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

Outcome of Patients with Complete Cleft Lip and Alveolus: 20-Year Follow-Up

BACKGROUND

Patients with cleft have functional and aesthetic impairment, and typically require several interventions as they grow. Long-term evaluation following a treatment protocol is essential, but such reports on patients with complete cleft lip and alveolus (CLA) are sparse in the literature.

METHODS

A retrospective review was conducted of all patients with complete CLA born between January of 1995 and August of 2002 and treated at our center. Patients who received continuous multidisciplinary team care until 20 years of age were included, and patients with cleft palate and syndromic abnormalities were excluded. Facial bone growth was evaluated using cephalometric analysis.

RESULTS

Eighty-seven and 11 patients with unilateral and bilateral CLA, respectively, were included. All patients underwent one-stage cheiloplasty with primary rhinoplasty. Revision lip/nose surgery was performed in 21.8% and 27.3% during growing age, and in 51.7% and 72.7% after skeletal maturity, respectively. Orthognathic surgery was performed in 20.7% and 27.3%, respectively. Compared with unilateral CLA patients, bilateral CLA patients had more operations (3.0 versus 3.7; P = 0.03) and a higher chance of undergoing alveolar bone grafting twice (1.1% versus 36.4%; P < 0.01). Patients with complete CLA had less hypoplastic maxilla, and underwent fewer operations than those with complete cleft lip and palate.

CONCLUSIONS

Complete CLA is a less severe form of cleft, but the patients still require multiple interventions. This review revealed certain suboptimal results, and modifications have been made in the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.

Cephalometric analyses of the correlation between nasal and maxilla morphology among adult patients with cleft

OBJECTIVE

To explore if the nasal profile is influenced by maxillary hypoplasia among patients with congenital cleft lip and palate.

METHODS

Young adult patients with cleft and noncleft controls were enrolled. Nasal and maxillary profiles were measured on lateral cephalometric radiographs. The Kruskal-Wallis and Tukey post-hoc tests were employed for intergroup comparison among various the cleft types, and Pearson's product moment correlation coefficients were calculated to detect the correlation between nasal and maxillary cephalometric measurements.

RESULTS

A total of 250 participants were enrolled, including 64 with unilateral cleft lip and alveolae; 22 with bilateral cleft lip and alveolae; 49 with unilateral cleft lip, alveolae, and palate; 35 with bilateral cleft lip, alveolae, and palate; and 80 controls. Patients with cleft demonstrated significant difference in nasal and maxillary profiles when compared with the normal controls. The nasal dorsum length had a significant positive correlation with anterior and posterior maxillary height. The upper nasal dorsum length had a significant negative correlation with the maxillary protrusion. Among patients with bilateral cleft, the nasal dorsum length was also significantly negatively correlated with the maxillary protrusion.

CONCLUSION

The nasal profile is closely related to the growth of maxillae among patients with cleft and the normal population.

Nasolabial Morphological Changes Post-Khon Kaen University Presurgical Nasoalveolar Molding Therapy in Infants with Complete Unilateral Cleft Lip and Palate

ObjectiveTo assess the efficacy of Khon Kaen University presurgical nasoalveolar molding (KKU PNAM) by evaluating nasolabial morphological changes in patients with complete unilateral cleft lip and palate (UCLP) using three-dimensional (3D) anthropometric measurements and comparing nasal morphology to age-matched noncleft controls.DesignA retrospective case series of infants with complete UCLP who underwent KKU PNAM therapy. Patients with complete 3D stereophotogrammetric records at initial (T0) and pre-cheiloplasty (T1) visits were included.SettingKhon Kaen University Cleft Lip and Palate CenterPatients/ParticipantsSixteen infants with complete UCLPInterventionsKKU PNAMMain Outcome MeasuresAnthropometric measurements of nasolabial tissue of infants with complete UCLP were compared between pre- (T0) and post-PNAM treatment (T1) and against age-matched noncleft controls at both time points.ResultsFrom T0 to T1, cleft-sided nostril height and columellar length, height, and angle increased significantly (0.85 mm, 0.83 mm, 1.54 mm, and 17.38 degrees, respectively). Conversely, cleft-sided nostril width, deviated alar base and columella, and vermilion gap significantly decreased (1.57, 1.04, 0.68, and 4.19 mm, respectively). The difference of nostril width and height between cleft and noncleft side was decreased. At T0, alar base, subnasal, and nostril width, alongside the nostril and columellar height, differed from those of control infants. At T1, the columellar height in the treatment cohort was comparable to that of the control. Other parameters remained significantly different; however, these differences decreased post treatment.ConclusionsKKU PNAM therapy improved nasolabial morphology and symmetry in patients with UCLP, suggesting its potential to facilitate successful future cheiloplasty.

Accuracy and Retention of Molding Plates Used for Infants with Cleft Lip and Palate Fabricated from Different Materials: A Cross-Sectional Clinical Study

ObjectivesThe study aimed to comparatively assess the accuracy and retention of molding plates made of polyethylene terephthalate modified with glycol (PET-G) and polymethyl methacrylate (PMMA) materials, while also investigating the effect of adhesive addition on retention.DesignA cross-sectional clinical study.Patients/settingThe study included 30 infants diagnosed with non-syndromic cleft lip and palate (16 unilateral, 14 bilateral). Two molding plates were fabricated for each infant, and their accuracy and retention were evaluated. The data were analyzed using independent t-tests, Mann-Whitney U tests, and Wilcoxon rank tests.Main outcome measuresAccuracy: The accuracy of the molding plates was assessed by measuring the virtual gap between the inner surface of the plates and their working cast using Exocad software. The accuracy was evaluated in different regions (anterior, middle, and posterior) and compared between PET-G and PMMA materials. Retention: The retention of the molding plates was measured using a digital force gauge, which recorded the force required to dislodge the plates from the infant's mouth. The retention was compared between PET-G and PMMA materials, as well as the effect of adhesive addition on retention. Overall adaptation; PET-G plates showed a significantly smaller gap (mean= 0.264 ±0.106) compared to PMMA (mean= 0.362 ±0.130). Region-specific adaptation: PET-G plates demonstrated better accuracy in all regions (means of anterior =0.246, middle =0.262, posterior =0.282 µm). Significant differences in accuracy were observed in the middle and posterior regions compared to PMMA. Retention assessment revealed that the PET-G groups (with or without adhesive) exhibited significantly higher retention compared to the PMMA groups (P<0.01).ConclusionPET-G plates demonstrated superior accuracy and retention compared to PMMA, with a significant difference observed in both accuracy and retention. Furthermore, the addition of denture adhesive had a positive effect on retention for both materials.

Growth-related nasal stability following unilateral complete cleft lip repair: A comparison of the standard and modified rotation-advancement technique

BACKGROUND

Improving growth-related nasal stability is a critical goal of primary cleft lip repair. The purpose of this study was to evaluate the growth-related stability of the nose after unilateral complete cleft lip (UCCL) repair with standard rotation-advancement (RA) and modified rotation-advancement (MRA) techniques.

MATERIAL AND METHOD

In this retrospective study, 52 non-syndromic (UCCL) patients were treated with a MRA technique, where a C-flap and a superiorly based advanced flap were used to lengthen and support the columella and nasal sill, and 48 patients were treated with a standard RA technique. Photos were taken before surgery (T1), immediately after surgery (T2), 1 year after surgery (T3), and 5 years after surgery (T4). Cleft width ratio, maxillary discrepancy, ala collapse, ala base position, columellar angle and height, nostril height, and width were all measured. The t-test, repeated-measure analysis of variance (ANOVA), stepwise multiple regression, inter-class correlation coefficient, and ANOVA with Bonferroni corrections were conducted.

RESULTS

MRA improved columellar height significantly at T3 and T4. Growth-related columellar height stability at T2-T4 was significantly better in the MRA group (P = 0.08) than in the standard RA group (P = 0.007). Nasal width was a moderate predictor of post-operative outcome, and maxillary discrepancy and ala collapse were moderate predictors of growth-related nostril height changes.

CONCLUSION

Both groups demonstrated the same measurement stability at 1 and 5 years, except for the columellar height in the standard RA group, which deteriorated and then improved over time due to unknown reasons. Furthermore, the MRA group had better columellar height symmetry than the standard RA group at 1 and 5 years after surgery.

Nasoalveolar Molding in Lately Presented Moderate to Severe Unilateral Cleft Lip and Palate Infants: Does it Add?

Alignment of the alveolar segments with early nasal cartilage tackling is the foundation upon which excellent surgical results are dependent. The purpose is to evaluate the short-term effect of triple combination of passive alveolar molding with early nasal molding augmented by controlled corrective power of lip tapping in lately presented moderate to severe unilateral complete cleft lip and palate infants. A prospective case series study was conducted in Plastic and Maxillofacial Surgery Department, Ain Shams University in collaboration with Orthodontics Department, from January 2021 till June 2023, 15 infants elder than 2 months till 6 months were enrolled in the study. Eight nasal anthropometric measurements ratios through 2-dimension assessment and 4 maxillary arch measurements ratios through 3-dimension assessment were recorded. Extraoral results revealed clinically and statistically decrease of nasal width, alar base width, alar base height ratios, and columellar angle, while increase of nasal height, nasal dome height, columellar length, and alar projection length ratios. Intraoral results revealed clinically and statistically decrease in cleft width with maintained posterior arch width and intercanine width. In conclusion, this triple combination helped in presurgical lessening the alveolar and nasal deformity of such elder infants in a shorter time in comparison with other conventional methods with lesser number of appointments decreasing burden of care to their families improving their compliance.

Artificial intelligence-driven automation of nasoalveolar molding device planning: A systematic review

STATEMENT OF PROBLEM

Despite the increasing number of publications on applying artificial intelligence (AI) in the dental field, clarity regarding the performance of different approaches for nasoalveolar molding (NAM) planning and designing is lacking. Additionally, the overall robustness of the evidence in this field remains uncertain.

PURPOSE

The purpose of this systematic review was to evaluate the role of AI in automating the prediction of anatomic landmarks and the design of NAM appliances.

MATERIAL AND METHODS

A comprehensive literature search was conducted in major databases up to April 2024 without language restrictions. Studies applying AI algorithms for NAM landmark detection or appliance design were included. Data on study characteristics, AI methods, outcomes, and limitations were extracted.

RESULTS

Six studies met the eligibility criteria. AI algorithms demonstrated high accuracy in automatically detecting landmarks and designing NAM appliances. Approaches ranged from fully automated to semi-automated workflows. Most studies reported significant time savings compared with manual methods.

CONCLUSIONS

AI applications in NAM demonstrate substantial potential in improving workflow design, as demonstrated by the high accuracy reported in various studies. The incorporation of AI in NAM planning leads to a significant reduction in treatment appointment times when compared with conventional manual methods, thereby potentially decreasing the overall duration of treatment. Nevertheless, additional research is required to foster better collaboration between dental professionals and AI experts, ultimately facilitating more efficient clinical integration.

Secondary rhinoplasty for unilateral cleft lip nasal deformity using the complex of autologous costal cartilage and fascia grafts

BACKGROUND

Secondary unilateral cleft lip nasal deformity is a prevalent condition in the world, and surgical repair remains a formidable challenge. The objective of the study is to investigate functionally and aesthetically outcomes of a new technique using a complex of autologous costal cartilage and fascia grafts to repair the secondary unilateral cleft lip nasal deformity.

METHODS

First, the autologous costal cartilage and fascia were harvested from a total of 34 patients with secondary unilateral cleft lip nasal deformity, who were undergoing treatments at the First Affiliated Hospital of Xi'an Jiaotong University from April 2020 to June 2023. Then, the cartilage was sub-divided into 6 pieces and placed on the depressed alar base, nasal columella, lower lateral cartilage, and nasal tip. At the same time, the fascia was trimmed to cover the nasal tip cap graft and augment the dorsum of the nose. Patient outcomes were assessed through subjective evaluation and objective anthropometric measurements. In addition, associated complications were also examined.

RESULTS

All were primary healing incisions, and no patients were encountered with any clinical complications. We found that the overall mean score of the Independent Rhinoplasty Outcome Score (IROS) was very good during the subjective assessment. Also, the objective measurements indicated an excellent nasal symmetry. Furthermore, both functionally and aesthetically satisfactory outcomes were obtained in all the patients during long-time follow-up.

CONCLUSIONS

Secondary rhinoplasty using the complex of autologous costal cartilage and fascia grafts is a safe and effective approach for unilateral cleft lip nasal deformity repair.

Research Trends in Presurgical Infant Orthopaedic Treatment in Patients with Cleft Lip and Palate: A Bibliometric Analysis of 100 Most-Cited Articles

OBJECTIVE

To assess research trends and publication patterns of literature related to presurgical infant orthopaedics (PSIO) through a bibliometric analysis of the top 100 most-cited articles.

MATERIAL AND METHODS

The top 100 most-cited articles were identified in the Web of Science (WoS) database using search terms related to PSIO on April 23, 2024, without any restrictions to study design, publication date and language. Standard information about each study was extracted. Citations from WoS, Scopus and PubMed databases were compared. The level of evidence for each article included was assessed. Association between different variables was calculated using Spearman's correlation coefficient with statistical significance set at p < 0.05. Visual analysis of the author's keyword co-occurrence, co-authorship analysis of authors, and citation analysis of journals and authors were performed using VOSviewer.

RESULTS

Top cited articles were published from 1994 to 2020, with total individual database citations being WoS (n = 5378), Scopus (n = 6184) and PubMed (n =  10 450). Eleven articles were considered classic articles. Cleft Palate and Craniofacial Journal (Impact Factor = 1.1) had a maximum number of articles and citations. Two hundred eighty-five individuals contributed to top-cited articles, with 62 corresponding authors from 19 countries. A maximum number of authors were affiliated with universities in the United States. The most common keyword used was "nasoalveolar molding (n = 24)", "cleft palate (n = 16)", and "infant orthopedics (n = 16)". The study design of the majority of articles was retrospective and follow-up studies (level 3; n = 53). A weak negative correlation was observed between citation metrics and both the publication year (P < 0.01) and the level of evidence (P < 0.01).

CONCLUSION

This analysis recognises the contributions of experts and offers valuable insights into trends that have shaped the development and evidence related to PSIO research. Future research should focus on integrating advanced technologies, conducting longitudinal studies, fostering collaboration, and emphasizing patient-centred outcomes.

Nasoalveolar Molding Therapy in a Newborn With Cleft Lip and Palate: A Case Report

Cleft lip and palate are common congenital deformities that significantly impact facial anatomy and function, often requiring surgical intervention to correct. Presurgical nasoalveolar molding (NAM) therapy has emerged as an effective nonsurgical approach to improve surgical outcomes by reducing the severity of clefts and molding the alveolar, lip, and nasal segments into more favorable positions. This case report describes the use of NAM therapy in a 15-day-old patient with unilateral cleft lip, palate, and nasal involvement to improve outcomes before cheiloplasty. The patient presented with significant feeding difficulties due to a large palatal cleft. After obtaining parental consent, we conducted a series of procedures to construct and insert an acrylic NAM plate with a retention button and nasal stent, performing weekly adjustments to reshape the alveolar segments and nasal cartilage. Weekly remodeling included selective modifications to the NAM plate, the addition of soft liners, and the use of nasal stents to lift the collapsed nasal cartilages and restore nasal symmetry. Post-treatment results showed a substantial reduction in the cleft lip gap from 17 mm to 6 mm, alveolus gap from 14 mm to 4 mm, left nasal width from 17 mm to 11 mm, and increased left alar height from 4 mm to 7 mm. The successful application of NAM therapy demonstrated its effectiveness in reducing cleft gaps, improving nasal anatomy, and preparing the patient for future surgical interventions with minimal scar formation. This case reinforces the benefits of NAM in reducing cleft deformities, improving feeding function, and avoiding more invasive surgical procedures.

Effective Correction of Columellar Base Deviation in Primary Unilateral Cleft Lip Repair: A Muscle-Driven Method

SUMMARY

Columellar base deviation is a common and challenging deformity in patients with unilateral cleft lip. Debate continues on its surgical correction without sufficient studies to establish effective management. This article presents the authors' experience in correcting the columellar base deviation with the muscle-driven method in primary lip repair. The key is to perform extensive muscle dissection and reconstruction. In the medial lip segment, muscle dissection is performed subcutaneously up to the contralateral nostril floor for effective lengthening and rotation. In the lateral lip segment, muscle dissection is executed in both submucosal and subcutaneous planes, and muscle component is extensively separated from the lip skin and buccal mucosa. The lateral muscle flap is advanced and reattached to the contralateral nostril floor and columellar base using a subcutaneous sustaining suture. Cinching suture between columellar base and alar base is performed. These 2 sutures help centralize and overcorrect the columellar base. Bilateral muscle components are reoriented and approximated in a Z-plasty format for lengthening of the lip. The patients were followed up for at least 3 years. Quantitative measurements of deviation in columellar base angulation were taken and revealed 55.8 ± 2.6 degrees (before nasoalveolar molding), 29.6 ± 1.7 degrees (after nasoalveolar molding), and 2.8 ± 0.4 degrees (postoperative follow-up), respectively. The muscle-driven method represents a safe and effective technique to correct columellar base deviation in patients with unilateral cleft lip.

Three-Dimensional Evaluation of Nasolabial Morphology After Applying Presurgical Nasoalveolar Molding in Primary Unilateral Cheiloplasty Using the Modified Millard Technique

OBJECTIVE

To compare the soft tissue measurements of the upper lip and the nose on the cleft side and the noncleft side before surgery, immediately after cheiloplasty and two months after surgery.

DESIGN

Descriptive clinical study with one group, prospective.

SETTING

Department of Odonto-Stomatology, Children's Hospital 1, at Ho Chi Minh City - Vietnam.

PATIENTS

31 patients with a unilateral complete cleft lip participated in this study, 30 patients were evaluated at the time two months after surgery.

INTERVENTIONS

Interventions include PNAM and cheiloplasty by modified Millard technique.

MAIN OUTCOME MEASURES

Patients proceed to acquire 3D images of lips and nose, define landmarks and measure dimensions. There are 11 evaluators to be compared, p < 0.05 was considered statictical significance.

RESULTS

After two months of surgery, on cleft side and noncleft side, the lengths of the upper lip were 10.87 ± 0.80 and 11.92 ± 0.78 (mm), the widths of the upper lip were 16.06 ± 1.10 and 16.40 ± 1.02 (mm), the heights of the nostril were 4.85 ± 0.44 and 5.93 ± 0.43 (mm), the lengths of columella were 4.08 ± 0.37 and 4.93 ± 0.38 (mm), and the widths of the nostril were 9.07 ± 0.37 and 8.37 ± 0.40 (mm).

CONCLUSION

Cheiloplasty by modified Millard technique on the patients who used PNAM showed that after two months of surgery, the morphology of the upper lip and nose has a slight disproportion with the nasolabial measurements of the cleft side being smaller than on the noncleft side.

Role of Growth Factors in Nasal Cartilage Development and Molding: A Comprehensive Review

This review aims to investigate the properties of growth factors concerning the morphogenesis and development of nasal cartilage, which is fundamentally important for facial form and appearance. Since cartilage lacks a blood supply, it is more difficult to regenerate, as cartilage tissue obtains sustenance by diffusion. Cytokines are signalling molecules that control chondrocyte metabolism and extracellular matrix formation, which is required for cartilage development, homeostasis, and healing. Some craniofacial illnesses alter the composition of the cartilage and the structural organization of growth factors, allowing for moulding. TGF-β (transforming growth factor-β) encourages chondrocyte differentiation, whereas IGF-1 (insulin-like growth factor-1) stimulates cartilage-forming collagen synthesis and chondrocyte multiplication. We used the scoping review approach to present current research on the role of growth factors in the creation and architecture of nasal cartilage. We generally observed this structure before conducting specific experiments to determine the impact of growth agents on the development of chondrocytes and cartilage. Prominent findings increase our understanding of how growth factors influence the extracellular matrix, cell activities and features, and cartilage growth rate; all are critical for cartilage tissue development and repair. Research into growth factors and their physiological interactions with cartilage may help improve treatment's functional and aesthetic outcomes and our understanding of the origins and consequences of nasal congenital anomalies. This study emphasizes the importance of expanding knowledge and experience, as well as the use of growth factors in clinical practice, to stimulate cartilage development.

Presurgical Nasoalveolar Molding and Columella Lengthening for Early Unilateral Cleft Lip and Palate Rehabilitation: A Comprehensive Clinical Case Report

Aim and background

In presurgical infant orthopedics, nasoalveolar molding (NAM) therapy has gained more popularity worldwide in treating patients with cleft lip and palate because of its soft tissue nasal corrections in addition to the alignment and close approximation of the cleft alveolar segments, which gives better postsurgical stability and esthetics with minimal tissue tension and scar formation to the patients.The clinical case report aims to show the better post-NAM results, which had helped to gain better postsurgical results in terms of stability and aesthetics in hard and soft tissues.

Case description

This clinical report presents the case of a 9-day-old female patient reported in the Department of Orthodontics and Dentofacial Orthopedics at Sharad Pawar Dental College and Hospital with nonsyndromic complete left-sided unilateral cleft lip and palate with a defect size of 13 mm, which was treated with a presurgical nasoalveolar molding (PNAM) appliance. NAM therapy takes advantage of circulating maternal estrogen, bringing pliability to the cartilage cells for presurgical cartilage molding. This has resulted in the closure of the alveolar defect from 13 mm to <2 mm in the present case, with nasal symmetry restoration due to nasal stent within 12 weeks of active treatment; hence, the postsurgical esthetics are maintained.

Conclusion

NAM therapy remained beneficial and had significant aesthetic results in reducing the cleft defect size. Because of this, it gained a big surgical advantage in reducing tissue tension, primary stability, and scar formation.

Clinical significance

By reducing the cleft defect size of the dysplastic maxillae, which brings the lip segments and alveolar segments closer to each other, it thus reduces the defect size for primary lip and palate repair. This serves as the biggest advantage for maxillofacial and plastic surgeons to maintain the posttreatment results with redefined aesthetics and symmetry.

How to cite this article

Taori KP, Niranjane P, Kamble R. Presurgical Nasoalveolar Molding and Columella Lengthening for Early Unilateral Cleft Lip and Palate Rehabilitation: A Comprehensive Clinical Case Report. Int J Clin Pediatr Dent 2024;17(8):955-961.

A Comprehensive Approach to Unilateral Cleft Lip and Palate Management through Presurgical Nasoalveolar Molding and Surgical Repair in a Neonate

This case report details the successful application of nasoalveolar molding (NAM) in a 4-day-old neonate with a complete unilateral cleft lip and palate, showcasing a comprehensive treatment approach involving presurgical NAM and subsequent surgical repair. The NAM technique, pioneered by Barry H. Grayson, utilizes a specialized appliance to shape the alveolar ridge and nasal cartilage concurrently. The case demonstrates favorable outcomes, with the alveolar segments brought closer to normalcy after approximately 4 months of NAM. The patient underwent further surgical repair, as per the protocol emphasizing the interdisciplinary approach in cleft management.

Nasolabial morphological changes in patients with unilateral cleft lip and palate using a Korat-modified nasoalveolar moulding appliance with primary correction

OBJECTIVE

The objective of this study is to measure the morphological changes of the nose and lip in patients with unilateral cleft lip and palate before and after cheiloplasty with primary rhinoplasty (primary correction) in conjunction with Korat-NAM usage.

DESIGN

Longitudinal cohort study.

SETTING

Cleft Center Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand.

SUBJECTS

Twenty-six patients with unilateral cleft lip and palate.

INTERVENTIONS

Control group: only active obturator before primary correction. Experimental group: an active obturator and Korat-NAM I before primary correction. A customized endotracheal tube was retained in the nostril for 3 weeks before switching to Korat-NAM II for 1 year.

MAIN OUTCOME MEASURES

Six measurements comprising nostril rim length, nostril height, nostril sill width, columella angle, vertical lip height, and horizontal lip length were measured from the patients' photographs. All measurements, except the columella angle, were reported as the cleft side/non-cleft side value ratio. Measurements were taken at the initial appointment, immediately before, 3 weeks after, and 1 year after primary correction.

RESULTS

Nostril rim length ratio, nostril height ratio, nostril sill width ratio, columella angle on the cleft side, and vertical lip height ratio were improved using Korat-NAM before and 3 weeks after primary correction. Nostril rim length and height ratios were significantly better than the control group.

CONCLUSIONS

Korat-NAM improved nose and lip morphology before primary correction. An overcorrection improved the nose and lip morphology on the cleft side. The nostril rim length and vertical lip height on the cleft side also improved with Korat-NAM II 1 year after primary correction.

Systematic Review and Critical Appraisal of the Evidence Base for Nasoalveolar Molding (NAM)

OBJECTIVE

To critically appraise the body of scientific literature supporting the risks and efficacy of nasoalveolar molding (NAM), specifically in contrast to alternative methods of presurgical infant orthopedics (PSIO) or to treatment without PSIO.

MAIN OUTCOME MEASURES

Five outcome domains were considered: nasolabial aesthetics; dentoalveolar relationship; midfacial growth; cost and burden of care; and number of anesthetic events.

DESIGN

MEDLINE, Embase, and Scopus were queried for articles from the first description of the Grayson-Santiago NAM technique (1993) through December 13, 2021. After the application of inclusionary and exclusionary criteria, selected articles were critically appraised using a systematic framework that included risk of bias assessment using the Cochrane RoB 2.0 and ROBINS-I tools.

RESULTS

A total of 88 studies were included. Level-I and -II evidence showed on par or better approximation and alveolar alignment achieved by NAM compared to other PSIO. Level-II and -III evidence showed improved nasolabial aesthetics compared to other PSIOs. Level-II and -III evidence supported no harm to maxillofacial skeletal growth through age 12. Sparse level-III evidence supported a reduced number of labial or nasal revisions following NAM. Level-II and -III evidence showed NAM requiring upfront cost and frequent appointments but reducing caregiver psychosocial burden and reducing long-term costs compared to select alternatives. Many studies carried a high risk of bias.

CONCLUSIONS

Current evidence supports the overall efficacy of NAM regarding short/mid-term outcomes, with a low risk of negative effects on midfacial growth or dental development. The high risk of bias discovered in many papers underscores the need for robust study design in future research.

Presurgical management trends and nasoalveolar molding usage for infants with cleft lip and palate in the capital of a developing country

BACKGROUNDS

Nasoalveolar molding (NAM) application is among presurgical management (PSM) techniques used for infants with cleft lip and palate (CLP). It helps to approximate the palatal cleft and to reshape the nasoalveolar complex prior to primary lip repair. This study aimed to explore types of PSM and the dental speciality provision for infants with CLP in Baghdad. The status of NAM usage and surgeons' perceptions toward NAM usage were assessed.

MATERIALS AND METHODS

This is a cross-sectional paper-based questionnaire study that collected responses of surgeons perform primary lip and nose repair regarding PSM. The questionnaire was distributed amongst public and private hospitals in Baghdad. Twenty surgeons were enrolled (only those surgeons who perform primary repair for infants with CLP); two females and eighteen males.

RESULTS

The majority of participants' responses suggested that the majority of infants with CLP were provided with baby feeding plates and lip straps. Six surgeons reported that a percentage of their patients who have been provided with NAM. PSM in Baghdad was mostly supplied by orthodontists and plastic surgeons, and the next most likely providers were prosthodontists. 82.35% of the surgeons found that primary surgical repair procedures were easier with NAM than for the other infants. The rest have not perceived any differences.

CONCLUSIONS

Orthodontists, surgeons and prosthodontists were involved in providing PSM. Baby feeding plates and lip straps were the most common PSM in Baghdad, although NAM is not uncommon. Most surgeons believe that using NAM made surgical procedures easier and permitted the prediction of surgical outcomes.

Dynamic Molding of Cleft Nasal Cartilage in Unilateral Complete Cleft Lip and Palate Using Simple Segmented NAM

Objective

Nasal morphology remodeling by nasoalveolar molding (NAM) before primary lip repair gives better post-surgery outcomes. However, traditional NAM has high technical sensitivity, a steep learning curve, frequent need for modifications, and interrupts lifting forces on the nasal cartilage during oral movements, thereby reducing overall efficacy of device. To eliminate interaction and interdependency of the nasal bulb with alveolar molding plate, we propose segmenting NAM (SNAM) into nasolabial complex molding (NCM) and alveolar complex molding (ACM). NCM addresses ala-septum, lip-premaxilla via lambda-nasal hook and lip taping. ACM addresses palate-alveolus via Yen-modified feeding plate. When the hook is suspended by elastic traction, nasal complex undergoes a natural rotation, where cleft-side ala lifts and septum medializes. Lip taping and feeding plate augment positive molding of cleft segments and maintain transverse relation. The current study outlines SNAM treatment strategy and assesses the effect on nasal deformity.

Design and setting

Retrospective observational cohort study set in a comprehensive cleft care centre.

Patients

Twenty patients with unilateral complete cleft lip and palate who underwent SNAM were selected.

Main outcome measures

Retrospectively, standardized basilar views, pre-, and post-SNAM therapy were evaluated for nostril height, and nostril width, as a ratio of cleft to non-cleft side along with columellar deviation angle.

Results

SNAM resulted in significantly improved nostril symmetry with no complications observed. Nostril height ratio increased from 0.35 ± 0.10 to 0.78 ± 0.17. Nostril width ratio decreased from 3.14 ± 0.66 to 2.18 ± 0.42. Columellar deviation angle increased from 26.5 ± 6.30 to 58.5 ± 9.88 degrees.

Conclusions

Dynamic correction of the nasal deformity in UCLP is possible through SNAM therapy.

Nasal Cartilage Molding in a Case of Unilateral Cleft Lip and Alveolus (Type D): A Case Report

Nasal cartilage is asymmetric in individuals with cleft lips and has a depressed nasal dome and medial and lateral crus of the nose on the affected cleft side which can be corrected before cheiloplasty by taking advantage of circulating maternal estrogen. This case report presents pre-surgical nasal cartilage molding in a patient with unilateral cleft lip and alveolus using the Sawangi Pre-surgical Nasal Cartilage Molder appliance. The appliance is made from 0.8 mm stainless-steel round wire and has three components, namely, a rectangular frame, a force-generating component, and a swan-shaped wire framework with a soft liner for nasal asymmetry correction.

Schematic Treatment Tree for the Presurgical Nasoalveolar Moulding of Patients with Cleft Lip and Palate

Background

Cleft lip and palate is the most common and unfortunate congenital defect that is debilitating for both the patients and their parents. Such complex condition demands for a precise and judicious management, as its outcome can drastically influence the quality of life of the child.

Aim

To provide a concise treatment algorithm or tree which might guide the clinicians and make it easier for them to opt for a better treatment option when confronting different severities and types of this defect.

Material and Methods

The clinical experience at our center alongwith review of current literature is used to propose a decision making treatment tree.

Discussion

For the better aesthetics, function and ease of cosmetic surgery, several presurgical procedures have been introduced including the nasoalveolar moulding (NAM) appliance, adhesive tapes with nasal elevators, Figueroa's appliance, Hotz appliance, etc.

Conclusion

The schematic decision-making tree may prove beneficial to the healthcare providers specially pedodontists who frequently come across such situations to choose the best treatment option for their patients.

Comparison of Facial Growth between Two Nasoalveolar Molding Techniques in Patients with Unilateral Complete Cleft Lip

BACKGROUND

Nasoalveolar molding (NAM) has become standard treatment in the authors' craniofacial center. There are two types of presurgical NAM: the Grayson and Figueroa techniques. The Grayson method involves active alveolar molding, and the Figueroa method involves passive alveolar molding. The authors previously found no differences in number of clinic visits, costs, or 6-month postoperative outcome between the two techniques. The authors extended the previous study to evaluate facial growth between these two groups.

METHODS

In this randomized single-blind study, conducted between May of 2010 and March of 2013, the authors recruited 30 patients with unilateral complete cleft lip and palate and randomized them for Grayson or Figueroa presurgical NAM. Standard lateral cephalometric measurements at 5 years were used to determine facial growth.

RESULTS

Twenty-nine patients completed 5 years of follow-up. There were no statistically significant differences in facial cephalometric measurements between the two groups.

CONCLUSION

Presurgical NAM using either a passive or active NAM technique produced similar facial growth patterns after unilateral cleft lip and palate repair.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

A comprehensive review of surgical techniques in unilateral cleft lip repair

Unilateral cleft lip is a common congenital anomaly that affects the appearance and function of the upper lip and nose. Surgical repair of cleft lip aims to restore the normal anatomy and functionality of the affected structures. In recent years, several advances have been made in the field of cleft lip repair, including new surgical techniques and approaches. This comprehensive review discusses the surgical management of patients with unilateral cleft lip and palate and provides step-by-step instructions for the surgical procedures.

Stability of nasal symmetry following primary cleft lip and nasal repair: five years of follow-up

Despite advances in cleft lip treatment, various levels of residual deformity remain after primary repair of cleft lip and palate. The aim of the current study was to compare the stability of short- and long-term postoperative nasal symmetry. This retrospective study included 100 consecutive non-syndromic patients with unilateral complete cleft lip who underwent primary cleft lip repair with follow-up of 5 years. Measurements taken from basal and frontal standard photograph views, obtained preoperatively (T1) and immediately (T2), 1 year (T3), and 5 years postoperative (T4), were analysed. Paired and independent t-tests were applied to assess the significance of differences and relationships, while the inter-class correlation coefficient was used to assess reliability; P < 0.05 was considered significant. The male to female ratio was 1:1; mean age at the time of surgery was 0.43 ± 0.25 years. All patients showed significant improvements following unilateral complete cleft lip repair. All variables measured at T3 revealed a significant relapse when compared to T2, except alar base position, which showed a constant mean across all postoperative follow-ups. Late relapse (T3-T4) was not significant for alar collapse, alar base position, or columellar angle (all P > 0.05). On the other hand, columellar height (P = 0.003), and nostril height (P = 0.038) and width (P = 0.007) showed significant improvements during the late relapse period. In conclusion, the majority of the relapse and changes following the nasal cleft repair occurred within the first postoperative year. However, nasal asymmetries tended to remain stable or reduced during the first 5 postoperative years.

Efficacy of Post-Surgical Nostril Retainer (PSNR) in patients with UCLP Treated with Pre-Surgical NasoAlveolar Molding (NAM) and Primary Cheiloplasty-Rhinoplasty

OBJECTIVE

The aim of this investigation is to determine if the nasal form of patients with unilateral cleft lip and palate (UCLP) treated with pre-surgical nasoalveolar molding (NAM) therapy, primary lip-nose surgery, and post-surgical Nostril Retainer (PSNR) is different from patients treated with pre-surgical NAM and primary lip and nose surgery alone.

DESIGN

A cross-sectional, retrospective review of 50 consecutive non-syndromic patients with UCLP: 24 treated with NAM and primary lip-nose surgery followed by PSNR (Group I) compared to 26 patients treated with NAM and primary lip-nose surgery without PSNR (Group II). Polyvinyl siloxane nasal impressions were performed at the average age of 12 months and 6 days. Bilateral measurements of alar width at maximum convexity, total alar base width, nasal tip projection, columella length, and nostril aperture width and height were recorded. Statistical comparison of cleft versus non-cleft side nasal measurements were performed within Group I and Group II, as well as comparison of the difference between the two groups.

RESULTS

Cleft side nasal dimension was statistically significantly better in Group I than Group II across all measures except nasal projection (P<0.05). Group I showed less difference between the cleft and non-cleft side in all six measurements than Group II (p<0.05).

CONCLUSION

There is a significant difference in the nasal shape of patients who underwent PSNR compared to those that did not. The patients who used PSNR showed better nasal shape at the average age of 12 months than the control group.

Three-dimensional Analysis of Factors Related to the Effective Alveolar Molding in Presurgical Infant Orthopedics: Findings From a Pilot Study

OBJECTIVE

Presurgical infant orthopedics (PIO) reduces the severity of the original cleft and burden on patients and their parents, provides better esthetics and function, and enables surgeons to achieve better surgical repair. To reduce the alveolar cleft width and to predict treatment difficulty using PIO, various measures were examined in pretreatment cast models.

DESIGN

Retrospective case-control pilot study.

PATIENTS

The patients were 22 infants with non-syndromic unilateral cleft lip and palate (UCLP), and cast models of these infants were used.

METHODS

After PIO using passive plates, infants with UCLP were divided into two groups: contact group (12 cases with close proximity of the greater and lesser segments) and non-contact group (10 cases without proximity of segments). The two groups were compared, and variables related to the proximity between alveolar clefts were examined.

RESULTS

There was no significant difference in age at PIO initiation between the two groups. However, the treatment duration was significantly longer in the non-contact group than in the contact group. Among the 13 variables, the initial lateral deviation of the nasal septum was significantly larger in the contact group than in the non-contact group. A significant positive correlation was observed between the initial lateral deviation of the nasal septum and reduction of the alveolar cleft width by PIO.

CONCLUSION

Initial lateral deviation of the nasal septum is a predictive factor for the proximity between alveolar segments in infants with UCLP at the PIO.

Application of a Novel Nasal Clip for Nostril Retention After Primary Unilateral Cleft Rhinoplasty

OBJECTIVE

This study aimed to investigate the outcomes of using a novel nasal clip designed for nostril retention after primary unilateral cleft rhinoplasty.

DESIGN

This is a retrospective study.

SETTING

Department of Cleft Lip and Palate in a stomatological hospital.

PATIENTS

A retrospective study was conducted on 57 patients who had a unilateral complete cleft lip without cleft palate and underwent primary surgical repair.

INTERVENTIONS

The patients were categorized into 3 groups: the group in which the conventional nasal retainer was used, that in which the nasal clip was used, and the control group in which no postoperative nasal retainer was used. The nasal retainer or our nasal clip was applied 7 days after primary surgical repair and kept in the nostrils of children from 6 to 12 months.

MAIN OUTCOME MEASURES

Noses underwent photogrammetry preoperatively, postoperatively, and at follow-up. The nose was also subjectively scored at the follow-up.

RESULTS

The nasal retainer and the nasal clip significantly minimized relapse as determined by nasal tip deviation. The nasal clip sustained nasal symmetry, as determined by the postoperative nostril width ratio, better than did the conventional retainer. After 6 to 12 months, the nasal clip achieved better columellar morphology and a more symmetric nasal base than did the conventional nasal retainer. Statistical differences in subjective scores between the control and nostril retention groups were noted.

CONCLUSION

The application of the novel nasal clip after primary unilateral cleft rhinoplasty preserves nasal morphology and reduces postoperative relapse without the need for adhesive tape.

The effect of botulinum toxin A in unilateral cleft lip scar: comparison of results with different sites of injection

Botulinum toxin type A (BTA) injections into the subjacent orbicularis oris muscle have been shown to improve appearance and produce narrower cheiloplasty scars. This study was performed to determine the effect of BTA injected at different sites on the unilateral cleft lip scar and cleft side nostril width. A double-blind, randomized prospective trial was conducted involving 64 consecutive patients with unilateral cleft lip undergoing primary cheiloplasty between September 2016 and January 2019. The patients were randomized to receive BTA injections either into the subjacent orbicularis oris muscle (4 points group) or into the bilateral nasolabial fold region (6 points group) during cheiloplasty. The scars were assessed by photographic scar width measurements and Vancouver scar scale assessment tool. The cleft side nostril width was compared to the non-cleft side width. Fifty-six patients completed the trial, 24 in the 4 points group and 31 in the 6 points group. There was no significant difference in scar width or nostril width measurements between the groups at the end of follow-up. The Vancouver scar scale assessment was also similar between the groups. There was no significant difference in scar width or nostril width measurements after cleft lip repair between patients treated with botulinum toxin injections to the subjacent orbicularis oris muscle and patients treated with injections in the nasolabial region.

Long-Term Comparison of the Aesthetic Outcomes between Nasoalveolar Molding- and Non-Nasoalveolar Molding-Treated Patients with Unilateral Cleft Lip and Palate

BACKGROUND

The cleft lip-nose deformity in unilateral cleft lip and palate is one of the most challenging problem for surgeons to correct. Although nasoalveolar molding has been shown to be effective in improving presurgical symmetry in patients with complete unilateral cleft lip and palate, there is need for better evidence regarding the long-term nasolabial aesthetics of patients who have received this therapy.

METHODS

Thirty-eight patients treated with nasoalveolar molding and 48 patients not treated with nasoalveolar molding (but otherwise treated similarly) with unilateral cleft lip and palate were studied to assess and compare the nasolabial aesthetics. The objective evaluation of the nasal symmetry was performed on the basal view of two-dimensional photographs and the subjective nasolabial aesthetic evaluation was performed using the Asher-McDade scale.

RESULTS

At 5-year postoperative follow-up, nasoalveolar molding group patients had better mean values on the objective scores; however, these were not statically significant. The nasoalveolar molding group of patients had a statistically significant improvement in the subjective evaluation in comparison to the non-nasoalveolar molding-treated patients. The number of lip revisions was also statistically higher in the non-nasoalveolar molding-treated group of patients.

CONCLUSIONS

In this retrospective, single-center study, the authors found that at 5-year postoperative follow-up, nasoalveolar molding-treated patients had improved nasolabial aesthetics and fewer revision operations. These are, however, preliminary results and the patients will be followed up until the end of growth to assess the longer term effects of nasoalveolar molding on the nasolabial aesthetics in unilateral cleft lip and palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Nasal molding prevents relapse of nasal deformity after primary rhinoplasty in patients with unilateral complete cleft lip: An outcomes-based comparative study of palatal plate alone versus nasoalveolar molding

Objectives

In recent years, many studies have reported that the presurgical nasoalveolar molding method improves the nose morphology; however, the reason for its effectiveness after surgery has never been understood. We evaluated the effect of nasoalveolar molding by comparing it with a passive orthopedic method without a nasal stent and focusing on the nostril morphology after primary cheiloplasty using various measurement methods. We then analyzed the essential factors.

Materials and methods

The patients involved were 31 infants with unilateral complete cleft lip and palate treated with primary cheiloplasty at the University of Tsukuba Hospital from 2004 to 2011. Of the 31 infants, 16 received nasoalveolar molding treatment and 15 received passive orthopedic treatment as controls. Photographic facial measurements were performed for all patients immediately and 7 months after primary cheiloplasty. The esthetics of the nostrils were assessed according to the left–right nostril symmetry, as measured by the Hausdorff distance, area ratio, perimeter ratio, and aspect a/u (the aspect ratio of the affected side)/(the aspect ratio of the unaffected side) ratio. In addition, the inclination of the nasal ridge was assessed using anthropometric measurements (Grc‐Grn∠midline and midline∠columellar axis).

Results

The area ratio, perimeter ratio, and Grc‐Grn∠midline were significantly greater in the nasoalveolar molding group immediately after surgery (p = 0.00062, 0.016, and 0.048, respectively) than in the control group. However, the Hausdorff distance and aspect a/u ratio were more favorable (p = 0.0018 and 0.0039, respectively) in the nasoalveolar molding group after 7 months.

Conclusions

The results of our study suggested that using nasoalveolar molding as a presurgical orthopedic treatment could improve the shape of the nasal cartilage with surgeon's corrections.

Comparative evaluation of nasal and alveolar changes in complete unilateral cleft lip and palate patients using intraoral and extraoral nasoalveolar molding techniques: randomized controlled trial

Objectives

Cleft lip and palate is a common congenital anomaly that impairs the aesthetics, speech, hearing, and psychological and social life of an individual. To achieve good aesthetic outcomes, presurgical nasoalveolar molding (NAM) has become important. Currently, the intraoral NAM technique is widely practiced. Numerous modifications have been made to intraoral NAM techniques, but the original problem of compliance leading to discontinuation of treatment remains unsolved. Therefore, the present study compared an extraoral NAM technique with the intraoral NAM technique.

Materials and Methods

Twenty infants with complete unilateral cleft lip and palate were included and divided into two equal groups. Group A received the intraoral NAM technique, and Group B received the extraoral NAM technique. Pre- and postoperative extraoral and intraoral measurements were recorded.

Results

Groups A and B did not differ significantly in any extraoral or intraoral parameter.

Conclusion

The extraoral NAM technique is as effective as the intraoral NAM technique in achieving significant nasal and alveolar changes in com-plete unilateral cleft lip and palate patients. Additionally, it reduces the need for frequent hospital visits for activation and the stress associated with the insertion and removal of the intraoral NAM plate, thereby improving compliance.

Nasal asymmetry changes during growth and development in 6- to 12-year-old children with repaired unilateral cleft lip and palate: A 3D computed tomography analysis

Repaired unilateral cleft lip and palate (UCLP) is often accompanied by the deformity and asymmetry of the nasal region. Three‐dimensional analysis was performed to investigate the relationship between nasal soft‐ and hard‐tissue asymmetries, as well as the changes in nasal asymmetry with age, among children with repaired UCLP (age: 6–12 years). Forty‐seven patients were included in this study. Their computed tomography records were retrieved for analysis of the 3D asymmetry of 10 landmarks of the nasal soft and hard tissues. We observed that asymmetry was more severe in nasal hard tissues than in soft tissues, particularly in the sagittal dimension. Compared with patients aged 6–9 years old, patients aged 10 to 12 years old had significantly increased vertical asymmetry at the base of the alar groove (Gbase, p = 0.027) and the lateral point of the piriform aperture (LPA), (p < 0.001). The correlation between the LPA and the alar region was weak to moderate (r = 0.290 to 0.488). In conclusion, we found no evidence of growth and development in nasal hard‐tissue asymmetry among 6‐ to 12‐year‐old children with repaired UCLP, except for the vertical dimension. Nasal soft tissue exhibited a more preferable symmetry than hard tissue, and this could be attributed to the compensatory growth of nasal soft tissue, particularly in the vertical and sagittal dimensions. The weak to moderate correlations between nasal soft‐tissue asymmetry and hard‐tissue asymmetry were observed in the three dimensions. Surgeons should consider these factors when repositioning the nasal alar and controlling the size of the nostrils.

Furlow Palatoplasty for Velopharyngeal Dysfunction Management: Auditing and Predicting Outcomes

OBJECTIVE

The Furlow palatoplasty is a proven procedure in the management of secondary velopharyngeal dysfunction in patients with cleft palate. But the selection of cases, the degree of clinical success, and the preoperative predictors of the same are less established. This study is an effort to retrospectively look at outcomes, in a large series of velopharyngeal dysfunction cases treated with the Furlow palatoplasty alone.

DESIGN

Retrospective analysis of preoperative and postoperative speech and videofluoroscopic data.

SETTING

Tertiary care center.

PATIENTS/PARTICIPANTS

Ninety-two patients who were diagnosed with velopharyngeal dysfunction post primary cleft palate repair.

INTERVENTIONS

Furlow palatoplasty for velopharyngeal dysfunction post primary cleft palate repair.

MAIN OUTCOME MEASURES

Variables analyzed were perceptual speech parameters and, closure ratios obtained from lateral video-fluoroscopic images.

RESULTS

Overall, 81.5% had postoperative improvements in their lateral video-fluoroscopic parameters, 63% improved their nasality scores, and 65.2% had improved speech intelligibility. A simple linear regression was done to predict the postoperative closure ratio. Preoperative closure ratio, hypernasality (moderate and severe), and audible nasal air emission are predictors for postoperative closure ratio.

CONCLUSIONS

The Furlow palatoplasty alone led to complete resolution, or significant improvement of velopharyngeal dysfunction in a majority of patients, despite the cohort having a wide range of severity in terms of degree of dysfunction. The predictive formula will be validated in a further study.

The Effectiveness of Preoperative Correction Techniques in Improving Nasal Deformity in Children With Unilateral Complete Cleft Lip and Palate

OBJECTIVE

Unilateral complete cleft lip and palate (UCCLP) is associated with apparent nasal deformities before the cheilorrhaphy. The aim of this study was to determine whether preoperative correction techniques are effective in the treatment of nasal deformities in infant with unilateral UCCLP used by the systematic review and meta-analysis.

METHODS

We searched Medline, Cochrane Library, EMBASE, PubMed, and Chinese BioMedical Literature Database (CBM) until January 31, 2019, to identify studies that compared the effectiveness of preoperative correction techniques in the treatment of nasal deformities in infant with UCCLP. Two authors individually extracted the data and performed the quality assessments. The height of nasal columella, the width of the affected side nasal ala and the inclination of the nasal columella were evaluated.

RESULTS

Seven articles were incorporated into the systematic review, and 5 (274 participants) in the meta-analysis according to the inclusion criteria. The preoperative correction could increase the height of nasal columella in children with UCCLP [SMD: 2.64 mm; 95% confidence intervals (CI); (1.35 mm, 3.94 mm); P < 0.0001]. Moreover, the preoperative correction resulted in reduced width of the affected side nasal ala [SMD: -5.14 mm; 95% CI; (-8.96 mm, -1.31 mm); P = 0.008]; However, the evidence was insufficient to determine a significant effect on the inclination of the nasal columella [SMD: -3.48 degrees; 95% CI; (-7.56 degrees, 0.59 degrees); P = 0.09].

CONCLUSIONS

Preoperative correction for children with UCCLP can increase the height of nasal columella, reduce the width of the affected side nasal ala, improve the nasal symmetry, and reduce nasal deformity, however, no significant effect could be observed for the inclination of the nasal columella.

Presurgical Orthopedic Intervention Prior to Cleft Lip and Palate Repair: Nasoalveolar Molding Versus Passive Molding Appliance Therapy

BACKGROUND

Nasoalveolar molding (NAM) is a widely used presurgical orthopedic device, despite disputes over its effectiveness. This study compares the outcomes after cleft lip and nose repair in patients who received NAM versus those who underwent passive alveolar molding with lip taping.

METHODS

A retrospective review of patients with complete unilateral cleft lip and palate who received either NAM (n = 16) or passive molding (n = 10) treatments was conducted. Alveolar gap width was measured on maxillary casts until time of palatoplasty. Nasolabial symmetry was assessed by examining anthropometric ratios on post-operative three-dimensional photographs. Burden of care was evaluated by analyzing the number of patient appointments attended, treatment costs, and caregiver satisfaction surveys.

RESULTS

No statistically significant difference existed in alveolar gap at time of initial appointment or palatoplasty, however the gap was smaller in the NAM cohort at time of lip and nose repair. No statistically significant difference existed in postsurgical heminasal width, nostril width, nostril height, labial height or nasal ala projection asymmetry between the NAM and the passive molding cohort. Patients in the NAM group attended more dental appointments and incurred higher treatment costs compared to the passive molding group. Caregivers reported high satisfaction with treatment outcomes in both cohorts.

CONCLUSIONS

There were no differences between NAM and passive molding regarding postsurgical nasolabial appearance and patient satisfaction. Both treatments narrow the alveolar gap. However, NAM places a higher burden of care on families.

Three-Dimensional Nasolabial Changes After Nasoalveolar Molding and Primary Lip/Nose Surgery in Infants With Bilateral Cleft Lip and Palate

OBJECTIVE

Utilize 3-dimensional (3D) photography to evaluate the nasolabial changes in infants with bilateral cleft lip and palate (BCLP) who underwent nasoalveolar molding (NAM) and primary reconstructive surgery.

DESIGN

This is a retrospective serial longitudinal study of consecutively enrolled infants from September 2012 to July 2016 with BCLP who underwent NAM before primary lip and nose reconstructive surgery. It included infants who had digital 3dMD stereophotogrammetry records at initial presentation (T1), completion of NAM (T2), and 3 weeks following primary repair (T3). Twelve infants fulfilled the inclusion criteria. 3dMD Vultus software was used to orient images and plot 16 nasolabial points with x, y, z coordinates to obtain the linear and angular measurements. Nasal form changes were measured and analyzed between T1 (0.5 months old), T2 (5 months old), and T3 (6 months old). Intraclass correlation coefficient was performed for intrarater reliability. Averaged data from the 3D images was statistically analyzed from T1 to T2 and T2 to T3 with Wilcoxon tests. Unaffected infant norms from the Farkas publication were used as a control sample.

RESULTS

After NAM therapy, statistically significant changes in the position of subnasale and labius superius improved nasolabial symmetry. Both retruded after NAM were displaced downward after NAM and surgical correction with respect to soft tissue nasion. The nasal tip's projection was maintained with NAM and surgical correction. The columella lengthened from 1.4 to 4.71 mm following NAM.

CONCLUSIONS

There was a significant improvement in the nasolabial anatomy after NAM, and this was further enhanced after primary reconstructive surgery.

NAM-help or burden? Intercultural evaluation of parental stress caused by nasoalveolar molding: a retrospective multi-center study

Objectives

Nasoalveolar molding (NAM) was developed to facilitate easier treatment and better outcomes for cleft lip and palate (CLP) patients. The aim of this study was to investigate the parental burden and possible intercultural differences of this treatment modality, which is often argued to burden parents to an extraordinary amount.

Materials and methods

Standardized questionnaires (available in English, Mandarin, and German) with 15 non-specific and 14 NAM-specific items to be retrospectively answered by Likert scales by parents of unilateral CLP patients with completed NAM treatment.

Results

The parents of 117 patients from two treatment centers in Taiwan and Germany were included. A very high level of overall satisfaction was found in both countries with significant intercultural differences in prenatal parent information, feeding problems, dealing with 3rd party’s perception, and experienced personal effort.

Conclusion

NAM is an effective treatment tool for children’s CLP deformities and their caregivers in overcoming the feeling of helplessness. Intercultural differences may be due to infrastructural reasons, cultural attitudes and habits, or different public medical education.

Clinical relevance

In addition to facilitating easier surgical treatment, NAM can be seen as a powerful coping strategy for parents dealing with a CLP deformity of their child and does not seem to burden them extraordinarily.

Function of Nasoalveolar Molding Devices in Bilateral Complete Cleft Lip and Palate: A 3-Dimensional Maxillary Arch Analysis

OBJECTIVE

This study aimed to observe and analyze the effects of nasoalveolar molding (NAM) on maxillary arch dimensions in patients with bilateral complete cleft lip and palate (BCLP) using 3-dimensional analyses.

DESIGN

Retrospective case series.

MATERIALS AND METHODS

Seventeen infants were treated using modified Khon Kaen University presurgical nasoalveolar molding devices (KKU-NAM). Dental casts were evaluated 3 dimensionally at 3 time points: pretreatment (T1), after using modified KKU-NAM for 2 weeks (T2), and before cheiloplasty (T3). Repeated-measures analysis of variance and Friedman test were used to compare the maxillary arch dimensions between time points.

RESULTS

Both sides of the cleft width, premaxilla deviation, and premaxilla protrusion had significantly reduced with the use of KKU-NAM. Premaxillary rotation had significantly improved, whereas the arch depth did not change significantly. Premaxilla width, posterior arch width, alveolar length, and height had significantly increased. The anterior arch width, intercanine width, and lateral sulcus width showed no significant changes. The intraclass correlation coefficient used to test the measurements indicated substantial reliability.

CONCLUSION

The modified KKU-NAM is an effective device for reducing the severity of bilateral cleft deformities, especially in the premaxilla area.

Variational Characteristics of Nasolabial Appearance and Its Influencing Factors for the Unilateral Cleft Lip Repair With Modified Huaxi Technique

PURPOSE

After many years in clinical practice, the authors found that the long-term aesthetics of the upper lip and nose following repair of a unilateral cleft lip deformity using the Huaxi method remained unsatisfactory. The immediate postoperative effect was often good, while the long-term postoperative effect was poor. Therefore, this study aimed to evaluate the characteristics and influencing factors of a modified Huaxi method for repairing unilateral cleft lip over time, and to explore the relationship between immediate and long-term outcomes after cleft lip surgery.

METHODS

Patients with unilateral cleft lip who visited the Department of Maxillofacial Surgery of the Stomatological Hospital of Zunyi Medical University from June 2014 to March 2016 were selected. The study group consisted of 51 consecutive patients (30 boys and 21 girls), aged between 3 months and 2 years. Of these, 24 presented with complete unilateral cleft lip (12 wore a nasoalveolar mold as required, 12 did not) and 27 with incomplete unilateral cleft lip (13 wore a nasoalveolar mold as required, 14 did not). Photographs were taken of 51 patients before surgery and immediately, 7 days, and 6 months postoperatively. Various indexes of nasolabial contour of each patient were measured using iWitness photogrammetry, and the slit width; lip height ratio, lip width ratio, nostril width ratio, and nostril height ratio of the healthy side; and degree of deviation of the nasal columella were calculated.

RESULTS

Long-term symmetry of lip height and width remained stable postoperatively (P > 0.05), whereas nostril height symmetry was significantly reduced (P > 0.05). Nasal width symmetry and midpoint deviation of the nasal columella were stable in patients with nasoalveolar molding (P > 0.05), but significantly decreased in patients without nasoalveolar molding (P < 0.05). In patients with complete unilateral cleft lip, there was a significant correlation between fissure width and lip width symmetry 6 months postoperatively (r = 0.431, P < 0.05).

CONCLUSIONS

The symmetry of the upper lip is satisfactory and stable following surgical repair with the modified Huaxi technique. However, undercorrection of nasal symmetry is commonplace. Fissure width and nasoalveolar molding may influence long-term aesthetics following unilateral cleft lip repair.

Does Infant Orthopedics and Neonate Lip Surgery Influence the Occlusal Relationship in Patients With Unilateral Cleft Lip and Palate (UCLP)?

OBJECTIVE

To compare occlusal relationship in patients undergoing neonate versus conventional lip surgery (LS) with and without infant orthopedics (IO) by assessment of dental arch relationship in individuals with complete unilateral cleft lip and palate.

MATERIAL AND METHODS

Three groups treated by different protocols; Group I: neonate LS (1-15 days) + IO and palatoplasty (13-31 months); Group II: LS (3-12 months) + IO and palatoplasty (15-35 months); and Group III: LS (3-6 months) without IO and palatoplasty (12-18 months). The 112 intraoral photographs of individuals of all groups, obtained between 6 and 12 years of age, were assessed by the occlusal index for intraoral photograph rating. The groups were compared by the χ² test. The correlation between surgical timing and the scores was tested by the Spearman test (P < .05).

RESULTS

Group I presented the highest percentage of score 5, group II exhibited highest percentage of score 1, and group III presented the lowest percentage of score 5 according to the χ² test (P = .029). The Spearman correlation test revealed statistically significant difference between timing of LS and the occlusal index. The earlier the surgical timing, the higher the occlusal index (P = .019).

CONCLUSIONS

Infant orthopedics has demonstrated the possibility of postponing primary plastic surgeries. Patients submitted to late lip and palate repair had the best prognosis, while patients undergoing lip repair from 1 to 15 days of life, even operating the palate later, had the worst prognosis. Neonate LS negatively influenced the occlusal relationships.

A Three-Dimensional Study of the Nasolabial Soft Tissue Symmetry in Children With Unilateral Complete Cleft Lip and Palate Using Traditional and Split-Type Nasoalveolar Molding

BACKGROUND

Presurgical nasoalveolar molding (NAM) is the most common preoperative treatment for cleft lip and palate. However, NAM may have some limitations such as requiring high technical sensitivity and frequent visits. To simplify the device, some scholars have changed the traditional NAM into a split-NAM consisting of a alveolar molding plate and a nasal hook. This study compared the shaping effect of split NAM and traditional NAM on nasolabial soft tissue using three-dimensional (3D) measurement.

METHODS

A total of 39 patients with unilateral cleft lip and palate (UCLP) were enrolled and divided into 2 groups. 13 patients were treated with split-NAM while the other 26 patients were treated with traditional NAM. 3D images of all patients' craniofacial soft tissue before and after NAM treatment were recorded and measured by three-dimensional software. Statistical analysis of measurements in both groups was performed using SPSS software.

RESULTS

After treatment, nasal soft tissue symmetry in the split-NAM group was better improved than that in the NAM group in vertical and anterior-posterior direction, but was worse improved in transverse direction. There was no significant difference in labial soft tissue symmetry between two groups.

CONCLUSIONS

The split NAM can better elevate the alar and nostrils of the cleft side, and have a better forward effect on alar outer edge, nasal base, and nostrils. However, the traditional NAM can better reduce the width of nasal base.

Primary Cleft Rhinoplasty: Surgical Outcomes and Complications Using Three Techniques for Unilateral Cleft Lip Nose Repair

BACKGROUND

This study represents a single surgeon's 10 years of experience addressing unilateral cleft lip and palate nose deformity. The purpose was to compare surgical outcomes and related complications using 3 different techniques to improve nasal shape in primary unilateral cleft rhinoplasty.

METHODS

This retrospective study with Institutional Ethical Committee approval compares 3 groups of patients with unilateral cleft lip nose and palate who were operated on using different techniques from 2007 to 2017. Surgical outcomes were analyzed by physical examination at least 1 year after primary rhinoplasty. Anthropometric measurements were obtained for the cleft and noncleft sides of the nose.

RESULTS

Approach with general analysis indicated differences among the 3 techniques. The author's comparative study revealed differences in nose symmetry and related complications, including increased recurrence of nose deformity using the modified McComb technique. Better short-term nose symmetry was observed using Potter technique and the V-Y-Z rhinoplasty.

CONCLUSIONS

Potter approach and the V-Y-Z techniques achieve better short-term nose symmetry than the McComb method. Complications were less common in the group of patients operated on using the modified McComb technique. Additional studies are required to evaluate functional and long-term outcomes after primary rhinoplasty using the proposed methods.

Short-Term Efficacy of Presurgical Vacuum Formed Nasoalveolar Molding Aligners on Nose, Lip, and Maxillary Arch Morphology in Infants With Unilateral Cleft Lip and Palate: A Prospective Clinical Trial

OBJECTIVES

The purpose of this study was to evaluate the short-term effect of series of preadjusted vacuum formed nasoalveolar molding VF NAM aligners on the morphology of nose, lip, and maxillary arch in infants with unilateral cleft lip and palate (UCLP).

DESIGN

Prospective clinical trial.

SETTING

Unilateral cleft lip and palate patients referred to outpatients' clinic.

PATIENTS

Sixteen nonsyndromic infants with UCLP, less than 2 months of age were included from April 2017 to April 2018.

INTERVENTIONS

All infants received VF NAM therapy. Standardized digital frontal and basilar photographs and 3D digital models were taken before initiation of VF NAM therapy (T1) and after completion of VF NAM therapy (T2).

MAIN OUTCOME MEASURE(S)

Changes in morphology of the nose, lip, and maxillary arch.

RESULTS

Statistical analysis comparing T1 and T2 measurements was performed. Frontal and basilar photographic analysis showed a statistically significant reduction of columella displacement, interlabial gap distance, and nostril width at cleft side (CS), while the nasal height, nostril height at CS, nostril width at noncleft side (NCS), columella deviation angle, nasal tip protrusion, and nostril area at both CS and NCS increased significantly with VF NAM therapy. The nasal width, nostril height at NCS showed no significant change after presurgical VF NAM aligners therapy. The analysis of digital models demonstrated a statistically significant reduction of alveolar cleft width, anterior arch width, arch length, midline deviation, and palatal cleft width, while the posterior arch width and arch perimeter increased significantly with VF NAM therapy.

CONCLUSION

Vacuum formed NAM therapy was effective in reducing the nasoalveolar deformities associated with infants with UCLP and improved the alveolar morphology and nasal symmetry.

[Application of nasal clip in the one-stage repair of unilateral cleft lip nasal deformity]

OBJECTIVE

To investigate the application of nasal clip in the one-stage repair of unilateral cleft lip nasal deformity.

METHODS

Sixty patients with unilateral cleft lip nasal deformity underwent one-stage repair in the Department of Cleft Lip and Palate, West China Hospital of Stomatology, Sichuan University, from January 2017-June 2018. Sixty patients were divided into three groups, nasal clip group, the nasal module group, and the control group. All of the patients were returned to the clinic after the operation (6-12 months), and the nasal appearance was evaluated.

RESULTS

The nasal shape development and aesthetic effect in the nasal clip group were significantly improved than that in the control group (P<0.05).

CONCLUSIONS

The nasal clip has a good effect on the improvement of nasal appearance after the one-stage repair of unilateral cleft lip nasal deformity. The nasal clip is easy to operate, and the patient compliance is good, which is worthy of clinical promotion.

Surgical Nasoalveolar Molding: A Rational Treatment for Bilateral Cleft Lip Nose and Systematic Review

Background:

The purpose of this study was to evaluate the surgical outcome after using primary surgery to address bilateral cleft lip nose and palate deformities. In addition, the authors performed a systematic review to evaluate the effects of the nasoalveolar molding on non-syndromic bilateral cleft lip and palate.

Methods:

A prospective cohort study on a surgeon’s surgical outcome of 25 consecutively performed primary bilateral cleft lip nasal deformity repairs was conducted and a systematic review of the literature for studies published until December 2019 was done to evaluate the effect of presurgical NAM on nasolabial aesthetics and alveolar gap.

Results:

Since 2014, 25 consecutive patients with complete bilateral cleft have undergone primary anatomical repair of the cleft nasal deformity using primary cheilorhinoplasty. The average columella length was 4.3 ± 1.3 mm. The average ratio of the columella height to nasal height was 0.48 mm 1 year postoperatively and 0.52 mm 5 years postoperatively. Statistically significant differences have been observed between the pre and postoperative alveolar and palatal gaps after using primary cheiloplasty or bilateral lip adhesion. After systematic literature searching, 14 identified studies were qualified for the final analysis, which included 433 patients. The overall study quality according to Oxford CEBM and GRADE scale was low.

Conclusions:

The results of this study suggest that the proposed primary cheilorhinoplasty is a good alternative to improve nose appearance and alveolar gap in patients with primary bilateral cleft lip nose and palate deformity. Based on the available scientific evidence, definitive conclusions about the effectiveness of presurgical Naso Alveolar Molding on nasolabial aesthetics cannot be drawn. Quality of the included articles were too low to make a conclusion.

The Effects of Nasoalveolar Molding on Nasal Proportions at the Time of Nasal Maturity

BACKGROUND

The aim of this study is to assess the effect of nasoalveolar molding (NAM) versus no-NAM on nasal morphology in patients with unilateral cleft lip and palate (UCLP) at the time of nasal maturity.

METHODS

A retrospective, single-institution review was conducted on all non-syndromic patients with UCLP. Inclusion criteria included age 14 years or above, unilateral cleft repair at the time of infancy, and adequate photography taken at nasal maturity and prior to rhinoplasty. Exclusion criteria included age less than 14 years, syndromic diagnosis, and rhinoplasty prior to nasal maturity. Ten parameters were measured twice from standardized clinical photographs using the Dolphin Imaging Software for establishment of intrarater reliability. Subjective analysis was achieved through completion of the Asher McDade grading scale by 3 expert cleft practitioners.

RESULTS

Nostril height, columellar angle, alar cant, vertical alar height, alar height angle, nasofacial angle, and nasolabial angle were found to be significantly less severe in patients who had undergone NAM in conjunction with surgical repair when compared with those who had undergone surgical repair alone. Asher McDade grading revealed significant improvement in nasal form, nasal symmetry/deviation, nasal profile, vermillion border, and overall score in patients who underwent NAM compared to no-NAM.

CONCLUSION

The use of presurgical NAM during infancy can improve nasal symmetry and nasal proportions at the time of nasal maturity.

A Longitudinal Study of The Nasal Symmetry in Unilateral Cleft Lip And Palate Patients Treated With Nasoalveolar Molding

Background  Nasoalveolar molding (NAM) has been extensively used as a presurgical technique in the treatment of unilateral cleft lip and palate (UCLP) over the last two decades. It has proven to be a useful tool to reduce the cleft size, improve nasal symmetry, and increase the columellar length. The long-term stability of these findings has not been conclusively proven.

Methods  In this longitudinal study, the nasal symmetry of 24 NAM treated UCLP patients was evaluated to assess the 5-year stability of NAM. The basal photographs were shot postcheiloplasty (T1), at 1-year follow-up (T2), at 3-year follow-up (T3), and 5-year follow-up (T4) appointments.

Results  In this study, we found that NAM was a useful adjuvant in achieving nasal symmetry in patients with UCLP in the immediate postoperative period. However, as the patients aged, there was a gradual loss of mean nasal height (by 22.83%) and columella length (by 24.89%), a mean gain in nasal width (by 40.25%) and alar base width (by 40.69%), and an increase in the columella deviation (by 3.46%) from the T1 to the T4 follow-up.

Conclusion  Although there is no conclusive evidence, the loss of symmetry may be due to the unequal growth on the cleft and noncleft sides. These patients will be followed-up till end of growth for a definite conclusion on the long-term effect of NAM.

A Surgical and Educational Video of the Inferior Turbinate Mucosal Flap for the Nasal Floor and Intraoral Reconstruction in Unilateral Complete Cleft Lip Repair

Since the original description of Millard rotation advancement principle for cleft lip repair, many important contributions have subsequently been described by other surgeons worldwide. However, the reconstruction of the nasal floor and intraoral lining has received less attention over time. This article demonstrates a modified unilateral complete cleft lip repair using the rotation advancement principle plus multipurpose inferior turbinate mucosal flap. The accompanying videos display the 10 key steps for rationale, design, and proper execution of the inferior turbinate mucosal flap for the nasal floor and intraoral reconstruction.

Management of the Nasal Deformity in the Unilateral Cleft of the Lip and Nose

Cleft rhinoplasty is a demanding, technique-sensitive procedure. Part art, part science; it poses several probing questions to the surgeon. The unilateral cleft nasal deformity is a distinct entity because the pursuit of symmetry in the unilateral cleft nose makes the repair much more challenging. The advent of nasoalveolar moulding, the gaining popularity of primary (early) nasal repair and greater refinements in secondary (definitive) rhinoplasty techniques have contributed to better nasal results in unilateral cleft repair. Yet, some obstacles remain. This paper aims to discuss the anatomy of the unilateral cleft nose, enumerate aims and objectives of repair at every stage, and to demonstrate the evolution and varied rationale of management of nasal deformities in the unilateral cleft lip and nose.