Pre-surgical alveolar molding has shown promising results in solving the problems which are associated with CLAP, to a great extent. We are reporting a case of a newborn patient with complete unilateral cleft lip and palate, who had inability in suckling and nasal regurgitation of oral fluids since birth, which were aided by providing a Pre-surgical alveolar molding to facilitate feeding and also to improve future facial appearance. This article highlights the effectiveness of alveolar molding appliance which was used to direct growth of the alveolar ridges and lips in the pre surgical treatment of cleft lip and palate. As a result of this appliance, the primary surgical repair of the nose and lip which was done, healed under minimal tension, thereby reducing scar formation and improving the aesthetic results.

Presurgical orthopedic treatment ameliorates postoperative nasal deformity after cheiloplasty

We assessed the postoperative nasal form and symmetry after presurgical use of a Hotz plate (HP) in patients with unilateral complete cleft lip and palate (UCLP). The subjects were 28 infants with UCLP who underwent cheiloplasty. Of these subjects, 14 underwent presurgical orthopedic treatment using the HP (HP group) and 14 underwent the same treatment without the HP (non-HP group). Photographic records were obtained 1 and 6 months after cheiloplasty, and the results of anthropometric analysis were compared between the 2 groups. The nasal inclination and the ratio of the width of the nasal base to the total width of the nose were significantly improved in the HP group compared with the non-HP group at both postoperative time points. Thus, presurgical use of the HP significantly improved the nasal asymmetry and deformity in UCLP patients after primary cheiloplasty and nasal repair.

Primary repair of cleft lip and nasal deformity

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the relevant anatomy and embryology that contribute to the cleft lip and nasal deformity. 2. Differentiate among the various forms of cleft lip, including microform, minor form, incomplete, complete, and bilateral. 3. List the options for presurgical infant orthopedics. 4. Describe the techniques and the expected outcomes of primary cleft lip and nasal repair.

SUMMARY

The authors describe cleft lip and its surgical management. They address the anatomy, forms, techniques, and outcomes of this complex and challenging deformity.

Nostril Morphometry Evaluation before and after Cleft Lip Surgical Correction: Clinical Evidence

Introduction The purpose to this work is to review systematically the morphological changes of the nostrils of patients undergoing surgery for correction of cleft lip and identify in the literature the issues involved in the evaluation of surgical results in this population.

Review of Literature A review was conducted, searching for clinical evidence from MEDLINE. The search occurred in January 2012. Selection criteria included original articles and research articles on individual subjects with cleft lip or cleft palate with unilateral nostril anthropometric measurements before and after surgical correction of cleft lip and measurements of soft tissues. There were 1,343 articles from the search descriptors and free terms. Of these, five articles were selected.

Discussion Most studies in this review evaluated children in Eastern countries, using different measurement techniques but with the aid of computers, and showed improved nostril asymmetry postoperatively compared with preoperatively.

Conclusion There is a reduction of the total nasal width postoperatively compared with preoperative measurements in patients with cleft lip.

Unilateral cleft lip: principles and practice of surgical management

Management of cleft lip and palate requires a unique understanding of the various dimensions of care to optimize outcomes of surgery. The breadth of treatment spans multiple disciplines and the length of treatment spans infancy to adulthood. Although the focus of reconstruction is on form and function, changes occur with growth and development. This review focuses on the surgical management of the primary cleft lip and nasal deformity. In addition to surgical treatment, the anatomy, clinical spectrum, preoperative care, and postoperative care are discussed. Principles of surgery are emphasized and controversies are highlighted.

Simplifying cleft surgery by presurgical nasoalveolar molding (PNAM) for infant born with unilateral cleft lip, alveolus, and palate: a clinical report

PATIENT

A 2-day-old female infant with complete unilateral cleft lip, alveolus, and palate (left side) was presented to the Department of Prosthodontics, Government Dental College and Hospital, Nagpur for evaluation and treatment with presurgical nasoalveolar molding (PNAM) prior to surgical intervention.

DISCUSSION

The alignment of the alveolar segments creates the foundation upon which excellent results of primary lip and nasal surgery are dependent in the repair of the cleft lip, alveolus, and palate patient. Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. One of the problems that the traditional approach failed to address was the deformity of the nasal cartilages and the deficiency of columella tissue in infants with unilateral and bilateral cleft lip and palate. The purpose of this article is to illustrate the step-by-step fabrication process of the PNAM prosthesis used to direct growth of the alveolar segments, lips, and nose in the presurgical treatment of cleft lip and palate.

CONCLUSION

As a result, the primary surgical repair of the lip and nose heals under minimal tension, thereby reducing scar formation and improving the esthetic result. Frequent surgical intervention to achieve the desired esthetic results can be avoided by PNAM.

Nasoalveolar moulding for children with unilateral cleft lip and palate

INTRODUCTION

Cleft lip and palate represents the most frequently occurring congenital deformity second only to club foot deformity in our country. Wide alveolar clefts if not preceded by pre surgical orthodontic adjuncts like nasoalveolar moulding, may affect the final outcome of the primary surgery. Presurgical nasoalveolar moulding is to align and approximate the alveolar cleft segments while at the same time achieving correction of the nasal cartilage and soft tissue deformity.

MATERIALS AND METHODS

The device we used is designed by Barry Grayson. It is simple to fabricate, causes less discomfort to the patient and optimum results are achieved in three months of time, compared to other complicated appliances like Latham's which are more invasive. A child of 3 months presented with a complaint of unilateral cleft deformity on one side of the face.

CONCLUSION

After three months of nasoalveolar moulding considerable changes were observed. The widths of the cleft alveolus were reduced and the nasal contours of columella on the cleft side showed considerable improvement.

Limited evidence for the effect of presurgical nasoalveolar molding in unilateral cleft on nasal symmetry: a call for unified research

BACKGROUND

In the past two decades, presurgical nasoalveolar molding has been applied increasingly in the care of patients with a cleft to improve nasal symmetry and facilitate closure of the lip and secondary rhinoplasty. Many cleft centers do not apply presurgical molding, because its effect is disputed. This review aims to quantify the effect of nasal symmetry in the long term.

METHODS

A systematic review of the literature with the intention of performing a meta-analysis was performed. The search terms "cleft" AND ("molding" OR "moulding") were used in three databases. Twelve studies met the following inclusion criteria: (1) participants were humans with nonsyndromic unilateral cleft; (2) data concerning the effect of nasoalveolar molding on symmetry of the nose are reported or can be deduced; (3) article was written in English, German, or Dutch.

RESULTS

The heterogeneity of the study designs, outcome variables, outcome variable expressions, follow-up periods, and inadequate data reporting made it impossible to calculate effect sizes and to perform a meta-analysis. All studies had a low Grading of Recommendations Assessment, Development and Evaluation level. Five studies reported exclusively positive effects on nasal symmetry, six studies reported mixed effects, and one study reported exclusively no effects.

CONCLUSIONS

Results of studies of nasoalveolar molding are inconsistent regarding changes in nasal symmetry; however, there is a trend toward a positive effect. Studies concerning nasoalveolar molding in unilateral cleft lip, jaw, and palate are heterogeneous and lack adequate reporting. Recommendations for future research were provided to construct a consensus about the effect of nasoalveolar molding.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparative outcomes of two nasoalveolar molding techniques for unilateral cleft nose deformity

BACKGROUND

Nasoalveolar molding is increasingly being used to treat unilateral cleft nose deformity before primary repair. The Grayson technique starts nasal molding when an alveolar gap is reduced to 5 mm, whereas the Figueroa technique performs nasal and alveolar molding at the same time. The authors investigated the comparative efficacy, efficiency, and incidence of complications of the two techniques.

METHODS

A blinded, retrospective study was conducted on 63 patients with complete unilateral cleft lip-cleft palate; 31 underwent the Grayson nasoalveolar molding and 32 underwent the Figueroa nasoalveolar molding. Pretreatment and posttreatment facial photographs and clinical charts were used to compare efficacy (nostril height ratio, nostril width ratio, columellar angle), efficiency (molding frequency), and incidence of complications (facial irritation, mucosal ulceration).

RESULTS

The Grayson and Figueroa techniques did not differ in treatment efficacy for nostril height ratio (0.86 ± 0.09 versus 0.85 ± 0.09; p > 0.05) and columellar angle (84.0 ± 4.5 degrees versus 85.3 ± 2.6 degrees; p > 0.05). Although the Grayson technique was more effective for reducing nostril width ratio (1.21 ± 0.29 versus 1.27 ± 0.19, p = 0.05), it was less efficient (i.e., required more adjustments) (10.9 ± 2.5 versus 8.8 ± 1.9; p < 0.001) and had a higher incidence of mucosal ulceration (23 percent versus 3 percent; p < 0.05).

CONCLUSIONS

The two nasoalveolar molding techniques differed in efficacy, efficiency, and incidence of complications in patients with complete unilateral cleft lip-cleft and palate. Understanding these differences may help surgeons and orthodontists improve outcome expectations and consultations with patients' families.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Scoring systems of cleft-related facial deformities: a review of literature

Objective :  There is a need for an internationally agreed objective method of assessing cleft-related deformities in order to compare the results of individual surgeons and different surgical techniques or to determine the optimal timing for primary lip closure. To assess the current methods, an overview of the recent developments in postoperative scoring systems of cleft-related deformities was made. Methods :  A Medline search from June 2003 through July 2011 was conducted, and references in the selected articles were checked. This search yielded 428 articles, and after application of the inclusion and exclusion criteria, 40 articles were included in this review. Results :  Twenty-five studies used two-dimensional (2D) photographs for the assessment of cleft-related deformities. Fourteen of these studies used a subjective method for the assessment and 11 performed anthropometric measurements. Good reliability has been found for subjective assessments and measurements from 2D photographs. Fifteen studies assessed three-dimensional (3D) imaging. Conclusions :  Although there is a wide variety in study design, 3D imaging seems most reliable in assessing cleft-related facial deformities. However, scoring on 2D photographs is easier to perform and more applicable in daily practice because all cleft patients are photographed through the course of their treatment.

Nasal outcomes of presurgical nasal molding in complete unilateral cleft lip and palate

Objective. Short-term nasal forms following primary lip repair were compared between presurgical nasal molding and control groups. Aim. To compare nasal symmetry between patients that had nasal molding and lip repair with those that had only lip repair. Design. Retrospective case-control study Patients. Complete unilateral CL+P patients had basilar and frontal photographs at two time points: (1) initial (2) postsurgical. 28 nasal molding patients and 14 control patients were included. Intervention. Presurgical nasal molding was performed prior to primary lip repair in intervention group. No nasal molding was performed in control group. Hypothesis. Nasal molding combined with lip surgery repair according to the Millard procedure provides superior nasal symmetry than surgery alone for nostril height-width ratios and alar groove ratios. Statistics. Shapiro-Wilk test of normality and Student's t-tests. Results. A statistically significant difference was found for postsurgical nostril height-width ratio (P < .05). No other statistically significant differences were found. Conclusions. Nasal molding and surgery resulted in more symmetrical nostril height-width ratios than surgery alone. Alar groove ratios were not statistically significantly different between groups perhaps because application of nasal molding was not early enough; postsurgical nasal splints were not utilized; overcorrection was not performed for nasal molding.

Assessment of nostril symmetry after primary cleft rhinoplasty in patients with complete unilateral cleft lip and palate

The aim of this study was to assess the nostril symmetry following primary cleft rhinoplasty done with either a dorsal onlay or columellar strut graft in patients with non-syndromic complete unilateral cleft lip and palate. In this retrospective study 30 consecutive patients treated with autogenous or alloplastic dorsal onlay grafts and 30 consecutive patients treated with autogenous or alloplastic columellar strut grafts for complete unilateral cleft nose reconstruction were analyzed for nasal symmetry. The autogenous grafts used were costo-chondral or septal cartilage and the alloplastic graft used was high density polyethylene (Medpore(®)). Assessment of the nostril symmetry was done using a two-dimensional nasal analysis 24-30 months postoperatively. Ratios between cleft and noncleft side nostril for three parameters were used to assess symmetry namely nostril width, nostril height and nostril gap area. None of the three parameters showed statistically significant changes. A satisfactory, though not statistically significant, difference in symmetrical outcome could be achieved in both the groups with the exception of nostril width symmetry in group treated with dorsal onlay graft.

Comparative study of nasoalveolar molding methods: nasal elevator plus DynaCleft® versus NAM-Grayson in patients with complete unilateral cleft lip and palate

Objective : To compare nasoalveolar molding (NAM) effect employing a nasal elevator plus DynaCleft® and NAM-Grayson system in patients with complete unilateral cleft lip and palate. Method : Prospective study in two groups. Group A included 20 consecutive patients treated with DynaCleft® and a nasal elevator before lip surgery. Group B included 20 patients treated with NAM-Grayson system. Maxillary casts and standard view photographs were done before and after treatment. Columella deviation angle, soft tissue distance of the cleft, intercommisural distance, and nostril height and width were traced and measured on the printed photos; a ratio was obtained and compared before and after treatment. Cleft width, anterior width, and anteroposterior distances were measured on the maxillary cast. Results : Group A began treatment at an average age of 14.3 days and group B at an average age of 16.9 days; no complications were observed. For group A, the initial average alveolar cleft within the cast was 10.7 mm, and after treatment it was 6.6 mm. For group B, pretreatment width was 11.2 mm, and after treatment it was 5.9 mm. No differences were found on the anterior and posterior width, and A-P distance of both groups. The initial mean columellar angle in group A was 38.1°, and after treatment it was 61.5°; for group B the initial mean columellar angle was 33.6°, and after treatment it was 59.5°. Results of Mann-Whitney U and Student's t tests showed no differences (P > .05). Width and height dimensions of the nostril showed minor differences. Conclusions : Both methods significantly reduced the cleft width and improved the nasal asymmetry. Our findings show that both methods produced similar results.

Digital anthropometric shape analysis of 110 rhinoplasty patients in the Black Sea Region in Turkey

PURPOSE

The aim of the study was to describe the average values of the nasal anthropometric measurements by using the landmark-based geometric morphometric technique in young male patients who applied for rhinoplasty in the Black Sea Region in Turkey.

MATERIALS AND METHODS

The study group consisted of 110 healthy male patients all were born in the Black Sea Region, Turkey. The landmark-based geometric morphometric technique was used to analyze the nasal shapes as described in the literature. The mean age was 29 years (ranging from 23 to 35). All patients underwent primary rhinoplasty in our clinic between 2006 and 2011 years. All data were obtained from standardized digital photographic images. Anterior and worm's eye view photos of the patients were analyzed by using standard anthropometric measurement methods.

RESULTS

The mean total length and nasal bridge length of the noses were 58.90 and 57.35 mm, respectively. The mean nasal bridge width and the morphologic nose width were 32.65 and 35.50mm, respectively. The average width of the anatomic nose was 26.25 mm. The mean length and width of the ala were 22.72 and 4.73 mm, respectively. The mean length and width of the columella were 11.35 and 5.20mm, respectively. The mean frontonasal angle was 137.88° and the mean nasolabial angle was 87.34°.

CONCLUSION

Black Sea nose was characterized by being considerably longer than average in nasal length and columellar height. Also nasolabial angle was found to be more acute than average when compared to other noses.

Presurgical nasoalveolar molding (PNAM) for a unilateral cleft lip and palate: a clinical report

Cleft lip and palate deformity is a congenital defect of the middle third of the face. Incidence varies from 1:500 to 1:2500 live births. Etiology depends upon hereditary and environmental factors. Restoration of these defects is important not only for functional and esthetic reasons, but also because there may be a positive psychological impact for the patient and parents. The goal of primary closure of the lip for unilateral cleft lip is to ensure a normal and symmetrical lip and nose. Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. Presurgical nasoalveolar molding (PNAM) represents a paradigm shift from the traditional methods of presurgical infant orthopedics. PNAM consists of active molding of the alveolar segments as well as the surrounding soft tissues. This clinical report describes a new approach of PNAM therapy for an infant with complete unilateral cleft lip and palate showing significant reduction in cleft defect size and improved contour and topography of deformed surrounding soft tissues.

Value of high-resolution ultrasound in the differential diagnosis of scaphocephaly and occipital plagiocephaly

Secondary to the increase in deformational plagiocephaly a growing number of infants with cranial deformity present to craniofacial teams. Computed tomography (CT) is diagnostic, but uses ionizing radiation. The purpose of this study was to evaluate ultrasound as a screening test for the patency of cranial sutures in scaphocephaly and occipital plagiocephaly. The cranial sutures of 54 infants with this cranial deformity were assessed by ultrasound. Sutures were read as patent or fused if a hypoechoic gap could or could not be demonstrated between the hyperechoic clavarial bones, respectively. Seven children suffered from true craniosynostosis of either the sagittal or the lambdoid suture. In five cases the ultrasound findings were diagnostic for a fused suture, in two cases the results were inconclusive. Forty-seven infants presented with deformational plagiocephaly. Ultrasound examination demonstrated patent sutures in 45 cases and was inconclusive in two cases. Sonography of the cranial sutures is a good screening tool to distinguish fused from patent cranial sutures in scaphocephaly and occipital plagiocephaly and avoids the radiation exposure associated with CT examinations.

Nasoalveolar molding and long-term postsurgical esthetics for unilateral cleft lip/palate: 5-year follow-up

The nasoalveolar molding (NAM) technique has been shown to significantly improve the surgical outcome of the primary repair in cleft lip and palate patients. A 6-day-old female infant was managed with the presurgical NAM technique. Periodic adjustments of the appliance were continued every week to mold the nasoalveolar complex into the desired shape for the next 5 months. The 13 mm of alveolar cleft width was reduced to 1.5 mm. The depressed nostril on the cleft side was molded into the normal anatomy. The nose and upper lip were surgically repaired at the age of 5 months. The second stage surgery of palatal closure was performed at the age of 18 months. The patient was followed up regularly at 6-month intervals for the next 5 years.

Primary correction of nasal deformity in unilateral incomplete cleft lip: a comparative study between three techniques

INTRODUCTION

Nasal deformities secondary to incomplete cleft lip are often underestimated in terms of their severity with resultant sub-optimal treatment. Constant refinements have led to the evolution of different surgical techniques in our institution for the treatment of these deformities. This study compared three different techniques in achieving nasal asymmetry for patients with unilateral incomplete cleft lip.

METHODS

Sixty-six patients who had primary correction of incomplete cleft lip nasal deformities at the age of 3 months were reviewed later at the age of 5 or 6. The patients were divided into three groups as according to the surgical treatment received: Group I (n=21) underwent a closed rhinoplasty with cartilage dissection and repositioning through lip incisions; Group II (n=25) underwent a semi-open rhinoplasty technique with cartilage dissection through bilateral rim incisions; and Group III (n=20) received a semi-open rhinoplasty technique through a Tajima incision on the cleft side and a rim incision on the contralateral side. Using photo-analysis, a total of seven measurements were obtained comparing the cleft side with the non-cleft sides, including bilateral nostril height, nostril width, height-to-width ratio, medial dome height, nasal sill height, nostril area, nasolabial angle and nostril axis.

RESULTS

All the patients benefitted from primary correction of their incomplete cleft lip and nasal deformities. In addition, Group III patients achieved superior results over Groups I and II in terms of nostril height ratio and nostril axis (p<0.005).

CONCLUSION

Primary correction of the nasal deformity is an important component of surgery at the time of lip correction. Our results indicated that a semi-open rhinoplasty technique accompanied by the Tajima incision provides the best overall nasal symmetry.

A comparison of results using nasoalveolar moulding in cleft infants treated within 1 month of life versus those treated after this period: development of a new protocol

The objectives of this study were to: evaluate the effects of nasoalveolar moulding (NAM) in complete unilateral cleft lip and palate infants presenting for treatment at different ages; propose a new NAM protocol in these patients; improve the predictability of NAM. Study groups comprised: group I (n=15) treated with NAM within 1 month of age; group II (n=15) treated with NAM between 1 and 5 months of age.

CONTROL

group III (n=15) comprised of non-cleft 18-month old children. A standard protocol was followed. Patients were evaluated before initiation of NAM, before cheiloplasty and at 18 months. 7 linear anthropometric measurements were compared using dento-facial models. Statistical analysis before and after NAM revealed that group I patients demonstrated 81%, 198%, 69% and 145% improvement in intersegment distance, nasal height, nasal dome height and columella height respectively; whilst group II patients demonstrated 51%, 33%, 21% and 38% improvement for the same. At 18 months, group I patients closely resembled group III patients. This study concluded that the effects of NAM were most significant in group I. Group II patients also benefited from NAM, although to a lesser extent. This study validates the use of NAM in infants presenting late for treatment.

Long-Term Effects of Presurgical Infant Orthopedics in Patients with Cleft Lip and Palate: A Systematic Review

Objective

This study aimed to assess the scientific evidence on the efficiency of presurgical infant orthopedic appliances in patients with cleft lip and palate to shed light on a specific, contemporary discussion of whether the appliances have long-term advantages with respect to treatment outcomes.

Design

A systematic review.

Method

Two literature surveys from the five electronic databases were performed with a 1-month interval. Randomized controlled trials and controlled clinical trials (controls had no presurgical infant orthopedics) that had follow-up periods of a minimum of 6 years were included in the study. The exceptions to the follow-up limit were studies related to feeding and parent satisfaction.

Results

Of the 319 articles retrieved in the literature surveys, 12 were qualified for the final analysis. The level of evidence of these articles ranged from 1b to 4. Eight randomized controlled trials and four controlled clinical trials were available on eight treatment outcomes. The longest follow-up period of the randomized controlled trials was 6 years. No randomized controlled trials were found on active presurgical infant orthopedic appliances and on nasoalveolar molding appliances.

Conclusions

Based on the results, presurgical infant orthopedic appliances have no long-term positive effects on seven of the eight studied treatment outcomes in patients with cleft lip and palate. More randomized controlled trials need to be done to have evidence regarding the effects of presurgical infant orthopedics in different surgical protocols. Also, the encouraging results about the effect of nasolaveolar molding appliances on nasal symmetry have to be supported by future randomized controlled trials.

Nasal changes after presurgical nasoalveolar molding (PNAM) in the unilateral cleft lip nose

PURPOSE

Nasal reconstruction for patients with unilateral cleft lip and palate (UCLP) is a challenge for the reconstructive surgeon. Presurgical nasoalveolar molding (PNAM) was introduced to reshape the cleft nasal structures prior to lip repair. This study analyzed two-dimensional nasal changes before and after PNAM in patients with complete UCLP.

METHODS

Thirty UCLP patients (19 males; 11 females) who received PNAM before lip repair were included in this study. PNAM was applied for 100 days. Nasal casts were obtained before and after PNAM. Frontal and 45° standardized digital photographs were taken from all casts, and a photogrammetric analysis (16 linear, six angular, and two area measurements) was performed. Paired Student's t tests were used to search for differences by time, and time versus side (cleft versus noncleft).

RESULTS

Significant reduction of cleft columella deviation with an increase in columella length, nostril height, and axial inclination on the cleft side were recorded. This resulted in an increase in the projection of the nasal tip. The noncleft measurements remained without significant changes. The cleft nostril area increased significantly more than the noncleft side by 90% with PNAM treatment. Significant normal growth changes were observed in nasal width and nasal height.

CONCLUSION

A favorable reshaping of the nose after PNAM was achieved, resulting in an improvement in form before lip surgery. These changes lead to improved nasal symmetry before primary lip and nasal reconstruction in UCLP patients.

Pre-surgical nasoalveolar moulding in patient with unilateral cleft of lip, alveolus and palate: case report

INTRODUCTION

A 2 month-old infant with unilateral cleft lip, alveolus and palate was presented with wide alveolar defect, soft-tissue deformity and a markedly sunken nasal wing at the cleft side.

METHODS

The patient was treated with a moulding plate and additionally with a nasal stent. The device consisted of an acrylic plate with an attached nasal stent that lifted the nasal dome.

RESULTS

Under this pre-surgical treatment, the cleft edges moved closer by 9 mm and 6 mm at the alveolar ridge and palate, respectively. The nasal wing was lifted considerably.

CONCLUSION

Pre-surgical nasoalveolar moulding helped to reduce the cleft gap, improve the arch form, approximate lip segments and distinctly improve the morphology of the nose by correcting flattened nasal wings.

Functional and aesthetic correction of secondary unilateral cleft lip nasal deformities

The treatment of patients with unilateral cleft lip has undergone significant development during the last decades. With better understanding of the anatomy of the unilateral cleft lip and nasal deformities, primary correction of the nasal deformity at the time of lip repair, critical evaluation of short and long-term results following various treatment protocols, and constant striving for perfection in both aesthetics and function, we have been able to design improved treatment strategies and more accurate surgical techniques so as to achieve overall superior and long-lasting results. In this review article, we present our protocols and experience for functional and aesthetic correction of secondary unilateral cleft lip nasal deformities and a retrospective review of 219 consecutive patients treated at our Craniofacial Centre for correction of secondary unilateral cleft lip nasal deformities. The protocols used in the treatment of 219 consecutive patients at our Craniofacial Centre for correction of secondary unilateral cleft lip nasal deformities were reviewed. In addition, analysis of the most recent 51 consecutive patients who underwent complete clinical and functional evaluation with rhinomanometry followed by correction of the cleft lip nasal deformity was performed. A variety of time-honoured techniques of rhinoplasty were applied in the correction of the residual deformities to achieve symmetry, aesthetic balance, and functional correction of the nose. Follow-up ranged from 5-11 years. Analysis of the data revealed that 39 patients (76.47%) had significant functional and aesthetic improvement; seven patients (13.07%) had significant aesthetic improvement but a modest functional improvement; and five patients (9.8%) required additional surgery to improve their appearance and had no functional improvement. Further analysis demonstrated that five out of seven patients in the second group had pharyngeal flaps in place that were primarily responsible for the airway obstruction. No attempt was made to revise the ports of these flaps because the speech was excellent. The surgical plan is based on the information gained from our extensive clinical evaluation and is tailored to the patient's specific functional and aesthetic needs.

Modified presurgical nasoalveolar molding in the infants with complete unilateral cleft lip and palate: a stepwise approach

Presurgical orthopedics in one or the other form has been an important part of the multidisciplinary approach towards the better cleft care. Presurgical nasoalveolar molding (PNAM) was described as a modified approach to the conventional form of orthopedics. PNAM not only reduces the severity of the alveolar defect before surgery, it also reduces the nasal deformity bringing it near to the normal. Nonsurgical nasal correction forms an important adjunct to the primary nasal repair at the time of primary lip repair. However, acceptance of nasoalveolar molding in Indian set-up has not been wide spread due to various reasons such as lack of the resources and inability of the parents to comply with the frequent adjustment schedule. At the Nitte Meenakshi Institute of Craniofacial surgery at the Nitte University, Mangalore, authors have developed a modification of the PNAM appliance previously described in the literature. The key modification is done at the time of fabrication of the occlusal prosthesis. This modification has made the overall procedure simpler and at the same time helped to reduce the recall visits by half of the originally required. This article describes the fabrication procedure of the modified nasal alveolar molding appliance and the modified treatment protocol in a stepwise manner.

Influence of lip closure on alveolar cleft width in patients with cleft lip and palate

Background

The influence of surgery on growth and stability after treatment in patients with cleft lip and palate are topics still under discussion. The aim of the present study was to investigate the influence of early lip closure on the width of the alveolar cleft using dental casts.

Methods

A total of 44 clefts were investigated using plaster casts, 30 unilateral and 7 bilateral clefts. All infants received a passive molding plate a few days after birth. The age at the time of closure of the lip was 2.1 month in average (range 1-6 months). Plaster casts were obtained at the following stages: shortly after birth, prior to lip closure, prior to soft palate closure. We determined the width of the alveolar cleft before lip closure and prior to soft palate closure measuring the alveolar cleft width from the most lateral point of the premaxilla/anterior segment to the most medial point of the smaller segment.

Results

After lip closure 15 clefts presented with a width of 0 mm, meaning that the mucosa of the segments was almost touching one another. 19 clefts showed a width of up to 2 mm and 10 clefts were still over 2 mm wide. This means a reduction of 0% in 5 clefts, of 1-50% in 6 clefts, of 51-99% in 19 clefts, and of 100% in 14 clefts.

Conclusions

Early lip closure reduces alveolar cleft width. In most cases our aim of a remaining cleft width of 2 mm or less can be achieved. These are promising conditions for primary alveolar bone grafting to restore the dental bony arch.

The role of anthropometric measurements in nasal surgery and research: a systematic review

BACKGROUND

Anthropometric measurements of the nose provide objective data about the size and shape of the nose. Data of average nasal anthropometric values for various ethnic groups is promoted to be of great importance in planning aesthetic nasal surgery, but there may be fundamental problems with this approach.

OBJECTIVE OF REVIEW

To collate existing knowledge on nasal anthropometry and, determine its value to the nasal surgeon, in planning aesthetic nasal surgery and in research.

SEARCH STRATEGY

A structured search of PubMed was performed from 1 January 1973 to 31 December 2009 focussing on nasal anthropometry. The MeSH keywords used were nasal/nose, anthropometry/history/methods/measurements, aesthetic, surgery, nose, otorhinolaryngologic surgical procedures.

RESULTS

There is published literature on the average values of the nasal dimensions for various ethnic groups, to aid surgeons in planning improvements of the face. However the large overlap of anthropometric data between racial groups and the lack of any scientific basis for the concept of race means that the published data for racial groups is of little use in planning nasal surgery. Nasal anthropometry, however, helps to answer important clinical questions in research. It has established the role of primary rhinoplasty in patients with cleft lip nasal deformity. It serves as an objective tool to investigate whether reconstructive nasal septoplasty in the paediatric population has any deleterious effect on nasal growth. Anthropometry also helps in the characterisation of dysmorphic syndromes.

CONCLUSIONS

The published anthropometric data for racial groups is of little use in planning nasal surgery. Anthropometric measurements of the nose may help to answer important clinical questions in research on the effects of surgery on nasal and facial development.

Long-term comparison of four techniques for obtaining nasal symmetry in unilateral complete cleft lip patients: a single surgeon's experience

BACKGROUND

This study was the result of a constant evaluation of surgical techniques and results to obtain excellence in primary cleft rhinoplasty.

METHODS

This was a retrospective study from 1992 to 2003 comparing the long-term outcomes of four techniques of nasal reconstruction. There were 76 patients divided into four groups: group I (n = 23 patients), primary rhinoplasty alone; group II (n = 16 patients), nasoalveolar molding alone; group III (n = 14 patients), nasoalveolar molding plus primary rhinoplasty; and group IV (n = 23 patients), nasoalveolar molding plus primary rhinoplasty plus overcorrection. The surgical results were analyzed using photographic records obtained at 5 years of age. A ratio of six measurements was obtained comparing the cleft and noncleft sides. A panel assessment was obtained to grade the appearance of the surgical results. All surgery was performed by the senior author (P.K.T.C.).

RESULTS

The results are given for groups I to IV, respectively. The nostril height ratio was 0.73, 0.77, 0.81, and 0.95. The nostril width ratio was 1.23, 1.36, 1.23, and 1.21. The one-fourth medial part of nostril height ratio was 0.70, 0.87, 0.92, and 1.00. The nasal sill height ratio was 0.75, 1.02, 1.07, and 1.07. The nostril area ratio was 0.86, 0.89, 0.95, and 1.08. The nostril height-to-width ratio was 0.58, 0.58, 0.71, and 0.92. Finally, group IV had the best panel assessment.

CONCLUSIONS

The results revealed that group IV had the best overall result. Overcorrection of 20 percent was necessary to maintain the nostril height. Further technical modifications are necessary to minimize widening of the nostril width.

Cleft lip and palate surgery: an update of clinical outcomes for primary repair

The comprehensive management of cleft lip and palate has received significant attention in the surgical literature over the last half century. It is the most common congenital facial malformation and has a significant developmental, physical, and psychological impact on those with the deformity and their families. In the United States, current estimates place the prevalence of cleft lip and palate or isolated cleft lip at approximately 1 in 600. There is significant phenotypic variation in the specific presentation of facial clefts. Understanding outcome data is important when making clinical decisions for patients with clefts. This article provides an update on current primary cleft lip and palate outcome data.

Design features and simple methods of incorporating nasal stents in presurgical nasoalveolar molding appliances

Presurgical nasoalveolar molding (NAM) in the orofacial orthopedic treatment of unilateral clefts of the lip and palate aims to align and approximate the maxillary hemialveolar segments and simultaneously support and mold the deformed nasal cartilages, correct and center nasal tip projection, and lengthen the deficient cleft-side columella in early infancy, before the primary reparative lip surgery. A number of techniques of achieving these objectives have been described in the literature and are increasingly being practiced by cleft care teams around the world. However, a detailed description of the nasal stent is lacking in the literature and needs to be elucidated to facilitate greater usage of presurgical NAM in contemporary practice. This report fills this void by providing an analytical description of the different parts of the nasal stent; clarifies their desirable design features, anatomic correlations, and clinical importance; and illustrates in a step-by-step manner simple direct and indirect methods of incorporating a nasal stent, improvised by the author in his practice, that can be used with any of the contemporary NAM appliances and techniques. From the simple methods described, clinicians will be enabled to select one that may be most easily adaptable to their preferred appliance and clinical setting.

Assessment of secondary cleft rhinoplasty using resorbable plates at the age of primary school

BACKGROUND

Secondary rhinoplasty after a cleft lip repair remains a significant challenge. We have developed a technique in which resorbable plates are used to support the cleft alar cartilage to minimize relapse. There are few guidelines by which one can objectively assess the outcome of cleft rhinoplasty over time. This study attempts to demonstrate a means by which the symmetry and form of the proposed rhinoplasty technique can be evaluated.

METHODS

Sixteen patients with unilateral cleft lip/palate repair had a secondary rhinoplasty performed at age 6 to 8 years, using a resorbable plate (resorption time, 2-3 years) placed between the nasal lining and cleft alar cartilage to simulate the shape of the noncleft cartilage. Photographs were taken preoperatively and postoperatively. Median follow-up was 9.6 +/- 2.8 months. Various angles and ratios were measured to demonstrate outcomes, comparing preoperative to postoperative measures, and symmetry between cleft and noncleft sides.

RESULTS

Postoperatively, the angle between the horizontal axis, drawn across the alar base and tangent to the alar rim on both sides, was significantly altered (P < 0.001); both sides were closer to 60 degrees (mean, 56.28 degrees), approximating the angle of the aesthetic norm. A measure of the angle between the horizontal axis and a line drawn from midpoint of axis to nasal tip was significantly closer to 90 degrees (P < 0.05). The shape of the affected nostril became more oval and symmetric relative to the unaffected side (P < 0.05). Angle between the horizontal axis and a line drawn through the widest point of each nostril was close to zero. (P < 0.001). The difference in nostril height between the cleft and noncleft sides was significantly decreased (P < 0.001).

CONCLUSION

We have objectively evaluated the outcomes of our technique of secondary cleft rhinoplasty using resorbable plates for alar support. A careful geometric evaluation of preoperative and postoperative photographs can help determine the symmetry and overall quality of the result. These measures may help to evaluate long-term outcomes of cleft rhinoplasty over time.

Cleft lip rhinoplasty

Many surgical approaches and techniques to repair cleft nasal deformities have been described. Because the presenting patient with a congenital deformity is young, the surgical plan must account for patient growth and surgical scarring. The surgeon should understand the pathophysiology of the deformity and have a systematic surgical plan. This article describes the classic nasal abnormalities associated with clefting of the lip, and outlines surgical techniques and timing used to minimize these deformities.

Complications and solutions in presurgical nasoalveolar molding therapy

OBJECTIVE

To outline three main categories of nasoalveolar molding complications, describe their etiologies and manifestations, and prescribe preventive and palliative therapy for their proper management. Estimates of the incidence of each complication also are provided.

MATERIALS AND METHODS

Data were collected retrospectively from the charts of 27 patients with complete unilateral cleft lip and palate treated by the first author (D.L.-B.) at the University of Puerto Rico (n = 12) and the Medical College of Georgia (n = 15). Confidence intervals for the true incidence of each complication were calculated using exact methods based on the binomial distribution. A significance level of .05 was used for all statistical tests.

RESULTS

Of the soft and hard tissue complications considered, only one (tissue irritation) had an estimated incidence greater than 10%. Compliance issues were of greater concern, with an estimated incidence of 30% for broken appointments and an estimated incidence of 26% for removal of the nasoalveolar molding appliance by the tongue.

CONCLUSIONS

Although benefits outnumber the complications, it is important to address all complications in order to prevent any deleterious outcomes.

Recent advances in presurgical molding in cleft lip and palate

PURPOSE OF REVIEW

Although many protocols for treating infants with cleft lip and palate have been successful, the severely wide deformities often require a multidisciplined team approach. Maxillary appliances have been used for 50 years; however, nasal molding is a relatively recent development that has shown progress but not without stalwart criticism.

RECENT FINDINGS

Presurgical nasal alveolar molding is an evolving technique in the treatment of cleft lip and palate. Used properly, molding can create improved nasal symmetry in unilateral cases and columellar lengthening in bilateral cases. Some regression of improvement is often seen in the following years due to differential growth patterns within the nasal subunits. The nasal septal and columellar deviation seen in unilateral cleft lip and palate can also be improved with a novel device.

SUMMARY

Although traditional repair of the cleft lip and nasal deformity is often adequate, severely wide clefts are amenable to a variety of presurgical measures. Presurgical nasal alveolar molding in children with cleft lip and palate allows repositioning of the maxillary alveolus and surrounding soft tissues in hopes of reducing wound tension and improving results. These techniques can be extremely challenging but an excellent addition to a cleft lip and palate team's armamentarium.

A new method to quantify subtle morphological deformities in nasal profile curvatures and its application for analysis of unilateral cleft lip noses

OBJECTIVE

The authors conducted the present study to elucidate what elements characterize the nasal profiles of patients with unilateral cleft lips (CLs).

MATERIALS AND METHODS

A total of 40 Japanese unilateral CL patients were studied. For each patient, the nasal profile curve was traced on three-dimensional computer tomography image. Then four points were marked on the contour. The points were NAS (Nasion), MAP (the Most Anterior Point on the nasal profile curve), GPRN (the Genuine Pronasale: the point on the nasal curve at which the curve protrudes most), and SBN (Subnasale: the point at the columellar base). Using specially designed software, the distances between these marking points were measured along the nasal profile curve.

RESULTS

In CL patients, the distance between the MAP and GPRN is longer, and the GPRN is located more inferiorly than in non-cleft persons.

CONCLUSION

The nasal tip tends to become round and to droop in unilateral CL patients. In order to avoid this deformity pattern, the nasal tip should be reshaped to present a sharper curvature and corrected superiorly.

Three-dimensional facial morphology following surgical repair of unilateral cleft lip and palate in patients after nasoalveolar molding

OBJECTIVE

To evaluate three-dimensional (3D) facial morphology in patients surgically corrected for unilateral cleft lip and palate (UCLP) following pre-surgical nasoalveolar molding (NAM).

DESIGN

Prospective, longitudinal study. Digital stereophotogrammetry was used to capture 3D facial images, and x, y, and z coordinates of five landmarks were digitized to compute mean morphologies. The sample comprised 15 patients with left UCLP and 10 matched control subjects. Facial form differences at age 37 weeks, using principal components analysis and finite-element scaling analysis (FESA) were assessed.

RESULTS

Using the first two principal components, which accounted for 63% of the total shape-change, UCLP and control groups showed similar distributions in the modal space (p > 0.05). For the UCLP group, the mean 3D facial form was smaller and less protrusive when superimposed on the non-cleft mean. Using FESA, reductions in facial volume were found in the UCLP group, involving the columella (29%), labial tubercle (51%), lower lip (29%) and lateral aspects of the face (19%). The UCLP group also showed increases in size above the tip of the nose (25%) and laterally to the columella directly below the nares (29%).

CONCLUSIONS

Following surgical repair of UCLP in patients previously treated with NAM, 3D facial morphology was virtually indistinguishable from the non-cleft mean. Clinically, the apparent improvement in the facial soft tissues may mask dysmorphic skeletal growth, and further studies are required to characterize the underlying bony changes associated with the soft tissue changes reported here.

Analysis of the cleft-lip nose in submental-vertical view, Part I--reliability of a new measurement instrument

BACKGROUND

Objective evaluation of nasal form and symmetry in cleft patients is difficult. The aim of this study was to establish a computer analysis of nasal form and symmetry (intranasal symmetry and symmetrical position of the nose), in order to evaluate primary and secondary cleft rhinoplasty outcomes.

MATERIAL AND METHODS

Indirect anthropometric measurements were performed on digital photographs processed by Photoshop 7.0 (Adobe Systems Inc., San Jose, California) with the help of Scion Image software (National Institutes of Health, Maryland, USA). For assessing intranasal symmetry, the ratio of nasal tip projection to total nasal width, the ratio of nostril widths, the ratio of nostril heights, the ratio of mid-alar widths and nostril symmetry were determined. Bifidity of the nose, columellar deviation and angulations of the nostrils were also measured. For assessing the symmetrical position of the nose, the ratio of the distances of alar points to the endocanthial lines and nasal base inclination were determined. The reliability of this analysis was tested by using submento-vertical photographs of bilateral cleft noses, of which the lips were primarily operated on by different techniques and different surgeons in Zurich and Bruges.

RESULTS

There were highly significant intraobserver (ICC=0.994) and interobserver reliabilities (ICC=0.893).

CONCLUSION

This nasal analysis is appropriate for comparing results of different surgical techniques.

Experience with presurgical nasal molding in infants with cleft lip and nose deformity

BACKGROUND

Nasal deformity in infants with nasolabial clefts persists if it is not actively corrected. Some surgeons repair the nose simultaneously with the lip. Nonsurgical nasal molding with mechanical support performed in the early neonatal period has proved to be an effective alternative to surgical correction.

METHODS

At the author's institution, for the past 4 years, infants with nasal asymmetry have been treated by presurgical nasal molding performed with a stent fixed to a conventional passive orthopedic plate. The efficiency of this method was evaluated retrospectively using photographs obtained at least 1 year after lip repair. Sixteen pairs of children were studied. One child of each pair had received the treatment with the stent, and the other one had been treated using the classic method of presurgical orthopedics with no stent; the diagnosis and remaining therapy were the same for both children. Nine maxillofacial surgeons and 22 students of dental medicine were asked to decide which nose of each pair was more symmetrical.

RESULTS

Seventy-five percent of students and 70 percent of surgeons found that the nasal stent nose was more symmetrical than its classically treated counterpart. Statistical analysis of the results revealed highly significant agreement between the two groups of evaluators.

CONCLUSIONS

Children who underwent presurgical treatment with a nasal stent had more symmetrical noses several years after lip repair than children treated by the classic method of preoperative orthopedics. Use of the modified appliance did not present major problems for the parents, but their cooperation is necessary. Treatment should start as soon as possible after birth, regardless of the width of the cleft.

Presurgical nasoalveolar molding in patients with unilateral clefts of lip, alveolus and palate. Case study and review of the literature

INTRODUCTION

The case of a newborn female patient with unilateral cleft lip, alveolus and palate is presented with a markedly sunken nasal wing at the cleft side. This finding may lead to a very unsatisfactory aesthetic result after primary cheiloplasty and nasoplasty.

PATIENT AND METHOD

Five months prior to surgery, the patient was treated with a palatal plate and additionally with a nasoalveolar conformer for 4 months thereof. The device consisted of an acrylic pelotte (attached to the maxillary plate with a wire) which lifted the nasal dome and was activated regularly. Under this presurgical treatment, the cleft edges moved closer to each other by 1.8 mm at the alveolar ridge and by 4.5 mm in the palatal area. The nasal wing was lifted by 5 mm. This was enabling elevation of the nasal wing during primary surgery in the case described. Questions are raised as to the remaining effects on nasal symmetry until completion of growth and, on the other hand, as to the chances to reduce postsurgical alar relapse by continued nasal molding beyond primary surgery.

CONCLUSION

Presurgical nasal molding seems to improve aesthetics of the nose in patients with unilateral clefts of lip, alveolus and palate and distinctly flattend nasal wings.

Presurgical nasoalveolar molding therapy for the treatment of unilateral cleft lip and palate: a preliminary study

OBJECTIVE

To evaluate the outcome of presurgical nasoalveolar molding (PNAM) therapy in the treatment of patients with nonsyndromic unilateral cleft and palate (UCLP).

DESIGN

A prospective study with blinded measurements.

PATIENTS

Twelve patients with UCLP treated from 1997 to 2003.

INTERVENTIONS

The starting age for PNAM therapy was 26 days and the average length of the therapy was 110 days.

MAIN OUTCOME MEASURES

Measurements of intraoral and extraoral casts were made, and statistical analyses were used to compare the differences between pre- and posttherapy measurements.

RESULTS

After PNAM therapy, there was a statistically significant decrease in both intersegment alveolar cleft distance and columellar deviation (p < .05). There was also a statistically significant increase in cleft nostril height, maxillary width, and columellar width (p < .05). Moreover, although there was no statistically significant reduction of the affected nostril width, it demonstrated on average 1.7-mm reduction after PNAM therapy. The length of the time the patient utilized the appliance and postmolding nostril height were found to have a statistically significant positive correlation (p < .05).

CONCLUSIONS

PNAM therapy decreases intersegment alveolar cleft distance while permitting an increase in posterior maxillary arch width. It also increases nasal symmetry by decreasing columellar deviation, increasing nostril height on the affected side, maintaining bialar width of nose, increasing columellar width, and creating more symmetrical nostril heights and widths. The improvement of the height of the cleft nostril was correlated with the time the appliance was applied.