Moldeado nasoalveolar prequirúrgico de un paciente con labio y paladar hendido unilateral izquierdo / Presurgical nasoalveolar molding in a patient with left unilateral cleft lip and palate

Resumen Introducción: El labio y paladar hendido son malformaciones craneofaciales que se presentan en 1:1000 nacidos vivos en Colombia. Realizar un moldeado nasoalveolar previo a la cirugía favorece el reposicionamiento de los cartílagos nasales deformados y de los procesos alveolares. Objetivo: Dar a conocer a los profesionales la importancia de realizar moldeado nasoalveolar en un paciente con labio y paladar hendido antes de la intervención quirúrgica. Materiales y métodos: En la clínica odontológica de la Universidad del Sinú de Montería (Córdoba, Colombia), se atendió una paciente de 17 días de nacida que presentaba labio y paladar hendido completo unilateral izquierdo severo. Luego de diligenciar la historia clínica odontológica, se realizó placa de órtesis, que se cambió cada 15 días y se hizo el retoque del "tutor" cada 8 días. Resultados: La placa de órtesis permitió un moldeado naso alveolar, con el progreso en la alimentación y mejoras en el contorneado de los tejidos nasales, que mejoró la preparación para la operación de la hendidura a los 8 meses de edad. Conclusiones: La importancia del moldeado nasoalveolar en casos como el presentado, es propiciar mejores condiciones físicas, favoreciendo la ingesta de alimentos y beneficiando la apariencia física.

Abstract Introduction: Cleft lip and palate is a craniofacial birth defect that accounts for 1:1000 live birhts in Colombia. Performing nasoalveolar molding before surgery facilitates the reshaping of deformed nasal cartilage and alveolar processes. Objective: To make professionals aware of the importance of performing nasoalveolar molding in a patient with cleft lip and palate before surgical intervention. Materials and methods: A 17-day-old infant with a full left unilateral cleft lip and palate was treated at the dental clinic of the University of Sinú, Montería (Córdoba, Colombia). Once the dental clinical history was recorded, an orthosis plate was made. The plate was changed every 15 days and the molding appliance was repositioned every 8 days. Results: The orthosis plate promoted nasoalveolar molding, which facilitated feeding and improved the shape of nasal tissues. Consequently, this early intervention improved the preparation for the surgery of the cleft when the child reached 8 months of age. Conclusions: Nasoalveolar molding in patients with full cleft lip and palate is important to promote better physical conditions, which favor food intake and benefit their physical appearance.

The first-year follow-up of a cleft lip and palate patient treated with nasoalveolar molding (NAM)

Abstract The objectives of pre-surgical orthopedics are to allow surgical repair with minimal tension of the involved tissues and less restriction to the craniofacial growth. The aim of this study was to evaluate the benefits of nasoalveolar model (NAM) as a pre-operative therapy in a patient with bilateral cleft lip and palate followed by labioplasty and palatoplasty. A 15-day-old patient underwent orthopedic treatment with NAM. After pre-operative treatment, retraction of the pre-maxilla was observed with reduction of the fissure. Due to the successful effects of NAM treatment the patient had a one-step surgery for lip correction. Six months later, due to lip pressure the fissure was further decreased. After six months, the patient underwent palatoplasty. Both surgeries contributed to the remaining closure of the fissure, which were reduced by half compared to the end of pre-operative treatment. The uses of NAM as a pre-operative treatment approached the alveolar segments, centralized the pre-maxilla, decreased the cleft palate resulting in a marked improvement of the arch and provide superior surgical results. In addition, it allows the primary repair of the patient's lip with asymmetric bilateral fissure in only one-step surgery; in consequence, it will reduce treatment morbidity and decrease cost of treatment.

Resumo Os objetivos da ortopedia pré-cirúrgica são permitir a correção cirúrgica com mínima tensão dos tecidos envolvidos e menor restrição ao crescimento craniofacial. O objetivo deste estudo foi avaliar os benefícios do modelo nasoalveolar (NAM) como terapia pré-operatória em um paciente com fissura labiopalatina bilateral seguida de labioplastia e palatoplastia. Um paciente de 15 dias de idade foi submetido a tratamento ortopédico com NAM. Após o tratamento pré-operatório, observou-se retração da pré-maxila com redução da fissura. Devido aos efeitos bem-sucedidos do tratamento com NAM, o paciente realizou a cirurgia em um único tempo cirúrgico para correção dos lábios. Seis meses após verificou-se a continuidade da redução da fissura devido à pressão labial. Após dozes meses, o paciente foi submetido à palatoplastia. Ambas as cirurgias contribuíram para o fechamento remanescente da fissura, que foram reduzidas pela metade em comparação com o final do tratamento pré-operatório. O uso do NAM como tratamento pré-operatório proporcionou a aproximação dos segmentos alveolares, centralização da pré-maxila, diminuição da fissura palatina, resultando em melhora acentuada do arco, resultando em procedimentos cirúrgicos mais eficazes. Além disso, permitiu o reparo primário do lábio do paciente com fissura bilateral assimétrica em apenas uma cirurgia; em conseqüência, reduzindo a morbidade do tratamento e diminuição dos custos do tratamento.

Three-dimensional analysis of alveolar changes of complete unilateral cleft lip patients after presurgical nasoalveolar molding treatment / 华西口腔医学杂志

<p><b>OBJECTIVE</b>This study analyzed the alveolar changes of complete unilateral cleft lip (UCCL) patients after pre-surgical nasoalveolar molding (PNAM) treatment using a three-dimensional method.</p><p><b>METHODS</b>Palate impressions of thirty UCCL patients who underwent PNAM treatment in the Affiliated Stomatology Hospital of Guangxi Medical University were taken pre- and post-PNAM. The plaster impressions were scanned using cone beam computed tomography (CBCT). The DICOM files were exported and 3D models reconstructed in Mimics 15.0. The following parameters were analyzed in SPSS 17.0: cleft alveolar gap width, alveolar arch end width, upper lip frenulum-median plane distance, alveolar shift distance, and length of alveolar section.</p><p><b>RESULTS</b>After PNAM treatment, the cleft alveolar gap width and upper lip frenulum-median plane distance decreased significantly (P<0.05). No statistically significant change was observed in the alveolar arch end width (P>0.05). Alveolar shift distances for both sides increased significantly (P<0.05), and the shift distance of major alveolar sec-tion had a more significant increase than the minor alveolar section. The lengths of the alveolar section of both sides increased significantly (P<0.05) with the length of the major alveolar section increasing more significantly than the minor alveolar section.</p><p><b>CONCLUSIONS</b>The impression-CBCT method supply accurate three-dimensional data of the alveolar process. The PNAM treatment can significantly correct alveolar deformity and improve appearance.</p>

Pre-surgical infant orthopedics with the nasoalveolar molding (NAM) device for unilateral and bilateral cleft lip and palate: Case series

Management of infants born with cleft lip and palate entails an interdisciplinary team effort that begins from infancy to adulthood. The goal of pre-surgical infant orthopedics is to reduce the severity of the cleft deformity before surgery. However, traditional methods do not address the deformity of the nasal cartilages and alveolar ridges simultaneously. The Nasoalveolar Molding (NAM) technique takes advantage of the malleability of immature nasal cartilage and its ability to maintain a permanent correction of its form. The NAM device is used to actively mold the alar dome, nasal cartilages, premaxilla, and alveolar ridges into a more normal anatomic form and position. It permits non-surgical elongation of the columella through application of tissue expansion principles. This results in better facial aesthetics and may help reduce the extent, number and cost of surgeries. The three cases presented illustrate the application of the NAM device for the pre-surgical infant orthopedics in unilateral and bilateral cleft lip and palate patients treated at the Philippine Children's Medical Center-Pediatric Dentistry Division (PCMC-PDD).

Experiência com a modelagem nasoalveolar precoce em um recém-nascido portador de fissura lábio-alveolar / Experience with early nasoalveolar molding in a clefted child

O tratamento das fissuras lábio-palatinas evoluiu muito nas últimas décadas. O tratamento atual da deformidade inclui técnicas ortopédicas de modelagem nasoalveolar como a Modelagem Nasoalveolar Passiva (MNA), que tem por objetivo a redução da largura da fissura alveolar e do palato, bem como da modelagem da região nasal afetada, logo após o nascimento. A MNA é iniciada na primeira semana de vida e se continua durante os primeiros meses, até a data do fechamento cirúrgico do lábio. O presente artigo relata o caso de um recém-nascido com diagnóstico ultrassonográfico de fissura lábio-alveolar. O diagnóstico precoce possibilitou o encaminhamento para o especialista, de tal forma que o tratamento foi iniciado logo após o nascimento. Ao final da MNA, a operação de correção da fissura nasoalveolar determinou o fechamento completo do defeito, e o aspecto da região tratada se assemelhava ao do lado não afetado.

The care of lip and palate clefts has progressed a lot in the last decades. Current treatment of the deformity includes orthopedic techniques of nasoalveolar molding such as the passive Nasoalveolar Molding (NAM), which is intended to reduce the width of the alveolar and palate cleft, as well as reshaping the affected nasal area, soon after birth. NAM is indicated to be performed in the first week of life and be continued over the next months, up to the eventual surgical closure of the lip. The present paper reports the case of a newborn with an ultrasonographic diagnosis of cleft alveolus and lip. Early diagnosis made it possible to promptly refer the patient to a specialist, so that treatment began soon after birth. At the end of NAM, the procedure to correct the nasoalveolar cleft determined the complete closure of the defect, and the aspect of the treated area can be appreciated.

Correction of Unilateral Cleft Lip Using Surgeon-Made Nasoalveolar Molding Device

The unilateral cleft of the lip and palate is a very complex deformity. This deformity comprises wide separation of the lip, defect of the ipsilateral columella and distorted nose, wide interalveolar gap due to accompanying alveolar cleft and displacement of the premaxilla. These variable deformities must be treated at the appropriate time. If not, it would result in severe facial mutilation, growth disturbance of the maxilla and functional defect of the teeth. Its ideal correction involves alignment of the dental arch, creation of a growing platform for the lip and nose, joining of the separated lip and correction of the distorted nose. Since McNeil(1950), variable presurgical orthopedic techniques have been evolved by many authors, but there is no uniform consensus. One commonly used appliance consists of an alveolar molding plate made of a hard outer shell and a soft acrylic lining described by Gnoinski. The author treated unilateral cleft lip and palate using presurgical nasal and alveolar molding (NAM) device which was introduced in 1993 by Grayson. In our cases (n=17), the author made the device by himself and performed presurgical nasoalveolar molding for the unilateral cleft lip and palate patients. Presurgical NAM device was applied in the second week following birth, and nasal stent for nasal cartilage molding was applied during nasoalveolar molding process around 6weeks after birth. Presurgical NAM was continued until repositioning of the nasal cartilages and alveolar processes (interalveolar gap <2mm), and lengthning of the deficient columella (mean vertical height of columella in postop 3 months: preop. 1.5mm--> postop 4.5mm). The primary lip-nose repair and gingivoperiosteoplasty were performed within 6months after birth (mean age: 17 weeks). Even though not evaluating the long term follow-up study in our cases, this technique enables a one-stage repair of the lip, nose and alveolus while the three-stage repair was necessary previously: primary lip repair, secondary rhinoplasty and alveolar repair with bone graft. In addition, when presurgical nasoalveolar molding is performed by a surgeon, it can be avoided complications such as meganostril and delaying of operation time. But orthodontic postoperative care should be planned after operation for unilateral cleft lip and palate patient.

Effect of presurgical nasoalveolar molding (PNAM) appliance and cheiloplasty on alveolar molding of complete unilateral cleft lip and palate patients / 대한치과교정학회지

The goal of the present study was to evaluate the effects of PNAM appliance and cheiloplasty on alveolar molding. Samples consisted of 16 unilateral cleft lip and palate infants (10 males and 6 female, mean age=37.0 days after birth, average alveolar cleft gap=10.46 mm), who were treated with PNAM appliances by one orthodontist and rotation- advancement cheiloplasty by one surgeon in Seoul National University Hospital. Average duration of alveolar molding treatment was 13.10 weeks and these patients were recalled at average 8.31 weeks after cheiloplasty. These patients' models were obtained at initial visit (T0, mean age : 37.0+/-27.89 days after birth), after successful alveolar molding (T1, mean age : 119.25+/-40.18 days after birth), and after cheilopasty (T2, mean age : 190.81+/-42.78 days after birth). Seven linear and five angular variables were measured using 1 : 1 photometry and soft ware program(V-ceph. Cybermed, Seoul, Korea). Paired t-test was performed to investigate statistical significance at p < 0.05 level. 1. The posterior parts of alveolar segments were the stable structures during alveolar molding treatment period and after cheiloplasty in infants. 2. The closure of cleft gap during alveolar molding was usually due to backward bending of the whole part of the greater segment. 3. Although forward growth of the greater segment was hindered by alveolar molding, it resumed after cheiloplasty. 4. Increase of anterior inter-segment angle after cheiloplasty was due to the molding effect of the lip scar pressuren

Correction of Complete Bilateral Cleft Lip with Noordhoff Method: Problems and Solutions

Bilateral cleft lip shows various clinical characteristics and the typical bilateral complete cleft lip usually features prominent premaxilla, short columella, non-protruded nasal tip, flared alar base and asymmetrical alar cartilage. The prolabium is usually short and demonstrate total absence of oricularis oris muscle. Therefore a satisfactory reconstruction of the lip in both the functional and cosmetic aspect is very difficult, especially in philtral column, columella, and nasal portion. Various techniques of cleft lip repair are being developed. The staged repair of bilateral cleft lip, one side and then the other, has been superseded by simultaneous/symmetrical repair of both sides that also included complete muscular closure. And by Mulliken1 and Cutting2,3, simultaneous/symmetrical repair also has been changed to one stage repair of bilateral complete cleft lip together with nasal deformity correction. The authors performed one stage closure by means of Noordhoff method without presurgical orthopedics, which provided simultaneous/symmetrical repair including complete muscular closure and at the same time reproduced the tubercle and Cupid's bow by using both lateral lip segment. There were some problems after surgical repair. First, short or absent columella were inevitably present which could be corrected by columellar lengthening. Secondly in complete cleft lip without cleft palate, there is persistent protruding of the premaxilla and finally resultant scar widening of the cupid's bow and philtral column, which could be corrected by orthognathic surgery. But these procedures are only secondary solutions for correction of already-made deformity. We demonstrated problems and their solutions in the performance of the Noordhoff method and introduced Cutting's presurgical nasoalveolar molding as a fundamental solution2,3.