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NASOALVEOLAR MOULDING AND PEDODONTIST

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NASOALVEOLAR MOULDING AND PEDODONTIST

  1. 1. NASO ALVEOLAR MOULDING AND PEDODONTIST
  2. 2. CONTENTS: o Introduction to NAM o Cleft lip and palate o Management approach o Role of pedodontist o In detail about NAM
  3. 3. Presurgical orthopedics forms an integral part of the treatment of patients with facial clefting. Cleft lip and palate is the most common congenital craniofacial anomaly caused by abnormal facial development during gestation. Cleft lip and palate though treatable; it has a great negative social impact on the patient as well as his/her family. However, the kind of treatment of cleft lip and palate depends on the type of cleft and the severity of the cleft. INTRODUCTION:
  4. 4. BEFORE 1940 ‘S IT WAS CONSIDERED AS A PROSTHODONTIC ERA FOLLOWED BY AN ORTHODONTIC ERA(AFTER 1940 S). ITS TIME FOR MORE INVOLVEMENT BY PEDODONTIST AS THEY DEAL WITH CHILDREN AND ARE WELL VERSED WITH ANATOMY, PHYSIOLOGY, PSYCHOLOGY AND COMPREHENSIVE TREATMENT OF A CHILD TO MAKE THE COMING YEARS A “PEDODONTIC ERA” : BY DR SAVITHA SATHYAPRASAD The Pedodontist involvement in the intervention and management of cleft lip and palate children is most important along with the growth of the child. So, its high time for all the pedodontists to get involved and to provide complete rehabilitation children as every child had the fundamental right to his total oral health and every pedodontist has an obligation to fulfill this faith. The child differs from an adult in their physiology, anatomy, as well as psychology.
  5. 5. CLEFT LIP AND PALATE: DEFINITION : Cleft palate – A congenital fissure or elongated opening in the soft and/or hard palate . OR An opening in the hard and/or soft palate due to improper union of the maxillary process and the median nasal process during the second month of intra uterine development. GPT 8
  6. 6. MANAGEMENT: By multidisciplinary approach Team approach to patients with craniofacial anomalies DENTISTRY Orthodontics Pediatric dentistry prosthodontics SURGERY Plastic Oral & maxillofacial surgery NURSING GENETICS Syndromologist dysmorphologist SOCIAL SUPPORT & SERVICE OPHTHALMOLOGY PSYCHOLOGY PEDIATRICS SPEECH & LANGUAGE PATHOLOGY OBSTERTRICS ENT AUDIOLOGY TEAM COORDINATOR
  7. 7. The overall care of affected infant should rely on interdisciplinary team decisions rather than a series of independent, critical events by individual specialists on a team. Cleft palate team or craniofacial team consists of: a pedodontist, a plastic surgeon, a paediatrician, a orthodontist, a speech therapist, oral and maxillofacial surgeon, a prosthodontist, nursing staff and a team coordinator.
  8. 8. The pedodontist forms an integral part of the rehabilitative process. The role of a pedodontist is to correct the function by providing nasoalveolar moulding, provide assistance to maintain healthy dentition and gums, monitor the craniofacial growth & development, to correct jaw relationship & dental occlusion and finally to achieve optimal functional occlusion, appearance & stability. ROLE OF PEDODONTISTS Cleft Lip and Palate Patients: Diagnosis and Treatment, book edited by Mazen Ahmad Almasri.
  9. 9. Counselling Feeding plate Presurgical nasoalveolar molding Replacement of teeth Stabilization of teeth Stabilization and/or achieving ideal arch configuration before surgery
  10. 10. Presurgical Nasoalveolar Molding (NAM) was introduced to reshape the alveolar and nasal segments prior to surgical repair and improve the surgical outcome of the primary repair in cleft lip and palate patients. Nasoalveolar Molding (NAM)
  11. 11. PRESURGICAL NASOALVEOLAR MOLDING: PNAM is a non surgical method of reshaping the gums, lips and nostrils before cleft lip and palate surgery, thus lessening the severity of the cleft. Before introduction of concept of nasoalveolar molding, repair of a large cleft required multiple surgeries between birth and 18 years of age, putting the child at risk for psychological and social adjustment problems. With advent of PNAM, the dentist can reduce the size of the cleft and mould the alveolar and nasal tissues in the correct anatomic position.
  12. 12. The primary aim of presurgical nasoalveolar moulding (PNAM) is reduction in the soft tissue and cartilaginous deformity to facilitate surgical soft tissue repair in optimal conditions under minimum tension to minimize scar formation
  13. 13. • Retraction of premaxilla. • Alignment of cleft alveolar segments. • Presurgical elongation of collumella • Up-righting of collumella • Correction of nasal cartilage deformity • Increase in surface area of mucosal lining. 14 Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of lip, alveolus and palate. Clin Plast Surg 2004;31:149-58. OBJECTIVES OF NAM
  14. 14. Active molding, providing symmetry and repositioning of nasal and alveolar processes; •Non-surgical lengthening of the columella; • Facilitating lip repair without scarring by placing the lip segments in a more anatomically position and reducing the distance between cleft lip segments; • Improving nasal correction and providing projection for a flat nasal tip; • Reducing the number of surgical procedures; • Reducing the need for secondary alveolar bone graft; • Serving as an obturator to help infant in suckling Razavi ESE. Nasoalveolar Molding: Part 1- A General Overview. Int J Dent Med Res 2015 OBJECTIVES OF NAM
  15. 15. AGE WORK TO DO 0-1 wk impression Phase 1: Molding of alveolus Phase 2: Nasal molding Elevation of collapsed lower lateral cartilage Tenting of nostril apex Uprighting and centering of columella Approximation of alveolar segments 1-2 wk Plate insertion 12-16 wk NAM adjustment PHASES OF UTILIZATION OF NAM IN UNILATERAL CLEFT LIP DEFORMITIES
  16. 16. • Evaluation by the interdisciplinary cleft palate team. • Examination • Explanation of treatment goals and procedure to parents • Impression • Fabrication of plate • PNAM activation • Retentive taping • Follow up • Nasal stent addition • Follow up 17 CLINICAL APPROACH
  17. 17. Material: • Impression compound/Elastomeric impression material are the better materials. • Consistent results have been obtained fastest setting time polysiloxane material with the Base: catalyst ratio being 2:1. • Light body wash not used : registration of minute details is not necessary and it may cause gagging. • Irreversible hydrocolloid never used: poor tear strength creates possibility of having small pieces break free occlude nasal passage or respiratory tree. It also does not provide two reliable cast from same impression. 18 Nasoalveolar Molding for Infants Born with Clefts of the Lip, Alveolus, and Palate Barry H. Grayson, D.D.S.1,2 and Deirdre Maull, D.M.D.2005 IMPRESSION OF INTRAORAL CLEFT
  18. 18. 20 • The infant is fully awake without any anesthesia. Infant is held face down to prevent aspiration of regurgitated stomach contents. • One person cradles the infant securely around the chest and torso supporting the head and neck, while another obtains the impression. • High volume evacuation should be ready. • Head is gently held in a slightly upright position. TECHNIQUE
  19. 19. 21 • The material should reach the border maxilla, premaxilla and cleft region. Too much pressure not required as it would harm the nasal tissue. • Excess material in the posterior area should not block the airway as infants are obligate nasal breathers. • Infant should cry while making the impression which means the airway is patent. • It should be done in hospital set up and surgeon should be present.
  20. 20. Impression of the nasal region: • It is not necessary but may be helpful in comparing the pre and post orthopedic molding results. • Obtained in clear polyvinylsiloxane. • Cotton plugs with floss used to prevent material lodging into deep nostrils. • Not used for fabricating the nasal stent. 22
  21. 21. • Pour two casts Fabrication of prosthesis Patients permanent record • Cleft region of palate and alveolus is filled with wax. • Cast is lubricated with thin layer of petroleum jelly. 24 Nasoalveolar Molding for Infants Born with Clefts of the Lip, Alveolus, and Palate Barry H. Grayson, D.D.S.1,2 and Deirdre Maull, D.M.D.2005 FABRICATION
  22. 22. 26 • Soft ,resilient, slowly polymerizing acrylic resin is added to the undercut areas of the cast. • The molding plate is fabricated on the dental stone model. It is made of hard clear acrylic and is lined with a thin layer of soft denture material. • Care is taken to reduce the border of the plate in the area of the labial frenum attachments and other areas that may be likely to ulcerate. • Parents are instructed to keep the plate in full time and to take it out for cleaning as needed, at least once a day. Nasoalveolar Molding for Infants Born with Clefts of the Lip, Alveolus, and Palate Barry H. Grayson, D.D.S.1,2 and Deirdre Maull, D.M.D.2005
  23. 23. Initially, it may take longer to feed the infant with the plate in place, but the child quickly adjusts and parents report that the infant soon will not eat without it. Nasoalveolar Molding for Infants Born with Clefts of the Lip, Alveolus, and Palate Barry H. Grayson, D.D.S.1,2 and Deirdre Maull, D.M.D.2005
  24. 24. • The appliance is secured extra orally to the cheeks and bilaterally by surgical tapes, which have an orthodontic elastic band at one end. • The elastics loop over a retention arm extending from the anterior flange of the plate • The retention arm is positioned approximately 40 degrees down from the horizontal to achieve proper activation and to prevent unseating of the appliance from the palate. • The tapes are changed once a day. Nasoalveolar Molding for Infants Born with Clefts of the Lip, Alveolus, and Palate Barry H. Grayson, D.D.S.1,2 and Deirdre Maull, D.M.D.2005
  25. 25. Retentive taping • Broader base tape-0.5-1.5 inch • Thin suture strips-0.25-4 inch 29
  26. 26. 30 • Small red orthodontic elastics-0.25 inch diameter. • Elastics- Stretched to twice the original length • Force vector: posterior and superior. • Timings for changing taping • Adhesive and Adhesive relieving agents
  27. 27. USE OF RETENTIVE TAPING • Retention of appliance • Controlled orthopedic effects • Alignment of nasal base region 31
  28. 28. Nasoalveolar Molding for Infants Born with Clefts of the Lip, Alveolus, and Palate Barry H. Grayson, D.D.S.1,2 and Deirdre Maull, D.M.D.2005
  29. 29. EXTRAORAL RETENTIVE BUTTON 33
  30. 30. • Weekly visits are required to modify the molding plate to guide the alveolar cleft segments into the desired position. • Closure of the alveolar gap brings the lip segments together, reduces the nasal base width, and introduces laxity of the alar rim. • When the cleft alveolus is reduced to 5 mm or less, the nasal stent is added. • The stent is made of 0.036-gauge round stainless steel wire and takes the shape of a swan neck. As the wire extends into the nostril, it is curved back on itself to create a small loop for retention of the intranasal portion of the nasal stent.
  31. 31. • The upper lobe enters the nose and gently lifts the dome until a moderate amount of tissue blanching is evident. • The lower lobe of the nasal stent lifts the nostril apex and defines the top of the columella.
  32. 32. • Observation: retention, extent posterior, not too tight fitting, no acrylic in cleft area. • Suckling verification, no gagging. • Molding of the alveolar segments 38 POST INSERTION CONSIDERATIONS
  33. 33. • Weekly basis • Progress of molding appliance monitored • Retention evaluated • Examination for possible sores • Monitoring Change in size of defect • Modification of appliance 39 FOLLOW UP
  34. 34. • Alignment of alveolar segments, nasal cartilages, columella and philtrum. • GPP- To close alveolar defect • Timing for surgery: 2-3 months. • Evaluation of infant: Rule of 10. 40 Tracy M. Pfeifer, Barry H. Grayson, Court B. Cutting. Nasoalveolar molding and gingivoperiosteoplasty versus alveolar bone graft: An outcome analysis of costs in the treatment of unilateral cleft alveolus.C left Palate Cra niofac J,2002 CONSIDERATIONS BEFORE SURGERY
  35. 35. • Lip is taped for several weeks even after surgery • No nasal stent or supporting device is employed. 41 POST SURGICAL CONSIDERATIONS
  36. 36. Levy-Bercowski D. et al., categorized complications of pre- surgical NAM in the following format: 1.Soft tissue complications including mucosal ulceration intraoral bleeding tissue fungal infections tissue irritation mega nostril - gap > 6 mm impingement of nasal epithelium and nasal bleeding •Tissue irritation was the most and nasal bleeding was the least common complication. Razavi ESE. Nasoalveolar Molding: Part 1- A General Overview. Int J Dent Med Res 2015 COMPLICATIONS
  37. 37. 2. Hard tissue complications like asymmetric T-shaped arch Razavi ESE. Nasoalveolar Molding: Part 1- A General Overview. Int J Dent Med Res 2015
  38. 38. 3. Compliance issues consist of broken appointments, removal of the appliance by tongue or hands Compliance issues were of greater concern, so compliance of the patient, parents or caregivers is a key factor for successful outcomes. Hard and soft tissue complications can be managed by the clinician without the need for suspending the treatment. Razavi ESE. Nasoalveolar Molding: Part 1- A General Overview. Int J Dent Med Res 2015
  39. 39. • Allows controlled, predictable repositioning without Lip adhesion surgery or Surgical insertion of pin retained dynamic molding plate • Reduction in size of cleft gap- 46 ADVANTAGES
  40. 40. 47 • Allows surgeon to perform a GPP without need for extensive tissue dissection. • PNAM used in conjunction with GPP – Avoids additional surgery to bone graft the alveolus Reduces need for early nasal revision surgery. Extremely cost-effective
  41. 41. 48 • Additional force from nasal stent provides final push that allows alveolar segments to meet. • Intra-oral molding plate provides foundation that enhances function of nasal stent.
  42. 42. 49 • In Bilateral cleft patient, PNAM combined with columellar elongation – Eliminates need of columellar elongation surgery. No scar at lip-nose-columella. Improves the infants ability to feed
  43. 43. CONCLUSION • NAM technique has been significantly shown to improve the surgical outcome of CLP patients compared with other techniques of presurgical orthopedics.NAM should be considered soon after birth to promote a physiological pattern of function, which eventually sets the course for the functional patterns in later life. • The pediatric dentists are one of the constant entities whose role starts from infancy through adolescence. Pedodontists are trained to provide a complete oral rehabilitation as he is well versed in the aspects of behavioral management, child psychology and can thus provide empathetic treatment for the child.
  44. 44. The Pedodontist involvement in the intervention and management of cleft lip and palate children is most important along with the growth of the child. So, its high time for all the pedodontists to get involved and to provide complete rehabilitation to children as every child had the fundamental right to his total oral health and every pedodontist has an obligation to fulfill this faith. Hence, PNAM, when performed prior to primary lip repair, will give psychological reassurance to parents, enhance surgical outcome, reduce the need for soft-tissue revision surgeries later and also reduce the overall cost of treatment

Notas

  • A heavy-bodied silicone impression material is used to take the initial impression as soon after birth as possible, when the cartilage is plastic and moldable.
    The tray is seated until impression material is
    observed just beginning to extrude past its posterior
    border. The infant is kept in the inverted position to
    keep the tongue forward and to allow fluids to drain out
    of the oral cavity. Once the impression material is set,
    the tray is removed, and the mouth is examined for
    residual impression material that may be left behind.
  • The vertical position of the retention arm should be at the junction of upper and lower lips at rest. This allows approximation of the cleft lip segments and does not interfere with the resting position of the lower lip.
  • When the retention arms are engaged by the tape elastic system, the elastics (inner diameter 0.25 inch, wall thickness heavy) should be stretched approximately two times the resting diameter for proper activation force (2 oz). The amount of force may vary depending on the clinical objective and the mucosal tolerance of pressure. Retraction of the premaxilla requires greater elastic traction force than is required for closure of a unilateral alveolar gap.
  • Care should be taken not to add the nasal stent before achieving laxity of the alar rim because an increase of the nostril circumference may result.
    A template for the nasal stent is made from a malleable rope of soft dental wax. The wax rope is attached to the labial flange of the molding plate, near the base of the retention arm. of a swan neck), entering 3 to 4 mm past the nostril aperture. By copying the shape of this wax template, one can easily form the wire armature of the nasal stent.
    This hard acrylic component is shaped into a bilobed form that resembles a kidney.
    A layer of soft denture liner is added to the hard acrylic for comfort.
  • GPP=gingivoperiosteoplasty
  • The most prevalence was broken appointments once or more, and the least was the removal of the appliance by hands.
    Meganostrl:Treatment: wedge procedure at initial surgical repair
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