Naso alveolar molding treatment protocol in patients with cleft

NasoAlveolar Molding
Treatment Protocol in
patients with Cleft Lip
and Palate
By Dr. Kritika Suroliya

Learning Objectives
• What is Pre-surgical Infant Orthopaedics?
• What is NasoAlveolar Molding?
• Fabrication of the appliance used for NasoAlveolar
Molding?

Contents:
• Introduction to CL/P
• Prevalence of CL/P
• Classification of CL/P
• Anatomy and characteristics of CL/P
• Problems Associated with CL/P in
children
• Pre-Surgical Infant Orthopaedics
• History
• Principle
• Advantages
• Disadvantages
• The NAM Appliance
 Principle
 Impression Technique
 Appliance Fabrication and Design
 Appliance Insertion and Taping
 Appliance adjustments
 Proponents and Opponents of NAM
• The Pre-Directional Appliance
• Conclusion

Introduction
• Facial Clefting is the second most common congenital
deformity.
• Orofacial Clefts, particularly non-syndromic cleft lip (CL),
with or without cleft palate (CLP), and isolated Cleft
Palate are the most common craniofacial deformities
affecting one in every 700 to 1000 newborns worldwide.
• Due to their disturbing appearance in many cases, these
deformities have attracted much attention in terms of
treatment and research.
Murray, J.C., 2002. Gene/environment causes of cleft lip
and/or palate. Clinical genetics, 61(4), pp.248-256.

Introduction
• Cleft lip and palate is one of the common facial deformities
that not only affect the aesthetics but also affect the speech
and hearing.
• Over the years various treatment modalities have been
attempted in these patients so as to achieve satisfactory
outcome.
• Surgical treatment of cleft lip and palate has been documented
since 317AD, when Chinese General Wei Yang Chi had his
cleft lip corrected by cutting and stitching the edges together.
• Since then various authors described the different surgical
techniques for correction of cleft lip.
Murthy P S, Deshmukh S, Bhagyalakshmi A, Srilatha K T. Pre Surgical Nasoalveolar Molding: Changing
Paradigms in Early Cleft Lip and Palate Rehabilitation. J Int Oral Health 2013; 5(2):76-86.

Introduction
• To further improve the esthetic result of surgical lip
repair, the concept of presurgical infant orthopedics was
developed.
• Presurgical infant orthopedics plays a significant role in
neonatal cleft lip and palate treatment.

Prevalence
• The prevalence for non-syndromic CLP and CP in the
Nagpur region was found to be 0.66 percent and 0.27
percent, respectively.
• Most of the worldwide studies showed male
predominance for CLP and CP. In the present study,
however, females outnumbered males.
Kalaskar, R., Kalaskar, A., Naqvi, F.S., Tawani, G.S. and Walke, D.R., 2013. Prevalence and
evaluation of environmental risk factors associated with cleft lip and palate in a central Indian
population. Pediatric dentistry, 35(3), pp.279-283.

Classification
Cleft lip with or without clefting of the alveolar process (cleft of the
primary palate) (CL):
• The alveolar ridge is intact
• The cleft involves the height of the lip to some degree.
• The cleft lip may be unilateral or bilateral.

Classification
Isolated Cleft Palate (CP):
• Both the soft palate and hard palate are divided.
• A complete palatal cleft is classified as unilateral if the vomer is
attached to one of the palatal shelves.
• When the vomer is totally separated from the palatal shelves, its
lower free border can be detected between them, the cleft is then
classified as bilateral, although it remains median.

Classification
Combined cleft lip and palate (UCLP and BCLP):
• Subjects with combined cleft lip and palate have clefts in both
primary and secondary palate.
• The cleft formation may be complete, or incomplete; unilateral or
bilateral.
• Although the palatal cleft is always median, rotation of the vomer
may cause it to appear lateral.

David and Ritchie Classification (1922)
• Group 1: Pre-alveolar clefts (unilateral, bilateral and median)
• Group 2: Post alveolar clefts
• Group 3:Complete alveolar clefts (unilateral, bilateral and median)
Textbook of Oral and Maxillofacial Surgery – Neelima Anil Malik (3rd edition)

Veau (1931)
• Group 1: Cleft of the soft palate only
• Group 2: Cleft of the hard and the soft palate
• Group 3: Complete unilateral cleft, extending from uvula to incisive
foramen and then deviates to one side extending through the
alveolus
• Group 4: Complete bilateral alveolar cleft

Fogh-Andersen (1942)
• Fogh-Andersen (1942) divided oral clefts into 3 main groups:
1) CL including clefts of the lip and alveolus
2) CL and CP including unilateral and bilateral cleft lip and palate.
3) CP being median and not extending beyond the incisive foramen.

Kernahan and Stark (1958)

Internationally Approved Classification
(1967), following Rome Congress

Jensen et al (1988)
• Jensen et al (1988) divided the cleft palate into 4 grades to describe
the extent of the cleft palate into 4 grades:
1) Grade 1: soft palate
2) Grade 2: one-third of hard palate
3) Grade 3: More than one-third of hard palate
4) Grade 4: Total

A new Classification system by Daigavane et al (2015)
Type A: Greater and Lesser segment are of
sufficient length
Type B: Greater alveolar segment is of
sufficient length but lesser alveolar
segment is small and/or placed posteriorly
Type C: Greater and lesser segments are of
small length or parallel to each other
Type D: Greater segment is overlapping the
lesser alveolar segment
(Daigavane P S, Hazarey PV, Niranjane P, Vasudevan SD, Thombare BR, Daigavane S. A New Classification System for Unilateral Cleft Lip
and Palate Infants to assist Presurgical Infant Orthopedics. The Journal of Clinical Pediatric Dentistry . Volume 39, Number 3/2015)

Anatomy and
Characteristics of
UCLP, CP and BCLP

Unilateral Cleft Lip and Palate
• The lip, nose and alveolus have a cleft at the right or the
left side.
• The cleft then continues into the palatal part of the
maxilla and separates the palatal bone at the level of the
nasal septum.
• The alveolar arch and palate are separated into a large
and a small segment.
• The segments are often laterally displaced and the
anterior end of the larger segments protrudes, and there
is a midline shift to the non-cleft side.
• The smaller segment is usually located dorsally and the
anterior part is slightly curved upwards, compared to the
larger segment.

• Severe deviation of the noncleft side of the maxilla away
from the cleft, carrying with it the nasal structures
including the nasal septum.
• This distortion is the response of inadequately supported
bone structures to pressure.

• Abnormal insertion of the cheek muscles on the maxilla
at the base of the nose causes a rotating force on the
larger segment during muscle contraction.
• This action is reinforced by tongue protrusion.
• The smaller segment on the cleft side is exposed to less
expanding force,& has a mild contracting force exerted by
the base of the nasal ala on this side.

• Wide nostril base
• Separated lip segments
• Increased alar rim
• Oblique columella
• Overhanging nostril apex
• Nose is deviated toward normal side
• Except for alar base on cleft side, nostril is stretched and
straightened
• The affected lower lateral nasal cartilage is displaced laterally
and inferiorly, which results in a depressed dome

Bilateral Cleft Lip and Palate
• The lower lateral cartilages fail to migrate up into the nasal tip to
stretch the columella.
• The prolabium also lacks muscle tissue and is positioned directly on
the end of the shortened columella.
• The alar cartilages are positioned along the alar margins and are
stretched over the cleft in a flared fashion.
• In a complete BCLP, the premaxilla is suspended from the tip of the
nasal septum, whereas the lateral alveolar segments remain behind.

• Underdeveloped contralateral philtral ridge
• Ill-defined Cupid's bow, thin vermilion-mucosa on both sides of the
cleft.
• Protruding prolabium, demonstrates total absence of orbicularis oris
and seems to be joined directly to the tip of the nose.

• The premaxilla relatively unsupported on nasal septum, is not able
to resist force of active tongue and tilts forward.
• If tongue habitually protrudes through one side, then premaxilla is
protruded and forced to opposite side, giving the asymmetry.
• The premaxilla is unrestrained by attachment to either segment of
the maxilla & is projected forward by the growth of the cartilagenous
septum.

Isolated Cleft Palate (CP)
• In isolated cleft palate, the extent of the cleft varies.
• The cleft can be submucous characterised by a bifid uvula, a notch in
the posterior hard palate and a muscular sling that is not united.
• The cleft can extend only into the soft palate or extend with varying
degrees into the hard palate.
• In complete cases, the cleft extends all the way to the incisive
foramen.

Simonart’s bands
• In some patients, lip clefting is not complete, but a soft tissue bridge is
located either at the base of the nostril or between the segmented alveolar
ridges.
• The soft tissue bridges are known as Simonart’s bands and can be present in
either unilateral or bilateral clefts.

Problems Associated
with Children born
with Cleft

•Nostril Defect: From mild Nose
Asymmetry to gross defect of nasal
cartilage and septum
•Short columella, hypoplastic maxilla,
short premaxilla and prolabium
Aesthetics
• In Pierre Robin Syndrome, along with cleft
palate, there is mandibular micrognathia
and glossoptosis. The underdeveloped
mandible results in tongue fall in the
oropharynx, airway obstruction of the child.
Airway
Obstruction
•Structural defects prevent negative
oral pressure for effective sucking.
•Normal Palate function is necessary
for deglutition
Feeding

Dental
Problems
Impaired
Speech
Auditory
Problems
• Congenitally absent/supernumerary teeth
• Crowding/ displacement of teeth
• Morphologically deformed/ hypomineralised
teeth
• Impaired velopharyngeal mechanism leading to
hypernasal speech.
• Retardation of consonant sounds (p,b,t,d,k and
g)
• The levator and tensor muscles of the soft palate
affect the opening of the auditory tube, increasing
susceptibility to middle ear infections.
• Additional hazard of lymphoid hyperplasia over the
auditory tube orifice in the nasopharynx

Role of an orthodontist?
• The craniofacial orthodontist is involved in the life of a patient born with a
craniofacial deformity and/or cleft lip and palate from birth through skeletal
maturity.
• This may include infant presurgical orthopedics, early mixed dentition treatment,
dentofacial orthopedics and orthodontics, preparation for alveolar bone graft
procedures, adolescent/adult orthodontics, preprosthetic orthodontics, and pre- and
postsurgical orthodontics.
Santiago, P.E. and Grayson, B.H., 2009, December. Role of the craniofacial orthodontist on the craniofacial
and cleft lip and palate team. In Seminars in Orthodontics (Vol. 15, No. 4, pp. 225-243). Elsevier.

Treatment Protocol associated with
treatment of cleft children
2-4 weeks: Lip
Closure (Infant
Orthopaedics)
12-18 months:
Palate Closure
7-8 years: Alignment
of maxillary incisors
7-9 years: Alveolar
bone graft (before
eruption of lateral
incisor, if present, or
canine)
Adolescence:
Comprehensive
Orthodontics,
Lip/nose revision?
Late Adolescence:
Orthognathic
Surgery
Contemporary Orthodontics: William R. Profitt (5th edition)

Eurocleft Protocol
• Clefts of the lip, alveolus and/or palate affect between 1 per 500 to 1 per 700
live births in Europe (World Health Organization, 1998).
• Approaches to cleft care in Europe vary considerably between countries.
Within the Nordic countries there is a tradition of centralization of services.
Other countries such as France, Germany and Italy (and until recently, the
UK) provide cleft care via large numbers of local services who may see but a
few patients with clefts.

A Six-Center International Study Of
Treatment Outcome in Patients with
Clefts of Lip and Palate
•Part 1: Principles and Study Design
•Part 2 : Craniofacial form and soft tissue profile.
•Part 3 : Dental Arch Relationships
•Part 4 : Assessment of nasolabial apperance
•Part 5 : General discussion and conclusion
Shaw, W.C., Dahl, E., Asher-Mcdade, C., Brattström, V., Mars, M., Mcwilliam, J., Mølsted, K., Plint, D.A., Prahl-Andersen, B., Roberts, C. and Semb, G.,
1992. A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 5. General discussion and conclusions. The
Cleft palate-craniofacial journal, 29(5), pp.413-418.

Americleft Protocol
• In 2006, the Executive Council of ACPA approved funds for the Research
Education Committee to organize a pilot project which has become
“Americleft”, an ACPA Task Force.
• Six centers were identified to participate in the pilot project which resulted
in 3 face-to-face meetings over the past two years, completion of initial
comparisons of dental arch relationship outcomes, cephalometric
morphology outcomes, nasolabial esthetic outcomes and the protocol for
assessing speech outcomes.
• The results of these have all confirmed the value and benefits of well-
controlled and well-designed inter-center outcome comparisons.
Americleft study guide

Sawangi Protocol for Treatment of Cleft Lip and Cleft Palate
Birth:
Initial
Assessment
Pre-surgical
assessment
(PNAM)
8-9 year:
Initial
Interventional
Orthodontics
Preparation of
Alveolar Bone
Grafting
3 Month:
Primary
Lip repair
10 years:
Alveolar
Bone Graft
9-18
Month:
Palate
Repair
12-14years:
Definite
Orthodonti
cs
2 year:
Speech
Assessment
16 years:
Nasal
Revision
Surgery
3-5 year:
Lip
Revision
Surgery
17-20
years:
Orthognath
ic Surgery

Infant Orthopaedics
• In children, with severe distortion of the maxillary arches, surgical closure
of the lip which is carried out in the early weeks of life, can be extremely
difficult.
• Orthodontic intervention to reposition the segments and to bring protruding
premaxillary segment back into the arch may be needed to obtain a good
surgical repair of the lip.
• This “infant orthopaedics” is one of the few instances in which orthodontic
treatment for a newborn infant, before the eruption of any teeth, may be
indicated.
Contemporary Orthodontics: William R. Profitt (5th edition)

Pre-Surgical Infant
Orthopaedics

Definition
• PSIO is defined as any orthopedic manipulation of the segments of the
clefted maxilla in a newborn with complete unilateral or bilateral CLP
aiming at establishing a more normal maxillary alveolar arch form or at
retracting a protruding premaxilla to facilitate the surgical repair of
lip.(Glossary of Orthodontic terms, 2000)

Pre-Surgical Infant Orthopaedics
• Presurgical Infant Orthopaedics has been used in the treatment of cleft lip
and palate patients for centuries.
• Early techniques focused on elastic retraction of the protruding premaxilla
followed by stabilization after surgical repair.
Shetye, P.R. and Grayson, B.H., 2017, September. NasoAlveolar molding treatment protocol in patients with
cleft lip and palate. In Seminars in Orthodontics (Vol. 23, No. 3, pp. 261-267). Elsevier.

Pre-Surgical Infant Orthopaedics (PSIO)
• This concept was introduced at University of Glasgow by Kerr McNeil in
1954 as an adjunctive neonatal therapy aiming at nonsurgical reduction of
the size of the alveolar cleft.
• The rationale behind “Maxillary Orthopedics” as described by McNeil,
Burston and Rosenstein is that early segment alignment will allow the
maxillary halves to develop normally even though a normal bony union is
not present.
• The primary purpose of the appliance prior to lip closure is not to proliferate
tissue or initiate growth but to guide the maxillary segments into proper
spatial position with each other and with the mandibular arch.
Singla, S. and Kaur, M., 2008. Cleft palate habilitation. The Indian Journal of Pediatrics, 75(7), pp.703-708.

Advantages of PSIO
Surgical benefits:
• Allows a surgical cleft closure without tension and mobilization of the surrounding soft tissue.
• In complete unilateral clefts of primary and secondary palate, the defective oropharyngeal
musculature allows unrestricted lateral and superior rotation of the maxillary segments in a
medial and inferior direction and recontour the greater segment, restoring a normal premaxillary-
maxillary arch relationship and thus facilitating surgical repair of cleft lip.
• In case of bilateral clefts, the premaxilla is rotated superiorly and anteriorly and the maxillary
segments are retruded and rotated medially and superiorly. Repair of lip without first
repositioning the segments of the maxilla would lock the premaxilla outside the maxillary
segments in a forward position. This allows the lower lip to fall behind the premaxilla, retruding
the mandible, allowing overdevelopment of the premaxillary alveolar area and creating an
excessive overbite.

Advantages of PSIO
• An Orthopaedic feeding appliance facilitates the correction by expanding the
maxillary buccal segments and retruding the premaxilla with or without
external strappings.
• The constant gentle pressure of the appliance against the palatal tissues
serves as a stimulus for the growth of underlying bone. This results in a
narrowing of the palatal cleft and greatly benefits surgical repair.
• Another advantage is reduction in width of the cleft in the alveolar process
which means that there is more chance of the segments forming a butt joint
in the alveolar process region and possibility of an over contracted upper
arch after lip repair is therefore, reduced.

Advantages of PSIO
Aid to plastic surgeon:
• The orthopedic repositioning of the premaxillary region of the greater
segment, and the repositioning of the premaxilla restore the skeletal base
under the nose and lip to a more normal position and permit a more
aesthetic reconstuction of the cleft lip. The better the original correction of
the lip, the less likelihood there is of secondary surgical correction

History
1) Shetye, P.R. and Grayson, B.H., 2017, September. NasoAlveolar molding treatment protocol in
patients with cleft lip and palate. In Seminars in Orthodontics (Vol. 23, No. 3, pp. 261-267). Elsevier.
3) Esenlik E. Presurgical Infant Orthopedics for Cleft Lip and Palate: A Review. Journal of Surgery
[Jurnalul de chirurgie] 2015; 11(1): 9-14. doi:10.7438/1584-9341-11-1-2
2) Bilgic F, Sozer OA. Diagnosis and presurgical orthopedics in infants with cleft lip and palate. Eur J
Gen Dent 2015;4:41-7

History
• 1689- Hoffman demonstrated the use of facial binding to narrow the cleft
and reduce post surgical dehiscence.
• 1790- Similar technique was shown by Desault
• 1844- Hullihen stressed the importance of presurgical preparation of clefts
using an adhesive tape binding.
• 1844- Esmarch and Kowalzig used a bonnet and strapping to stabilize the
premaxilla after surgical retraction.
• 1927- Brophy demonstrated the passing of a silver wire through both the
ends of the cleft alveolus, and then progressively tightened the wire

McNeil Method (1950)
• The modern school of cleft lip and palate was started by McNeil.
• McNeil was the first in aligning presurgically the alveolar parts in
cleft lip and palate patients.
• He suggested the use of serial appliances to approximate cleft
alveolar segments.
• By molding the palatal segments into the correct position using a
series of acrylic plates, McNeil believed that this would produce a
normal maxilla, while reducing the alveolar and palatal cleft at the
same time.
• McNeil and Burston claimed that soft tissues overlying the hard
palate were stimulated to grow, and they also added that neonatal
maxillary orthopedics could control and modify the postnatal
development of the maxilla.

Latham Device (1975)
• Georgiade and Latham introduced a pin retained
active appliance to simultaneously retract the
premaxilla and expand the posterior segments,
which is followed by alveoloperiosteoplasty and
lip adhesion.
• According to Drs. Latham and Millard, these
alignments allow the performance of
gingivoperiosteoplasty (GPP), providing
stabilization of the maxillary segments and
reconstruction of the nasal floor.
• Also known as the dentomaxillary advancement
(DMA) appliance

• The appliance is surgically placed anywhere from 2 to 5 months of age.
• The Latham appliance works by simultaneously applying pressure to the
cleft segments over a 4 to 6 week period to move the alveolar segments into
proper position.
• However, an anterior as well as a posterior cross-bite is an unwarranted side
effect that may occur more frequently

• Bercowitz et al. reported a longitudinal study in unilateral and
bilateral cleft lip and palate treated with the Latham device. They
also performed periosteoplasty in all cases, and compared the results
to patients treated with a non-orthopedics procedure without GPP,
and treated just with a lip adhesion method. They found a higher
frequency of anterior and posterior crossbite in the presurgical
orthopedics group.
• Dr. Latham applied the Latham device with less extensive surgery in
cases of bilateral cleft lip and palate, and he assessed their dental
occlusion and lateral head radiographs at 5 years of age. He found
greater values for cephalometric measures in maxillary length,
maxillary prominence, and ANB angle compared to previous cases

Hotz Appliance (1987)
• Hotz et al. described the use of a passive orthopaedic plate to slowly
align the cleft segments.
• Also known as the Zurich approach.
• Arch alignment is achieved by grinding away the acrylic in specific
areas.
• According to Hotz and Gnoinski, the primary aim of presurgical
orthopedics is not to facilitate surgery or to stimulate growth, as
postulated by McNeil, but to take advantage of intrinsic
developmental potentials.

• There are studies that have shown that this appliance has failed to prevent
collapse of the alveolar segments

• Therefore, the Zurich approach, after a lip operation is
performed at the age of 6 months, palate repair is
postponed until 5 years of age.
• In a long term study, Silvera et al. concluded that The
two-stage palatoplasty in combination with application of
the Hotz plate had good effects on the maxillary growth
than one stage palatoplasty without Hotz plate up to the
age of 12 years.

Grayson’s Technique (1993)
• Grayson et al. described a new technique to pre surgically mold the alveolus,
lip and nose, in infants born with cleft lip and palate.
• PNAM has become very popular among orthodontists because of its nasal
molding effect.
• It is also suggested to correct septal deviation in early ages without surgery.

Grayson’s Technique (1993)
• Grayson pointed out that multiple nasal surgical revisions are often indicated
to approximate the nasal symmetry, because surgical techniques for
managing nasal deformity are lacking.
• He also pointed out that in bilateral cleft lip and palate (BCLP), the deficient
columella and ectopic premaxilla are the primary reconstructive challenges.
Multiple nasal surgeries are required, which often result in excessive
scarring at the columella-prolabial junction, and lack of nasal projection.
• Therefore, he emphasized the importance of nasal molding before surgery in
the early neonatal period.

DynaCleft and Nasal Elevators
• DynaCleft® is a premade nasal and alveolar molding device which can be
used to successfully mold the upper lip, alveolus and nose prior to cleft lip
repair.
• Unlike tape, DynaCleft offers the benefit of being able to provide a constant
approximation force with an elastic center that allows it to conform to a
baby’s mouth better because of its ability to expand and contract.
• Additionally, the controlled force that it provides to the prolabium and
premaxilla could improve surgical results and decrease the necessity of early
lip adhesion surgery
Vinson, L.A., 2016. Presurgical orthopedics in cleft lip and
palate care. Open J Dent and Oral Med, 4, pp.14-19.

Vinson, L.A., 2016. Presurgical orthopedics in cleft lip and
palate care. Open J Dent and Oral Med, 4, pp.14-19.

Classification of PSIO Appliances
Huener&Liu(1993)
Active or Passive
Pre-Surgical and Post-
Surgical
Intra-Oral or Extra-oral
EuropeanCleft
Association-ECA(1999)
Active
Semi-Active
Passive

Active Appliances
Active appliances mold the separate alveolar processes into position by
applying active forces on them or, in other words, by directing them to
grow or to be moved into a preplanned position.
Figure 5
Active appliance, designed to expand and to move the lesser alveolar segment laterally.
Notes: (A) The two alveolar segments are not aligned as shown by the red doted lines. (B) An acrylic
appliance was placed (red shaded area) and as a result of molding the greater alveolar segment was moved
towards the lesser one while the lesser segment was moved laterally by expansion to allow this. The green
arrows show the direction of movement of both segments. The greater segment may then be retracted and
molded into a more natural position.
Alzain, I., Batwa, W., Cash, A. and Murshid, Z.A., 2017. Presurgical cleft lip and palate
orthopedics: an overview. Clinical, cosmetic and investigational dentistry, 9, p.53.

Passive Appliances
Figure 6
Passive appliance.
Notes: No need to move the smaller alveolar segment laterally; there is enough space for larger segment to
mold. (A) The two alveolar segments are not aligned as shown by the red doted lines. (B) An acrylic
appliance was placed (shaded area) and as a result of molding the greater alveolar segment was moved
towards the lesser one. The green arrow shows the direction of movement of the segments. Note that the
lesser segment did not move. (C) The two segments after alignment.

Lip Strap/Lip Taping
• A combination of intra-oral appliances
and/or extra-oral orthopedic strapping
can be used in preparation for
primary lip and plate surgery. In
combination with the intraoral mouth
plates, external tapes and elastics
may be strapped to the cheeks to
provide some external forces in the
alveolar molding process.
• Elastic forces will exert a retracting,
backward pressure against the
protruding premaxilla, and careful
use of forces on the cleft segments will
improve their positions and allow
definitive lip skin and muscle repair

Pre-Surgical
NasoAlveolar
Molding (PNAM)

• The PNAM treatment protocol for cleft patients has been described by
Grayson et al (1993)
Brecht et al (1995)
Grayson and Santiago (1997)
And Cutting et al (1998)
Presurgical nasoalveolar molding; Grayson et al.,
Cleft palate craniofacial journal, November 1999, vol 36, No. 6

Principle
High levels of hyaluronic acid, a component of
proteoglycan intracellular matrix, found
circulating in infants several weeks after birth
Temporary plasticity of the nasal cartilage
increases
Favourable for active molding and
repositioning of the nasal cartilages.
Grayson, B.H. and Cutting, C.B., 2001. Presurgical nasoalveolar orthopedic molding in primary correction of
the nose, lip, and alveolus of infants born with unilateral and bilateral clefts. The Cleft palate-craniofacial
journal, 38(3), pp.193-198.

Matsuo’s Concept
Auricular cartilage could
be molded with
permanent results if
treatment was started
within 6 weeks of life
During this period there
are high levels of
maternal estrogen in the
fetal circulation
Which triggers an
increase in the
hyaluronic acid
Hyaluronic acid alters
the cartilage, ligament
and connective tissue
elasticity by breaking
down intercellular
matrix.
Levels of estrogen start
dropping at 6 weeks of
age.

Objectives of PNAM
• Active molding and repositioning of the deformed nasal cartilages and alveolar processes.
• Lengthening of the columella and correcting the position of the philtrum.
• Placement of the lip segments in a more anatomically correct position facilitating lip repair without
scarring.
• Forces exerted on nasal structures while performing alveolar molding permit straightening of
columella and correction of alar cartilage displacement. Thereby reducing the number of nasal
surgical procedures and improving nasal esthetics.
• It has also been suggested by Pritchard (1946) that bone healing was inversely proportional to the
size of cleft viz larger the cleft slower is the bone healing. Hence presurgical naso alveolar molding is
recommended to produce more favorable bone formation by reducing the size of the cleft.
• Reduces the need for secondary alveolar bone grafts.

Advantages
• Improvement in arch form
• Facilitation of surgical closure
• Improvement of aesthetic outcome
• Facilitation of feeding
• Improvement of speech
• Elimination of surgical columella reconstruction and the resultant scar
tissue in bilateral cleft lip and palate.
Niranjane, P.P., Kamble, R.H., Diagavane, S.P., Shrivastav, S.S., Batra, P., Vasudevan, S.D. and Patil, P., 2014. Current
status of presurgical infant orthopaedic treatment for cleft lip and palate patients: A critical review. Indian Journal of
Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India, 47(3), p.293.

Disadvantages
• PSIO approaches are complex and expensive and might have an adverse
effect on maxillary growth.
• Constricted upper maxilla in all 3 dimensions
• Development of Crossbites
• Uncontrolled mandibular growth if unnoticed
• Overlapping of the two segments
• Complete closure of the defect with alveolar molding does not allow the
surgeon to create perfect nasal floor.
Niranjane, P.P., Kamble, R.H., Diagavane, S.P., Shrivastav, S.S., Batra, P., Vasudevan, S.D. and Patil, P., 2014.
Current status of presurgical infant orthopaedic treatment for cleft lip and palate patients: A critical review. Indian
Journal of Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India, 47(3), p.293.

Concept of Gingivoperioplasty
• The surgical bridging of the cleft alveolar process with periosteal flap was
initially described by Skoog (1965) as a means of stabilizing the separated
segments of the maxilla.
• Skoog’s technique necessitated wide mucoperiosteal dissection to mobilize
the flaps enough to allow for approximation of cleft alveolus as he did not
perform pre surgical nasoalveolar molding.
• Current technique of gingivoperioplasty introduced by Millard and Latham
(1990) is performed after the patients undergo presurgical orthopedic closure
of the cleft alveolar gap.

Concept of Nasal Molding
• According to Millard (1984) clefting is due to disturbance of embryogenesis
and proper closure of all involved structures should be achieved as soon as
possible to favor normal growth of the face.
• Matsuo et al designed a nasal stent for the correction of the nasal
deformity.
• Another modification as suggested by Grayson was addition of nasal stent in
the alveolar molding plate.
• Modified extra oral nasal molding appliance was suggested by Doruk C et al
(2005).

Criteria for
Naso
Alveolar
Molding
(NAM)
Infants must present
for treatment
between 2-4 weeks of
age
NAM is limited to
most severe cases
and treatment MUST
be performed on-site.
As per guidelines of Smile Train

Candidates for NAM
• Infants presenting with extremely wide unilateral clefts and severe nasal
deformity.
• Infants presenting with bilateral clefts with moderate to severe pre-
maxillary protrusion.
• Parents should be aware that NAM involves 7-10 follow up visits over a
period of approximately 3 months
• Committed and motivated parents of infants living far from the treatment
facility and unable to return for the required follow-up visits, should be
offered facial taping with or without a nasal stent as a treatment option
• Information on nutritional/oral hygiene as it pertains to the future dental
health of the infant should be provided to parents (post NAM, facial taping).
As per guidelines of Smile Train

Cases without the need for NAM?
• If there is no cleft at hard palate and cleft is a secondary cleft palate
involving soft tissues and uvula or if there is no nasal deformity with a cleft
forming an alveolar notch without a condition that make nutrition of infant
challenging, no preoperative orthodontic treatment is needed.
• However, a nutrition plate will be appropriate if there is an isolated cleft
palate that makes nutrition of infant challenging.
Bilgic F, Sozer OA. Diagnosis and presurgical orthopedics in infants with cleft lip and palate. Eur J Gen Dent
2015;4:41-7

NasoAlveolar Molding Appliance
• The NasoAlveolar Molding (NAM) Appliance consists of an intraoral molding
plate and nasal stents to mold the alveolar ridge and nasal cartilage
concurrently.
• NAM has been shown to significantly improve the surgical outcome of
primary repair in cleft lip and palate patients compared to other techniques
of presurgical orthopaedics.

Impression Technique
• Initial impression of the infant with cleft lip and palate is obtained within
the first week of birth.
• Heavy bodied silicone impression material is used to take the initial
impression.
• The impression is best taken in a clinical setting that is prepared to handle
airway emergency, if at all encountered.
• A surgeon is always present during the impression process.

Grayson’s Technique
• The infant is held upside down and the impression tray is inserted into
the oral cavity.
• The infant is held in an inverted position to prevent the tongue from
falling back and to allow fluids to drain out of the oral cavity.
• The tray is seated until the impression material reaches the posterior
border of the impression tray, but not beyond.
• The impression must adequately cover the anatomy of the upper gum
pads and palatal shelves and include the vestibular folds.

• Infant experiences Pressure on chest and torso.
• An extra person was required to hold the child.

Other Methods
• Prashanth Mishra et al, obtained impression when the infant was awake in a prone
position.
• Dubey et al made impression of upper arch using ice cream stick and impression
compound.

Appliance Fabrication and Design
• The molding plate is fabricated on the dental stone model.
• The plate is made of self-cure acrylic resin.
• The plate must be 2–3 mm in thickness to provide structural integrity and to
permit adjustments during the process of molding.
• A retention button is fabricated and positioned anteriorly at an angle of
approximately 40˚ to the plate. This angle is adjusted or optimized to
achieve maximum stability on the alveolar ridges.

Appliance Fabrication and Design
• For the appliance employed in the treatment of a unilateral cleft, only one
retention arm is used.
• The vertical position of the retention arm should be at the junction of the
upper and lower lip.
• Orthodontic elastics and tapes attached to the retention button secures the
molding plate in the mouth, resting on the alveolar ridges and palatal
shelves.
• A small opening measuring 6–8 mm in diameter is made on the palatal
surface of the molding plate to provide an airway in the event that the plate
drops down posteriorly.

Concept of Alveolar Molding
• The appliance is selectively grinded in the areas were movement is expected
at the same time soft denture liner is added in the region which require
molding.
• The soft denture liner applies pressure on the alveolar ridge.

Appliance Insertion and Taping
• The appliance is then secured extraorally to the cheeks and
bilaterally by surgical tapes that have orthodontic elastic bands
at one end.
• The elastic on the surgical tape is looped on the retention arm of
the molding plate and the tape is secured to the cheeks.
• The elastics (inner diameter 0.25 in wall thickness-heavy)
should be stretched approximately two times their resting
diameter for proper activation force of about 100 g.

Appliance adjustments
• These adjustments are made by selectively removing the hard acrylic and
adding soft denture base material to the molding plate.
• No more than 1 mm of modification of the molding plate should be made at
one visit.
• The alveolar segments should be directed to its final and optimal position.
• Care must be taken to prevent the soft denture material from building up on
the height of the alveolar crest as this will prevent complete seating of the
molding plate.

Incorporation of Nasal Stent
• The nasal stent component of the NAM appliance is incorporated when the
width of the alveolar gap is reduced to about 6 mm.
• The rationale for delaying addition of the nasal stent is that as the alveolar
gap is reduced, the base of the nose and the lip segment alignment is also
improved.
• The alar rim, which at birth was stretched over a wide alveolar cleft
deformity, will show some laxity as the cleft segments are brought together.
• Once the alar base on the cleft side shows less stretch and tension, it can be
elevated into symmetrical and convex form with the nasal stent and not be
subjected to additional stretch.

• When the nasal stent is introduced to a nostril
that is overlying a very wide alveolar gap, it
may stretch further the nostril rim and increase
nostril circumference.
• This may result in a postsurgical “mega-nostril”
or a nostril of greater circumference on the cleft
side than the noncleft side.
• The nasal stent is made of 0.36 inch round
stainless steel wire and takes the shape of a
“Swan Neck”.

• The stent is attached to the labial flange of the molding plate, near the base
of the retention arm.
• It extends forward and then curves backwards (in the form of a swan neck)
entering 3–4 mm past the nostril aperture.
• 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.
• The hard acrylic component is shaped into a bi-lobed form that resembles a
kidney

• The upper lobe enters the nose and gently projects the dome forward until a
moderate amount of tissue blanching is evident.
• The lower lobe of the stent lifts the nostril apex and defines the top of the
columella

Nonsurgical columella lengthening in
patients with bilateral cleft lip and
palate
• In patients with bilateral cleft lip and palate, there is a need
for two retention arms as well as two nasal stents, which are
similar in shape to the unilateral stent.
• The initial goal of molding is to center the premaxilla, retract
the premaxilla and reduce the bilateral cleft gaps to 5–6 mm
prior to adding the nasal stents

• The first goal of PNAM in bilateral cases is to move the premaxillary
segment posteriorly and medially, while preparing the lateral alveolar clefts
to come in contact with the premaxilla.
• The posterior lateral palatal shelves are molded to the appropriate width to
accept the premaxilla. The premaxilla is retracted and derotated as
necessary using the molding plate in conjunction with external tape and
elastics.

palate
• A horizontal band (columella band) of denture material is added to join the
left and right lower lobes of the nasal stent, spanning the columella.
• The inferior surface of the columella band sits at the nasolabial junction and
helps to define this angle.
• The superior surface of the columella band presses up against the nostril
apex, located at the top of the columella.

palate
• Tape is adhered to the prolabium underneath the horizontal lip tape and
stretches downward to engage the retention arm with elastics .
• This vertical pull provides a counter stretch to the upward force applied to
the left and right nostril apex of the columella band.
• Taping downwards on the prolabium helps to lengthen the columella and
vertically lengthens the often small prolabium.

Primary surgical repair of the
alveolus lip and nose
• The alignment of alveolar segments and premaxilla, correction of nasal
asymmetry, elongation of the columella and projection of the nasal tip are
accomplished before the primary surgical repair.
• Surgical closure of the lip and nose is performed from 3 to 4 months of age.
• Achievement of presurgical clinical objectives in patients with bilateral cleft
lip and palate tends to take 1–2 additional months.

Primary surgical repair of the
alveolus lip and nose
• The surgical technique must be modified to take advantage of the NAM
preparation.
• Approximation of the alveolar segments permits the surgeon to perform
gingivoperiosteoplasty.
• Reshaping of the deformed alar cartilage and stretching of the nasal mucosa
enhances the surgeons ability to achieve a good primary rhinoplasty and
surgical alveolar repair.

Complications
• Most common problems: irritation to the oral mucosa,
gingival tissue, or nasal mucosa.
• Intraoral tissues may ulcerate from excessive pressure
applied by the appliance.
• The intranasal lining of the nasal tip can become
inflamed if too much force is applied by the upper lobe of
the nasal stent.
• Skin irritation because of the tape.

Disadvantages of PNAM
Maxillary
growth
restriction
Negative influences
on speech because of
delayed palate
closure
The costs of the
treatment
Complexity of
treatment
Lip surgery alone
has the same effect
as that of PSIO
The therapeutic
implication of presurgical
orthopedics is not growth
guidance but
repositioning of the
maxillary segments
(Kriens, 1989).
Opponents of the
approach also state that
PSIO is ineffective and
unnecessary (Subtelny,
1964; Pruzansky and
Aduss, 1964; Berkowitz,
1990).
(Pruzansky and Aduss, 1964; Huddart and Bodenham, 1972; Ross, 1987;
Kramer et al. 1992; Prahl et al., 2001).

Facial growth, maxillary arch, and
dentition and occlusion
Proponent
• Mishima et al.,using a two-group
quasirandomised design with a control group
(n = 8) children without PSIO, found that prior
to lip surgery the maxillary segments in the
PSIO group (n = 12) moved towards the midline,
and in the non-PSIO group, the maxillary
segments remained in the same position or
displaced laterally. At 18 months of age, the
curvature of palatal shelves was less steep, and
there was less arch collapse in PSIO group when
compared with control group. At 4-years of age,
the distance between deciduous canines and
second deciduous molars was larger in the PSIO
group; other variables did not differ between the
two groups.
Opponent
• Lee et al. assessed the effects of NAM
and gingivoperiosteoplasty (GPP) in 20
UCLP patients at 6-year and at 11.5-
year that is, at pre-pubertal age using
lateral cephalogram and found that
midface growth in sagittal or vertical
planes (up to the age of 9-13 years) was
not affected by pre-surgical alveolar
moulding and GPP.
Niranjane, P.P., Kamble, R.H., Diagavane, S.P., Shrivastav, S.S., Batra, P., Vasudevan, S.D. and Patil, P., 2014. Current status of presurgical infant
orthopaedic treatment for cleft lip and palate patients: A critical review. Indian Journal of Plastic Surgery: Official Publication of the Association of
Plastic Surgeons of India, 47(3), p.293.

Nasal symmetry and nasolabial appearance
Proponent
• In a 6-year follow-up by Bennun et
al. to compare growth and cosmetic
results of 97 UCLP patients using
plaster models by using surface
impressions of the babies revealed a
better and permanent nostril symmetry,
increase in the columellar length and no
alar cartilage luxation in patients who
had the nasal component.
• A 9-year follow-up by
Barillas et al. using stone cast
measurements in 25 UCLP patients
revealed that the nasal symmetry was
improved by PNAM and was maintained
at 9-year.
Opponent
• Sulaiman et al. did a 15-year follow-up
of pre-surgical orthopaedics, followed by
primary correction for unilateral cleft
lip nose and found that the nostril
height and width ratio and the height of
the alar groove were significantly
improved post-operatively and
maintained for 15-years, but also stated
that repositioning of nasal cartilage at
infancy might not eliminate need for
secondary correction after puberty.

Speech
Proponent
• Suzuki et al. studied the effect of pre-
operative orthopaedic plate on
articulatory function in 17 CLP
children. Speech was assessed by
speech therapists 3-year 11 months
after palatoplasty. The results
indicated that the continuous use of
orthopaedic plate was effective in
preventing palatalized articulation.
Opponent
• Konst et al. evaluated language skills
of children between the ages of 2 and
6-year. The results showed that the
early positive effects of PSIO changed
over time, and no differences were
found in language development
between the two groups at the age of
6-years.

• Liou et al. reported that nasal asymmetry was significantly improved after
nasoalveolar molding in infants with cleft lip and palate; but after the
primary closure of the cleft lip and nose, there was a significant relapse of
the nasal asymmetry in the first year postsurgery, which remained stable
afterwards. This relapse was the result of a significant differential growth
between cleft and noncleft sides in the first year postsurgery.
• Pai et al., who used the nasoalveolar molding (NAM) appliance in their
study, concluded that there was some relapse of nostril shape in width
(10%), height (20%), and angle of columella (4.7%) at 1 year of age, compared
to their presurgical status.
• Papadopoulos et al. also investigated the effectiveness of presurgical infant
orthopedics using a systematic review. They showed that there were no
significant differences in craniofacial and dentoalveolar changes, indicating
that PSIO treatment had no effect on cleft lip and palate patients.
3) Esenlik E. Presurgical Infant Orthopedics for Cleft Lip and Palate: A Review. Journal of Surgery
[Jurnalul de chirurgie] 2015; 11(1): 9-14. doi:10.7438/1584-9341-11-1-2

Proponents of PNAM
• Aids in the surgical repair of the lip and palate by reducing defect width of the palatal and
alveolar ridge, which in turn will reduce lip tension and benefits wound healing
postoperatively
• Prevents initial collapse after surgery and crossbites
• Achieves symmetrical arch form
• Improves position of alar base
• Less extensive orthodontic treatment at later ages
Surgery
• Improved growth of the maxilla as repositioning of the bony segments will help
in future growth and development
• Reduced tongue interference with the palatal shelves may encourage the
normal growth of the palatal shelves, thus allowing spontaneous reduction in
the width of the cleft
Growth
• Improved speech development due to improved physiological tongue function and position
(prevents twisting and dorsal position of the tongue in the cleft).
• The improvement was significant in children aged 1–3 years; this was seen as the ability of the
child to produce longer sentences. However, this improvement diminished in children aged 6
years
• Improved feeding (less danger of aspiration); however, there is no evidence to support this
• Better nose breathing and decreased nasal regurgitation
• A positive psychological effect on the parents
Function
Alzain, I., Batwa, W., Cash, A. and Murshid, Z.A., 2017. Presurgical cleft lip and palate orthopedics: an overview. Clinical, cosmetic and investigational dentistry, 9, p.53.

Opponents of PNAM
• Neonatal maxillary orthopedics is a complex and expensive
therapy that is ineffective and unnecessary because parents are
obliged to travel frequently to the treatment center and endure an
increased burden of care.
• There is no significant improvement in parents’ satisfaction.
• The overall cost of treatment is significantly high.
Cost-
Effectiveness
•Neonatal maxillary orthopedics restricts maxillary development as a
result of the molding process
•There are no apparent long-term effects on facial growth in either
vertical or anteroposterior dimensions.
•However, there is some evidence emerging that those patients who have
had NAM do have improved nasal anatomy.
Growth
• Influences speech negatively due to delayed surgery of the hard
palate.
• It is not necessary for feeding or orthodontic reasons,did not
improve feeding efficiency or general body growth,and did not
improve deviated swallowing characteristics.
Function

A newer classification system
(Daigavane P S, Hazarey PV, Niranjane P, Vasudevan SD, Thombare BR, Daigavane S. A New Classification System for Unilateral Cleft
Lip and Palate Infants to assist Presurgical Infant Orthopedics. The Journal of Clinical Pediatric Dentistry . Volume 39, Number 3/2015)
Type Model Features Treatment Plan
Type A Greater and lesser segment are of
sufficient length
1. Well expanded tuberosities are used for support.
2. Soft liner is placed on the anterior 1/3rd
3. Equal amount of the acrylic is removed from the
opposite side of the segment to make space for the
alveolar segment to move.
Type B Greater segment is of sufficient
length but lesser segment is small
and/or placed posteriorly
1. Only the greater segment is molded into an arch
form.
2. An attempt to achieve complete closure of the
alveolar segments may lead to arch constriction.
3. Alveolar Bone Grafting can be done later.
Type C Greater and lesser segments are of
small length and parallel to each
other
1. Transverse width of the arch will be maintained
using permasoft.
2. No attempt must be made to close the alveolar
defect.
3. Later closure can be done with flap, or the defect
can be sealed with an obturator modified with
denture.
Type D Greater segment is overlapping the
lesser segment
1. The “Locked Segments” commonly seen in cases
with cleft lip and alveolus.
2. Consideration should be given to only nasal
molding.
3. Transverse growth of the maxilla will unlock the
overlapping to attain arch uniformity.

Pre-directional
appliance: A new
approach to correct
shifted premaxilla in
bilateral cleft cases
Daigavane, P.S., Hazarey, P., Vasant, R. and Thombare, R., 2011. Pre-
directional appliance: A new approach to correct shifted premaxilla in
bilateral cleft cases. Journal of Indian Society of Pedodontics and
Preventive Dentistry, 29(6), p.39.

Introduction
• Management of bilateral cleft lip and palate cases is a
challenging task, and if the premaxilla is shifted to either
side, it poses a problem for the surgeon to operate and
also for the orthodontist to do the orthodontic alignment.
• The aim of this study was to reposition the shifted
premaxilla for better retraction with presurgical infant
orthopedics, thus reducing the tissue tension and further
scarring which have detrimental effects on maxillary
growth.
• The innovative technique with pre-directional (PD)
appliance is easy to fabricate and use and works in this
direction.

Method of Fabrication
• Pre-directional (PD) appliance, fabricated in heat-cure
resin, is a modification of Grayson's presurgical naso
alveolar molding (PNAM) appliance.
• To make the anterior segment flexible, the appliance was
modified by marking two parallel vertical lines and a
transverse cut was given in the anterior segment of the
appliance to separate it from the posterior segment.
• 1 mm acrylic was reduced from edges of both the
segments.

• With the straight fissure
bur, cuts were made on the
vertical lines.
• Both these segments were
repositioned on the cast; two
8-mm NITI coil springs were
placed in the vertical cuts
and rejoined with self-cure
resin.

• Permasoft was applied on the inner surface of
the anterior segment on the right side to push
the premaxilla to left side, and also, on the
medial aspect of the posterior alveolar
segment for expansion.
• The appliance was retained with tapes (3M
micropore surgi tape) and red elastics.
• The elastic force on both sides differed; on the
right side it was kept inactive for appliance
stability, while on the left side it was
stretched double its diameter, exerting a force
of 6 ounces on the premaxilla. The patient
was evaluated weekly for correction.

Results
• On evaluation after
2 months 20 days,
the premaxilla was
shifted to the left
side by 5.5 mm, the
premaxilla and
prolabium were
positioned in the
middle, facial
symmetry was
observed with both
the nostrils equally
visible

• .At this stage, the PD appliance was
replaced by Grayson's PNAM
appliance. Nasal stents were added for
molding.
• For prolabium lengthening, a vertical
tape was overlapped on two red
elastics (knotted with eachother)
placed on retentive buttons.
• During suckling, stent forces the nose
dome upward and forward, while the
lip tape forces the prolabium
downward, thus lengthening the
columella.

• It was observed that after 2½ months,
the premaxilla was retracted 4.5 mm
uniformly with successful nasal
molding.
• At 6½-7 months of age, both side lips
were operated in the same operative
session with Millard and Nordoff
technique.
• On evaluation, at the age of 1 year 3
months, it was observed that facial
symmetry, columellar lengthening, and
nasal molding were maintained.

• As this appliance could reposition the premaxilla within
short duration, it was possible to do nasal molding
utilizing the elasticity of the nasal cartilage.
• Alveolar segments were expanded to 1.5 mm, premaxilla
was retracted symmetrically by 4.5 mm, facial esthetic
was improved, prolabium was lengthened to 6 mm, no
tissue tension was observed during surgery and
satisfactory lip repair was accomplished in one stage

Advantages
• Inexpensive
• Easy to fabricate
• Does not require complicated laboratory procedures
• Gives quick results
• The rate of bone healing is inversely proportional to size
of defect; thus, presurgical orthopedics favors bone
formation.

Conclusion
• Treatment outcomes, and favorable or unfavorable
maxillary growth, may be anticipated according to initial
severity of the cleft deformity and less related to the
given treatment.
• More importantly, because there is a demonstrated
variation in severity of cleft deformity, treatment protocol
could vary according to severity of the initial deformity
and children with CLP could be sorted by severity before
correlating specific treatment variables with outcomes.

Bibliography
• Murray, J.C., 2002. Gene/environment causes of cleft lip and/or palate. Clinical
genetics, 61(4), pp.248-256.
• Murthy P S, Deshmukh S, Bhagyalakshmi A, Srilatha K T. Pre Surgical Nasoalveolar
Molding: Changing Paradigms in Early Cleft Lip and Palate Rehabilitation. J Int Oral
Health 2013; 5(2):76-86.
• Contemporary Orthodontics: William R. Profitt (5th edition)
• Shetye, P.R. and Grayson, B.H., 2017, September. NasoAlveolar molding treatment protocol
in patients with cleft lip and palate. In Seminars in Orthodontics (Vol. 23, No. 3, pp. 261-
267). Elsevier.
• Grayson, B.H. and Cutting, C.B., 2001. Presurgical nasoalveolar orthopedic molding in
primary correction of the nose, lip, and alveolus of infants born with unilateral and bilateral
clefts. The Cleft palate-craniofacial journal, 38(3), pp.193-198.
• Niranjane, P.P., Kamble, R.H., Diagavane, S.P., Shrivastav, S.S., Batra, P., Vasudevan, S.D.
and Patil, P., 2014. Current status of presurgical infant orthopaedic treatment for cleft lip
and palate patients: A critical review. Indian Journal of Plastic Surgery: Official Publication
of the Association of Plastic Surgeons of India, 47(3), p.293.

• Singla, S. and Kaur, M., 2008. Cleft palate habilitation. The Indian Journal
of Pediatrics, 75(7), pp.703-708.
• Kalaskar, R., Kalaskar, A., Naqvi, F.S., Tawani, G.S. and Walke, D.R., 2013.
Prevalence and evaluation of environmental risk factors associated with cleft lip
and palate in a central Indian population. Pediatric dentistry, 35(3), pp.279-283.
• Textbook of Oral and Maxillofacial Surgery – Neelima Anil Malik (3rd
edition)
(Daigavane P S, Hazarey PV, Niranjane P, Vasudevan SD, Thombare BR, Daigavane S. A
New Classification System for Unilateral Cleft Lip and Palate Infants to assist Presurgical
Infant Orthopedics. The Journal of Clinical Pediatric Dentistry . Volume 39, Number 3/2015)

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