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.

Time-Driven, Activity-Based Costing of Presurgical Infant Orthopedics: A Critical Component of Establishing Value of Latham Appliance and Nasoalveolar Molding.

BACKGROUND: Value-based health-care reform requires assessment of outcomes and costs of medical interventions. In cleft care, presurgical infant orthopedics is still being evaluated for clinical benefits and risks; however, the cost of these procedures has been largely ignored. This study uses robust accounting methods to quantify the cost of providing two types of presurgical infant orthopedics: Latham appliance treatment and nasoalveolar molding. METHODS: This is a prospective study of patients with nonsyndromic cleft lip and/or palate who underwent treatment with presurgical infant orthopedics from 2017 to 2019 at two academic centers. Costs were measured using time-driven activity-based costing. Personnel costs, facility costs (operating room, clinic, and inpatient ward), and equipment costs were included. Travel expenses were incorporated as an estimate of direct costs borne by the family, but indirect costs (e.g., time off from work) were not considered. RESULTS: Twenty-three patients were treated with Latham appliance treatment and 14 were treated with nasoalveolar molding. For Latham appliance treatment, average total cost was $7553 per patient ($1041 for personnel, $637 for equipment, $4871 for facility, and $1004 for travel over 6.5 visits). Unilateral and bilateral costs were $6891 and $8860, respectively. For nasoalveolar molding, average cost totaled $2541 ($364 for personnel, $151 for equipment, $300 for facility, and $1726 for travel over 13 visits); $2120 for unilateral and $3048 for bilateral treatment. CONCLUSIONS: The major difference in cost is attributable to operative placement of the Latham device. Travel cost for nasoalveolar molding is often higher because of frequent clinical encounters required. Future investigation should focus on whether outcomes achieved by presurgical infant orthopedics justify the $2100 to $8900 expenditure for these adjunctive procedures.

Computer-Aided Design and Manufacture of Intraoral Splints: A Potential Role in Cleft Care.

BACKGROUND: Nasoalveolar molding is a nonsurgical modality for the treatment of cleft lip and palate that uses an intraoral splint to align the palatal shelves. Repeated impressions are needed for splint modification, each carrying risk of airway obstruction. Computer-aided design and manufacturing (CAD/CAM) has the ability to simplify the process. As a precursor to CAD/CAM splint fabrication, a proof-of-concept study was conducted to compare three-dimensional splints printed from alginate impressions versus digital scans. We hypothesized that intraoral digital scanning would compare favorably to alginate impressions for palate registration and subsequent splint manufacture, with decreased production times. METHODS: Alginate and digital impressions were taken from 25 healthy teenage volunteers. Digital impressions were performed with a commercially available intraoral scanner. Plaster casts made from alginate impressions were converted to Standard Triangle Language files. Patient-specific matched scans were evaluated for total surface area with the concordance correlation coefficient. Acrylic palatal splints were three-dimensionally printed from inverse digital molds. Subjective appliance fit was assessed using a five-point scale. RESULTS: A total of 23 participants were included. Most subjects preferred digital impression acquisition. Impression methods showed moderate agreement (concordance correlation coefficient 0.93). Subjects rated splints from digital impressions as having a more precise fit (4.4 versus 3.9). The digital approach decreased impression phase time by over 10-fold and overall production time by 28%. CONCLUSIONS: CAD/CAM has evolved extensively over the past two decades and is now commonplace in medicine. However, its utility in cleft patients has not been fully realized. This pilot study demonstrated that CAD/CAM technologies may prove useful in patients requiring intraoral splints.