Presurgical nasoalveolar molding for cleft lip and palate

Pravinkumar G Patil

doi:10.4103/0970-9290.114931

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LETTER TO EDITOR

Year : 2013 | Volume : 24 | Issue : 1 | Page : 145-146

Presurgical nasoalveolar molding for cleft lip and palate

Pravinkumar G Patil
Department of Prosthodontics, Government Dental College and Hospital, Nagpur, Maharashtra, India

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Date of Web Publication

12-Jul-2013

How to cite this article:
Patil PG. Presurgical nasoalveolar molding for cleft lip and palate. Indian J Dent Res 2013;24:145-6

How to cite this URL:
Patil PG. Presurgical nasoalveolar molding for cleft lip and palate. Indian J Dent Res [serial online] 2013 [cited 2023 Mar 31];24:145-6. Available from: https://www.ijdr.in/text.asp?2013/24/1/145/114931

Sir,

Although advances in reconstructive surgery have significantly improved the quality of repair for clefts of the lip, alveolus, and the palate, surgery alone cannot correct all aspects of the cleft defect. ^[1] This also leaves severe scarring of the nasolabial complex. Multiple surgical interventions are required to achieve the desired results. Presurgical molding is required to restore normal anatomy, to expand deficient tissues, and to reposition malpositioned structures. The presurgical molding had been attempted since the 17 ^th century. The presurgical infant orthopedic appliances described by McNeil, ^[2] the passive molding of the segments with growth described by Rosenstien and Jacobson, ^[3] and the pin retained appliance for rapid closure of unilateral cleft described by Lathem ^[4] are some of the orthopedic appliances. All these orthopedic appliances move only alveolar segments together and do not modify the nasal architecture. The presurgical nasoalveolar molding (PNAM) was first developed by Grayson et al. (at the Institute of Reconstructive Plastic Surgery, New York University Medical Center) and consists of active molding of the alveolar segments as well as the surrounding soft tissues and nasal cartilages. ^[5] The scientific basis behind early molding of the nasoalveolar complex is that during the first postnatal month, there is a high degree of plasticity in the cartilage. Matsuo et al. described that the maternal estrogen level is highest immediately after birth, which increases hyaluronic acid in the neonatal cartilage, which is responsible for the high degree of plasticity. ^[6] The PNAM can be achieved in unilateral as well as bilateral cleft lip and palate.

The advantages of PNAM are controlled predictable reposition of alveolar segments without the need for lip adhesion surgery and surgical insertion of pin retained dynamic molding plate, repair of nose-lip-alveolus complex in one surgery, reduces the need for additional bone graft surgery, eliminates the need for columella lengthening surgery, no scaring hence optimized esthetics, cost-effective, and the devices also serve as obturators and the infant can generate suckling force. Some of the complications of the procedure are nostril overexpansion, tissue laceration, failure to retain appliance, primary tooth exposure, and failure to tape lip segments. The limitations of this procedure are the process needs to be started as soon as possible after birth as the cartilage gets less plastic as age progresses, patient learns to remove the appliance with growing age, and parental cooperation is the key for the success of the PNAM.

In spite of the above-mentioned complications and limitations, I personally feel that every indicated cleft lip and palate patient should first be treated with the PNAM before any plastic reconstructive surgery to achieve the multiple advantages of this procedure. There is a relative incidence rate of 1:860 for cleft lip and palate in newborns in the Indian population. ^[7] Unfortunately, most of the dental specialists are still unaware of the PNAM procedure, which is needed to be accomplished in the Department of Prosthodontics or Orthodontics before referring the patients to Plastic Surgeons. The aim of this letter is to draw the attention of the Prosthodontic, Orthodontic, Oral surgery, and Plastic surgery specialists regarding the use of PNAM in the practice consistently.

References

1.	Brecht LE, Grayson BH, Cutting CB. Nasoalveolar molding in early management of cleft lip and palate. In: Taylor TD, editor. Clinical maxillofacial prosthetics. Chicago: Quintessence Publishing; 2000. p. 63-84.
2.	McNeil C. Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec 1950;70:126-32.
3.	Rosenstein SW, Jacobson BN. Early maxillary orthopedics: A sequence of events. Cleft Palate J 1967;4:197-204. [PUBMED]
4.	Latham R. Orthodontic advancement of the cleft maxillary segment: A preliminary report. Cleft Palate J 1980;17:227-33.
5.	Grayson BH, Cutting C, Wood R. Preoperative columella lengthening in bilateral cleft lip and palate. Plast Reconstr Surg 1993;92:1422-3. [PUBMED]
6.	Matsuo K, Hirose T, Tonomo T. Nonsurgical correction of congenital auricular deformities in the early neonate: A preliminary report. Plast Reconstr Surg 1984;73:38-50.
7.	Theogaraj SD, Joseph LB, Mani M. Statistical analysis of 750 cleft lip and palate patients. Indian J Plast Surg 2007;40:70-4.