Effectiveness of a Novel 3D-Printed Nasoalveolar Molding Appliance (D-NAM) on Improving the Maxillary Arch Dimensions in Unilateral Cleft Lip and Palate Infants: A Randomized Controlled Trial

Treatment outcomes of digital nasoalveolar moulding in infants with cleft lip and palate: A systematic review with meta-analysis

The aim of this systematic review was to compare the treatment outcomes of digital nasoalveolar moulding (dNAM) technique with conventional nasoalveolar moulding (cNAM) or non-presurgical intervention protocol in infants with unilateral (UCLP) or bilateral (BCLP) cleft lip and palate. A bibliometric search by MEDLINE (via Ovid), Embase, Cochrane Library, grey literature and manual method was conducted without language restriction until November 2023. Literature screening and data extraction were undertaken in Covidence. The risk of bias was evaluated using the Newcastle-Ottawa Scale and RoB-2. Pooled effect sizes were determined through random-effects statistical model using R-Software, and the certainty of evidence was assessed using the GRADE approach. Among 775 retrieved articles, nine studies were included for qualitative synthesis (6-UCLP, 3-BCLP), with only three eligible UCLP studies for meta-analysis. In the UCLP group, very low certainty of evidence indicated no difference in alveolar cleft width (SMD, 0.13 mm; 95% CI, -0.31 to 0.57; I2, 0%), soft tissue (lip) cleft gap, nasal width, nasal height, and columellar deviation angle changes between dNAM and cNAM. In the BCLP group, qualitative synthesis suggested similar changes in alveolar, lip, and nasal dimensions with dNAM and cNAM. In both cleft groups (UCLP, BCLP), reduced alveolar cleft width was observed in the dNAM group compared to the non-presurgical intervention protocol, along with fewer clinical visits and reduced chairside time for dNAM compared to cNAM. It can be concluded that the treatment outcomes with dNAM were comparable to cNAM in reducing malformation severity and were advantageous in terms of chairside time and clinical visit frequency. However, the overall quality of evidence is very low and standardization is needed for the virtual workflow regarding the alveolar movements and growth factor algorithms. Registration: PROSPERO-database (CRD42020186452).

Application of 3D Printing in Cleft Lip and Palate Repair

This manuscript reviews the transformative impact of 3-dimensional (3D) printing technologies in the treatment and management of cleft lip and palate (CLP), highlighting its application across presurgical planning, surgical training, implantable scaffolds, and postoperative care. By integrating patient-specific data through computer-aided design and manufacturing, 3D printing offers tailored solutions that improve surgical outcomes, reduce operation times, and enhance patient care. The review synthesizes current research findings, technical advancements, and clinical applications, illustrating the potential of 3D printing to revolutionize CLP treatment. Further, it discusses the future directions of combining 3D printing with other innovative technologies like artificial intelligence, 4D printing, and in situ bioprinting for more comprehensive care strategies. This paper underscores the necessity for multidisciplinary collaboration and further research to overcome existing challenges and fully utilize the capabilities of 3D printing in CLP repair.

3-Dimensional Evaluation of Two PNAM Techniques (Modified Grayson & AlignerNAM) on Facial Soft Tissue Morphology: A Randomised Clinical Trial

OBJECTIVE

Evaluate facial changes after Presurgical Naso-Alveolar Molding (PNAM) in unilateral cleft lip and palate (UCLP) patients treated with Modified Grayson Technique and AlignerNAM (with DynaCleft nasal elevator) using a 3D facial scan.

DESIGN

Randomised clinical trial.

SETTING

Institutional study. Participants: 20 UCLP patients allocated to two groups (10 patients each).

INTERVENTIONS

Group A patients underwent PNAM with Modified Grayson Technique and Group B patients underwent AlignerNAM (with DynaCleft nasal elevator). Their 3D facial scans were obtained by using an iOSbased application (Bellus3D FaceApp) mounted on a novel frame. These .stl files were analysed using 3D software (GOM INSPECT) at three-time intervals; before intervention (T0), after intervention (T1) and one month after lip repair surgery (T2).

MAIN OUTCOME MEASURE(S)

Changes in facial and nasolabial morphology.

RESULTS

Both techniques brought significant improvement in the columellar length, nasal tip projection, columella angle, nasal tip angle and a significant reduction in cleft width. At T1, a statistically significant difference in angular and linear measurements was present in both groups. At T2, no statistically significant difference in linear parameters was observed between the two groups except for the outer lateral height of the non-cleft side, basal lateral height of the non-cleft side, and philtrum width. Similar pattern was observed in angular measurements with no statistically significant difference between the two groups except in nasolabial angle, anterior nasal base triangle III, and anterior nasal root triangle.

CONCLUSIONS

Aligner NAM and Modified Grayson technique are equally effective PNAM methods with similar clinical results in nasolabial morphology after lip repair surgery.

The accuracy and retention of presurgical infant orthopaedics constructed from different polymer materials: A comparative study

Objectives

This laboratory-based study aimed to evaluate and compare the accuracy and retention of moulding plates when used as pre-surgical orthopaedic appliances (PSIOs) for infants with cleft lip and/or palate (CL/P).

Methods

Ten moulding plates were fabricated from three different materials (total sample size: 30), including polymethyl methacrylate (PMMA), a hard clear aligner (PET-G polymer), and a dual-layered hard and soft clear aligner (mixed PET-G/EVA) on ten three-dimensional (3D) printed working models. Accuracy was evaluated by measuring the virtual gap between the data acquired from the moulding plate and the working model after the optical scanning at each of the designated 36 points for each plate. Exocad software was used to facilitate all virtual alignments and measurements. Retention was measured using a digital gauge that quantified the traction force required to separate the plates from the retention test cast (a soft resin printed cast).

Results

PET-G plates exhibited the best fit with the working cast, with overall adaptations of 0.146 ± 0.012 for PET-G, 0.250 ± 0.073 for PET-G/EVA, and 0.294 ± 0.113 for PMMA. For region-specific misfit, PET-G plates exhibited superior accuracy across all regions, with mean discrepancies of 0.16 ± 0.08 mm, 0.15 ± 0.061 mm, and 0.12 ± 0.128 mm in the anterior, middle, and posterior regions, respectively. Retention for PET-G was significantly higher than the other materials, with a mean of 3.34 N ± 0.487, as opposed to 1.65 N ± 0.331for PMMA and 1.27 N ± 0.239 for PET-G/EVA (P < 0.05).

Conclusions

Moulding plates constructed from PET-G exhibited a better fit and higher retention than those made from PET-G/EVA and PMMA.

Clinical significance

Collectively, our findings suggest that the selection of PET-G for PSIO appliances could have clinical significance by potentially improving treatment outcomes in infants with CL/P.

Use of nasal retainers in the primary management of cleft lip: Current practices in France

BACKGROUND

The primary surgical management of cleft lip (CL) or cleft lip and palate (CLP) aims to achieve harmonious lip and nasal symmetry while ensuring satisfactory ventilation. Postoperative nasal retainers are commonly used, though both duration of use and conformer type used vary widely. This study aimed to establish an inventory of current practices for primary cheilorhinoplasty and nasal retainer use in France.

METHODS

A survey was sent to surgeons within and outside the French National Clefts and Facial Malformations (MAFACE) network. Questions focused on age when primary cleft closure is performed, retainer types used, conformation duration, and estimated patient compliance. Responses were collected March-July 2023.

RESULTS

Thirty-two surgeons responded with substantial variations in practices. For isolated CL, the age for primary cleft closure was 1-6 months, with 28 % performing surgery at 3 months, 12.5 % between 3 and 6 months, 44 % at 6 months. In cases with CLP, 63 % performed simultaneous surgery at 6 months. Two surgeons (6 %) reported preoperative nasoalveolar molding and 30 surgeons (94 %) reported postoperative nasal retainer use. Retainer type used immediately after surgery varied, with equal use of commercial retainers (31 %), silicone sheets (31 %), and in-house retainers (31 %). Duration of retainer prescription was in majority 3-4 months. Notably, 44 % of surgeons reported <70 % adherence rates for the recommended conformation duration, while 25 % reported very good compliance.

CONCLUSION

Primary cheilorhinoplasty and nasal conformation practices are highly diverse in France. Suboptimal patient compliance demonstrates the need for improved retainer design and strategies to enhance compliance.

Advances in Cleft Lip and Palate Surgery

Cleft lip with or without cleft palate is one of the most common congenital malformations, with an average prevalence of 1 in 1000 live births. Cleft lip and/or palate is incredibly phenotypically diverse, with constant advancements and refinements in how we care for patients. This article presents an in-depth review of the latest advances and current evidence in cleft lip and palate surgery. This includes presurgical infant orthopedics, perioperative practice patterns including use of enhanced recovery after surgery (ERAS) protocols, patient-reported outcome measures, and the latest adjuncts in cheiloplasty and palatoplasty.

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

OBJECTIVES

The 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.

DESIGN

A cross-sectional clinical study.

PATIENTS/SETTING

The 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 MEASURES

Accuracy: 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).

CONCLUSION

PET-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.

Evaluation of Facial Esthetics Following NAM Versus CAD/NAM in Infants With Bilateral Cleft Lip and Palate: A Randomized Clinical Trial

OBJECTIVE

The aim is to compare the facial esthetics following nasoalveolar molding (NAM) versus computer-aided design NAM (CAD/NAM) in patients with bilateral cleft lip/palate (CLP).

DESIGN

The trial is a randomized comparative trial with a 1:1 allocation ratio.

PARTICIPANTS

Thirty infants with bilateral complete cleft lip and palate were recruited.

INTERVENTIONS

Patients were randomized between NAM and CAD/NAM groups. The treatment steps described by Grayson were followed for the NAM group. In the CAD/NAM group, digitized maxillary models were made to create a series of modified virtual models, which were used to fabricate the molding plates using 3-dimensional printing technology. The nasal stents were then added to the intraoral plates following the Grayson method. The study lasted for 4 months.

MAIN OUTCOMES

The assessment of the changes observed in the interlabial gap and nasolabial esthetics was done using standardized 2-dimensional photographs. The correlation between dental arch changes and extraoral facial esthetics was studied.

RESULTS

Both modalities showed improvement in nasolabial esthetics before the lip surgery. No statistically significant difference was found between NAM and CAD/NAM groups in any of the assessed variables.

CONCLUSIONS

Both interventions were effective in the management of infants with bilateral CLP.

Novel Digital Workflow for Nasoalveolar Molding and Postoperative Nasal Stent for Infants With Cleft Lip and Palate

OBJECTIVE

We present a novel digital workflow to provide presurgical infant orthopedic (PSIO) treatment for a patient with a unilateral cleft lip/palate utilizing nasoalveolar molding (NAM) and a custom postsurgical nasal stent.

SETTING

Within the US military healthcare system, the Joint Base San Antonio Craniofacial Anomalies Team utilizes dental scanners, predictive 3D modeling software, and 3D printing technology in a digital workflow for NAM appliance fabrication.

WORKFLOW

Soft tissue facial scanning, peri-oral scanning, and dental putty impressions are used to facilitate fabrication and measure outcomes. Digital modeling software and 3D resin printing are utilized to manufacture the prescribed devices.

MAIN OUTCOME MEASURES AND RESULTS

Extra-oral facial scans and intra-oral impressions are compared between 3 timepoints: pre-treatment, posttreatment with NAM, and postsurgical treatment.

CONCLUSIONS

The ability to share workflows, establish outcome standards, and streamline patient care will continue to advance best practices in digital PSIO.

Correlation between cleft width and dental arch symmetry in cleft lip and palate: a longitudinal study

This study aimed to evaluate the influence of cleft width on dental arch symmetry of children with unilateral cleft lip and palate. Forty-one children were subjected to impression preoperatively (T1; mean age = 0.31 ± 0.07 years) and postoperatively (T2; mean age = 6 .73 ± 1.02 years). Eighty-two digitized dental casts were analyzed by stereophotogrammetry software. The cleft palate width was measured in the anterior (P-P'), middle (M-M'), and posterior (U-U') regions. Also, the following measurements were obtained: anterior intersegment (I-C') and intrasegment (I-C); total intersegment (I-T') and intrasegment (I-T); cleft-side (C'-T') and non-cleft-side (C-T) canine tuberosity. Paired t test and Pearson correlation coefficient were applied (α = 5%). Cleft width had the following means: 10.16 (± 3.46) mm for P-P', 12.45 (± 3.00) mm for M-M', and 12.57 (± 2.71) mm for U-U'. In the longitudinal analysis, I-C' had a significant reduction, while the other measurements significantly increased (p < 0.001). Asymmetry was verified in the following analyses at T1: I-C' vs. I-C and I-T' vs. I-T (p < 0.001); at T2, only in I-C' vs. I-C (p < 0.001). At T1, P-P' vs. I-C' (r = 0.722 and p < 0.001), P-P' vs. I-T' (r = 0.593 and p < 0.001), M-M' vs. I-C' (r = 0.620 and p < 0.001), and M-M' vs. I-T' (r = 0.327 and p < 0.05) showed a positive and significant correlation. At T2, there was a correlation between M-M' and I-C' (r = 0.377 and p < 0.05). In conclusion, the anterior and middle cleft widths influenced palatal asymmetry in the first months of life, while middle width influenced residual asymmetry.

Protocols in the management of Cleft Lip and Palate: A Systematic Review

AIM

To identify clinical decisions on surgical as well as non-surgical modalities for the treatment of CLP patients based on randomized controlled trials (RCTs).

MATERIALS AND METHODS

PubMed, Ebscohost, and Cochrane Library were searched and 20 articles based on RCTs conducted on cleft patient management were identified.

RESULTS

The topics explored were infant orthopedics, lip and palate repair, alveolar bone grafting, and management of cleft maxillary hypoplasia. Nasoalveolar molding (NAM) was found to have great benefits when carried out within one month of birth. Fisher and Mohler's lip repair technique and use of recombinant human bone morphogenetic protein-2 (rh-BMP2) for alveolar bone grafting showed promising results. rh-BMP2 for alveolar bone grafting appears to be a promising alternative to autografts.

CONCLUSION

Early commencement of NAM in neonatal life is of great benefit to cleft patients. There is a need for more multicentre collaborations, mainly to identify the ideal surgical technique to reduce the variability in treatment and to ensure that the patient receives appropriate evidence-based treatment.

Pierre Robin Sequence and 3D Printed Personalized Composite Appliances in Interdisciplinary Approach

This paper introduces a complex novel concept and methodology for the creation of personalized biomedical appliances 3D-printed from certified biocompatible photopolymer resin Dental LT Clear (V2). The explained workflow includes intraoral and CT scanning, patient virtualization, digital appliance design, additive manufacturing, and clinical application with evaluation of the appliance intended for patients with cranio-facial syndromes. The presented concept defines virtual 3D fusion of intraoral optical scan and segmented CT as sufficient and accurate data defining the 3D surface of the face, intraoral and airway morphology necessary for the 3D design of complex personalized intraoral and extraoral parts of the orthopedic appliance. A central aspect of the concept is a feasible utilization of composite resin for biomedical prototyping of the sequence of marginally different appliances necessary to keep the pace with the patient rapid growth. Affordability, noninvasiveness, and practicality of the appliance update process shall be highlighted. The methodology is demonstrated on a particular case of two-year-old infant with Pierre Robin sequence. Materialization by additive manufacturing of this photopolymer provides a highly durable and resistant-to-fracture two-part appliance similar to a Tübingen palatal plate, for example. The paper concludes with the viability of the described method and material upon interdisciplinary clinical evaluation of experts from departments of orthodontics and cleft anomalies, pediatric pneumology and phthisiology, and pediatric otorhinolaryngology.