Orthodontic management of cleft lip and palate

Orthodontic management
of cleft lip and palate
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

NASOALVEOLAR MOLDING


• BASICS OF NASOALVEOLAR
MOLDING
• NAM IN UNILATERAL CLCP
• NAM IN BILATERAL CLCP
• ADVANTAGES OF NAM
• COMPLICATIONS OF NAM

DISADVANTAGES OF
TRADITIONAL INFANT
ORTHOPAEDICS
• Deformity of the nasal cartilages in
unilateral and bilateral cleft lip and palate
• Deficiency of the length of the collumela in
bilateral cleft lip and palate


• The technique was described by –
•
•
•
•

Grayson ( 1993)
Brechet ( 1995)
Santiago ( 1997)
Cutting ( 1998)


Technique
• It mainly uses acrylic stents attached to a
vestibular shield of a oral molding plate to
mold the nasal cartillages into a more
normal form and position during the
neonatal period
• This takes advantage of the malleability of
the immature nasal cartilages and its ability
to maintain a permanent correction in form.

• In addition the collumela is also non
surgically corrected using tissue expansion
principles.
• This correction is achieved by gradual
expansion of the nasal stents and
application of tissue expanding elastic
forces that are applied to the prolabium


Objectives of Nasoalveolar
Molding
• Active molding and repositioning of the
deformed nasal cartilages and alveolar
process
• Correction of the deficient collumela
mainly in bilateral cases.


Correction of unilateral oronasal
cleft deformity
• The lower lateral alar cartilage is depressed
and concave in the alar rim and is separated
from the contra lateral cartilage high in the
nasal tip
• The nasal tip is displaced and depressed and
there is also resultant overhang of the
nostril apex

• The collumela and nasal septum are
inclined with the base deviated to the non
cleft side.
• In addition the orbicularis oris fibres in the
lateral lip segments contracts into a bulge
with some fibres running superiorly over
the cleft towards the nasal tip


OBJECTIVES OF PNAM
• To correct and align and approximate the
intra oral alveolar segments
• To correct the deformed nasal cartilages
• To correct the nasal tip and alar base on the
affected side.
• To correct the position of the philtrum and
collumela.

• These corrections are achieved using an
intra oral molding plate,with a nasal stent
rising from the labial vestibular flange.


Procedure
• Impressions of the infant are made using an
elastomeric impression material
• Impressions of the cleft are useful in
assessing pre and post alveolar molding
results and also in fabrication of the nasal
stent.


Fabrication of molding plate
• A molding plate is fabricated using
conventional acrylic resin


• The molding plate is secured to the palate
and alveolar process through external
strapping (surgical adhesive tapes) to the
cheeks and to an acrylic extension from the
oral plate between the lips below the cleft.


Modification of the molding plate
• The molding plate is modified at weekly
intervals to gradually approximate the
alveolar segments and reduce the size of the
cleft gap.
• This is achieved by removal of acrylic resin
in areas where alveolar segments are to
move and application of soft liner in areas
where alveolar bone is to be reduced.

• The ultimate aim of he selective removal
and addition of the acrylic material is to
align the alveolar segments and to achieve
the closure of the alveolar cleft gap
• This is similar to the Zurich type molding
plate described by Hotz (1969)


• The effectiveness of the molding therapy is
enhanced by supporting the palatal tissues
and by taping the lip segments together
across the cleft.
• Maintaining the tight lip apposition with the
external tape provides orthopaedic benefits
and reduces the consequent scar.


• The lip adhesion alone provides
uncontrolled orthopaedic effects but the lip
tape adhesion along with the molding plate
produces controlled approximation of the
alveolar segments.
• Taping the lip segments also helps the
alignment of the nasal base region by
bringing the collumela towards the mid
saggital plane and by improving the
symmetry of the nostril apertures.

NASAL STENT
• When the alveolar cleft width has reduced
to less than 6 mm then the nasal stent is
added to the molding plate so that nasal
cartilage molding may start
• Any attempt to close the deformity if the
cleft is large may result in undesirable
increase in the size of lateral nasal wall

• The nasal stent is a projection of acrylic
from the labial flange of the molding plate.
• Through gradual addition of acrylic the sent
is positioned underneath the apex of alar
cartilage on the cleft side
• The dome of the alar cartilage is elevated to
normal position and symmetry.
• The stent should be located midway
between the middle of the cleft lip segments


• At the tip of the stent soft liner is added so
that tissue breakdown does not occur when
positive pressure is added to the nasal
lining.
• The stent performs as a custom tissue
expander for cleft side of the collumela
• The elevation of the nasal tip on the cleft
side will also increase the patency of the
nostril aperture.


• Through gradual modification of the nasal
stent the shape of the cartilaginous
septum,alar cartilage tip and lateral and
medial crus are carefully molded to
resemble the normal shape of these
structures.
• when properly taped temporary blanching
of the tissue overlying the tip of the nasal
stent occurs as the infant suckles and
activates the appliance.

• Elevation of the nasal soft tissue results in
an intra oral molding plate that is conducted
down the nasal stent results in more
effective molding of the alveolar segments.
• Lip taping is still continued after the
placement of the nasal stent
• At the closing of moulding the collumela,
philtrum and alveolar segments should be
aligned to facilitate the surgical restoration
of normal anatomic relationships.

GOALS
• To approximate the gingival tissues on
either side of the cleft.
• However a successful surgical result is
obtained when a small cleft remains
between the segments.
• PNAM allows a single surgical repair of the
deformity of the nasolabial complex with
successful results.

Advantages of PNAM
• Ability to guide the alveolar segments to a
more normal position prior to surgery.
• Reduction of the cleft gap facilitates the
primary gingivoperiosteal closure of the
cleft defect,because there is a greater
probability that a complete osseous bridge
formation will happen when cleft width is
reduced.

• The combined action of the nasoalveolar
molding plate and non surgical lip
approximation with surgical taping results
in a predictable correction of the
nasal,alveolar and soft tissue deformities.
• As a result under surgical repair the lip and
nose heals under minimal tension with no or
minimal scar formation.


Benefits in unilateral clefts
• Restoration of the collumela from a more
oblique to a midline position which also
results in improved projection of the nasal
tip and alar cartilage symmetry.
• The collumela base is no longer deviated to
the non cleft side as it uprights and takes up
normal convexity.

• The nasal cartilage on the cleft side is fashioned to
be similar to the one of the non affected side as the
alar cartilage is molded to a more normal convex
shape.
• The nasal tip is directed anteriorly and upwards ,
this is possible because tissue expansion allows to
include the inherent tissue defects n the cleft side.
• All these are achieved without surgery and reduce
the need for additional soft tissue surgeries and
alveolar bone grafting . Thus reducing consequent
trauma and tissue scarring.

BILATERAL ORO NASAL
CLEFTS
• The lower cartilages have failed to migrate
to the nasal tip to stretch the collumela
• Pro labium also lacks muscle thickness and
is positioned directly behind the collumela.
• The alar cartilages are positioned along the
alar margin and are stretched over the cleft
in a flared fashion.

• The premaxilla is suspended from the tip of
the nasal septum where as the lateral
segments remain behind.


OBJECTIVES
• Lengthen the collumela
• Reposition the alar cartilages towards the
tip
• Align the alveolar segments and pre maxilla
to form a more normal maxillary arch.

• Soft tissue and cartilaginous correction are
achieved through a conventional molding
plate.
• The nasal stents also stretch the lower nasal
lining,thereby allowing the domes of the
lateral lateral cartilages to be approximated
under minimal tension during surgical
repair.
• The device and its stents are secured with
adhesive surgical tapes and elastics.

PROCEDURE
• Impressions are taken using elastomeric
impression material
• Molding plate is fabricated that
encompasses the lateral alveolar segments
and pre maxilla.
• The everted pre maxilla is positioned
between the lateral alveolar segments by
modification of the molding plate.

• A surgical adhesive tape and elastics is used
to secure the molding plate actively against
the alveolar process and pre maxilla.
• Through modifications of the internal
molding plate and elastic forces applied by
the elastics attached to the adhesive tapes
the pre maxilla is placed in a keystone
position between the lateral alveolar
segments.
• The molding plate is adjusted weekly to
position the alveolar segments as the pre
maxilla is retracted.

• The pre maxilla is positioned by modifying
the molding plate by adding soft resin liners
anterior to the pre maxilla and removal
posterior to the pre maxilla.


Second stage
• Approximately three weeks after fabrication
of the plate.

• Nasal stents are built up from the anterior of
the oral molding plate to enter the nasal
aperture.

• The nasal stent elevate the nasal cartilages
and prevent the downward pull by the tapes
placed on the pro labium


• A horizontal pro labial band pulls back on
the collumela at the base of the nasolabial
fold.
• The bands force is used to preserve the
nasolabial angle at the junction of the
collumela base and the philtrum as the
collumela is lengthened.
.

• The nasal stent supports the nasal tip and exerts
tissue expanding forces that are directed to the
collumela and nasal lining
• The stents are also modified to give convexity to
the alar cartilages.
• The stent also advance the medial and lateral crus
of the alar cartilages into the nasal tip while
lengthening the collumela.

• Nasal stent is bifid with a superior and
inferior lobe.
• The superior lobe enters the nostril and
pressing up and forward against the nasal
lining behind the dome of alar cartilage.
• The lower lobe is positioned under the apex
of the nostril aperture,pressing up against
the soft tissue triangle.

• Surgical tape attached from the prolabium
to the anteroinferior part of the molding
plate pulls down and reshapes the
collumela.


• Attached across the nasal stent is the horizontal
prolabial band that pushes against the collumela
and further lengthens it.
• The prolabial band is made of a chain of elastics
and coated with a denture liner to prevent
ulceration of the tissue
• It is contoured on the tissue to restrict the width of
the collumela.
• It is attached to metal pins on the molding plate
(nasal stents) and stretched.


How is the collumela
lengthened ?
• The stretching force applied by the adhesive
tape.
• The horizontal posteriorly directed froce by
the elastic band ( pro labial band)
• Upward and anterior force applied to the
nasal tip by the nasal stent.


• One of the biggest benefits of builateral
nasoalveolar molding is the lengthening of
the collumela.
• About 4mm to 7mm lengthening of
collumela can be achieved by this
procedure.
• Nasoalveolar molding without collumelar
lengthening may require surgical correction.
• Surgical correction may result in scar tissue
and may damage the anatomy of the
nasolabial complex.

• This also improves the esthetics of the
nasolabial complex.

• It stretches the nasal lining and allows the
surgeon to approximate the domes of the
lower alar cartilages with lesser dificulty.


COMPLICATIONS
• Soft tissue breakdown may occur in areas of
modification of the plate if they are not
properly polished
• Ulceration may developed and this can be
prevented by adding tissue lubricant or by
proper polishing of the plate.
• If tapes and elastics are not applied then the
plate will not be adequately retained

• If the appliance is lost or not worn then the
previously closed cleft area may relapse due
to tongue pressure.
• Occasionally the labial surface of the
central incisor may erupt prematurely due
to molding pressure.
• Ectopic tooth bud may be seen on the
lateral aspect of the pre maxillary segment
which might have to removed to prevent
aspiration.

Maull et al ( 1999)
• Did a study on patients who underwent
nasoalveolar molding and claimed that there
was an increase in symmetry of nasal
structures following nasoalveolar molding.


Cutting et al (1998)
• Showed that NAM combined with a
modified surgical technique improved the
esthetics of both unilateral and bilateral
cleft patients.


CONCLUSION
• Pre surgical reduction of alveolar cleft
allows the surgeon to perform a
gingivoparietoplasty.
• This procedure reduces the need for
alveolar bone grafts in more than 60% of
cases in mixed dentition.


• The pre surgical alignment and correction
and alignment of nasal structures reduces
the need for primary nasal surgery and
thereby reducing the scar formation and
more consistent post operative results.


• In bilateral cases the need for secondary
elongation of collumela by surgery is
eliminated and consequent scar formation at
the lip collumela junction is prevented.
• NAM combined with a modified surgical
procedure addresses the needs of the lipnasal-alveolar complex in a single surgery
and reduces the number of surgeries an
individual has to undergo in a life time.

Thank you


Orthodontic management of cleft lip and palate

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