This document provides information about nasoalveolar molding (NAM) for treating cleft lip and palate. It defines cleft lip and cleft palate, and describes presurgical NAM which reshapes the alveolar and nasal segments before surgical repair. The key steps of NAM include taking an impression, fabricating an acrylic molding plate with a nasal stent, inserting the plate and using tape for retention, and making weekly adjustments to reshape the tissues over 3-5 months before surgery. The goals of NAM are to decrease the cleft deformity and improve symmetry, with benefits such as reducing the need for future bone grafts or surgeries.

1. JOURNAL CLUB
NASOALVEOLAR MOLDING
DR RAMESH R
DEPT OF PEDODONTICS AND
PREVENTIVE DENTISTRY

2. CONTENTS
• INTRODUCTION
• DEFINITION
• PNAM
• PRINCIPLE
• OBJECTIVES
• IMPRESSION TECHNIQUE
• APPLIANCE FABRICATION
• CONCLUSION
• JOURNAL ARTICLES

3. INTRODUCTION

4. DEFINITION
CLEFT LIP
• Birth defect which results in unilateral or bilateral opening in
the upper lip between the mouth and nose due to failure of
fusion of lateral and medial nasal process.
CLEFT PALATE
• Birth defect characterized by opening in the roof of mouth
due to lack of fusion of palatal process of maxilla
• An opening in hard/soft palate due to improper union of
maxillary and medial nasal process during second month of
intrauterine life.

5. Presurgical Nasoalveolar Molding (NAM)
• Presurgical Nasoalveolar Molding (NAM) was introduced to
reshape the alveolar and nasal segments prior to surgical repair.
• The first presurgical nasoalveolar molding (pnam) appliance was
designed by Grayson et al. (1999).

6. PRINCIPLE
• PNAM works on the
principle of “Negative
sculpturing” and “Passive
molding”.
• In negative sculpturing serial
modifications are made to the
internal surfaces of the
molding appliance with
addition or deletion of
material in certain areas to get
desired shape of the alveolus
and nose.
• In passive molding, custom
made molding plate of acrylic
is used gently to direct the
growth of the alveolus to get
the desired result later on.

7. The objectives of PNAM are:
• Decrease the severity of the primary cleft deformity
• Provide symmetry to distorted nasal cartilage.
• Nonsurgical lengthening of the columella.
• Approximation of lip segments to decrease tension in the tissues
after lip repair and thus reduce scarring.
• To produce additional favorable bone formation by decreasing the
size of the cleft and improving nasal tip projection, decreasing the
width of nasal alar base and nasal tip
• Reduce the need for secondary alveolar bone grafts.
Retnakumari N, Divya S, Meenakumari S, Ajith PS. Nasoalveolar molding treatment in presurgical infant orthopedics in cleft
lip and cleft palate patients. Arch Med Health Sci 2014;29:36-47.
Grayson BH, Garfi nkle JS. Early cleft management: Th e case for nasoalveolar molding. Am J Orthod Dentofacial Orthop

8. • In infants with bilateral CLAP, the goal consists of the nonsurgical
lengthening of the columella, retraction of premaxilla and centering
of the premaxilla along the mid-sagittal plane.
• The main point of nasal molding is to move the alar domes
anteriorly in a sagittal path for increasing length of columella.

9. PHASES OF UTILIZATION OF NAM IN
UNILATERAL CLEFT LIP DEFORMITIES
AGE WORK TO BE DONE
0-1 week 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 week Plate insertion
12-16 week NAM adjustments

10. • 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 the concept of nasoalveolar molding, repair of a large
cleft required multiple surgeries between birth and 18 years
of age.
• 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.
Habel A, Sell D. Management of cleft lip and palate, Archives of diseases in childhood 1996;74:360-4

11. Steps for NAM therapy
• Evaluation of the infant for PNAM is started soon after birth.
During the 1st week or early 2nd week after birth the clinical
procedures and fabrication of PNAM plate should be started.
• Molding of tissues is easier because of raised level of hyaluronic
acid and maternal circulating estrogen in neonates.
Dubey RK, Gupta DK, Chandraker NK. Presurgical nasoalveolar molding: A technical note with
case report. Indian J Dent Res Rev 2011;2:66-8.

12. IMPRESSION TECHNIQUE
• The initial impression - heavy-
bodied silicone impression material.
• It should be taken soon after birth as
the cartilage is plastic and is
moldable.
• The presence of the surgeon.
• Grayson and Maull held infant
upside down position
• The tray should be placed until
impression material just begins to
extrude from the posterior border.

13. • Yang et al. took the impression using a pre-trimmed customized
pediatric tray with the baby mainly in the erect position, being held
by one of the parents.
• Prashanth et al.,Mishra et al obtained impression when the infant
was awake in a prone position on the dental chair. The child is held
on the lap of their parents with no anesthesia in an outpatient clinic.
• Dubey et al. made impression of the cleft region upper arch using
ice cream stick and impression compound.

14. TECHNIQUE
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

15. • The material should reach the border maxilla, premaxilla and
cleft region.
• Two 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.

16. Impression of the nasal region:
• It is not necessary but may be helpful in comparing the pre and
post orthopedic molding results.
• Obtained with clear polyvinylsiloxane.
• Cotton plugs with floss used to prevent material lodging into
deep nostrils.
• Not used for fabricating the nasal stent

17. • The impression material is
allowed to set, and then the tray
is taken out of infant’s mouth.
• The mouth is checked for
remaining impression material. A
cast or model is poured with a
dense plaster material (dental
stone).
• The plate is made-up on the
stone model. If using special
tray, and putty consistency
polyvinyl elastomeric impression
material final impression is
made, with the same technique
as of primary impression.

18. APPLIANCE FABRICATION
• Undercuts present on the cast
are blocked out with utility
wax. Separating media is
applied.
• The NAM plate described by
Grayson and Maull is
prepared up of hard, clear
self-cure acrylic.
• It is lined with a thin layer of
a denture soft material.

19. RETENTIVE TAPING
• Broader base tape - 0.5-1.5 inch
• Thin suture strips - 0.25-4 inch

20. • Small red orthodontic elastics - 0.25 inch diameter.
• Elastics- Stretched to twice the original length
• Force vector: posterior and superior.
• Timings for changing taping

21. RETENTIVE BUTTON
Extroral retentive buttons should be placed at an angle of 45° to
occlusal plane.
For unilateral cleft , 1 button and bilateral cleft 2 buttons are given.

22. • The elastics used should have
an inner diameter of 0.25 inch,
and it should be stretched about
2 times the diameter for
activation force of about 2 oz.
• One-retention arm is used in
cases with the unilateral cleft
only.
• It is positioned approximately
40 degrees down from the
horizontal to achieve proper
activation.

23. APPLIANCE INSERTION
• The molding plate is
examined for rough areas
• Appliance is checked for
proper fitting and retention.
• The primary retention of the
appliance is through extra-
oral facial adhesive tapes
applied to cheeks

24. • After the initial insertion, the
baby is observed for several
minutes to check the stability of
the appliance in place against the
palate.
• Bottle feeding done to ensure
proper suckling without gagging.
• Some authors suggest a liquid
adhesive such as Mastisol
painted with a cotton-tipped
applicator horizontally on the
cheeks where the Steri Strips will
be placed.

25. • Maintaining the tight apposition of lip segments with the tape
results in the orthopedic benefits of the traditional lip adhesion
without the consequent scar.
• It also serves to improve the position of the nasal base region by
bringing the columella toward the mid-sagittal plane and by
progressing the regularity of the nostril apertures.
• The lip adhesion alone produces uncontrolled orthopedic benefits;
whereas the lip tape adhesion combined with the molding plates
produce controlled movement of alveolar segments.
• The tapes are changed once a day

26. APPLIANCE ADJUSTMENT
• The appliance is left for 24 h in
mouth and parents are
instructed to remove it only for
cleaning purposes.
• After 24 h patient is recalled to
evaluate and correct sore spots
or other problems with the
appliance, if any.
• The recall appointments are
scheduled weekly to modify the
molding plate by selective
trimming and addition of
acrylic to direct the alveolar
fragments into the required
location.

27. • As the alveolar gap closure
occurs, the lip segments come
together & reduces the nasal
base width
• Addition of Nasal stent should
be delayed till laxity of the
alar rim is achieved because it
may result in the enlarged
circumference of the nostril.

28. NASAL STENT
• The incorporation of nasal stent is recommended when the alveolar
gap width is decreased to 5mm. It is made up of 0.036 gauge round
wire and resembles kidney shape. It is added to the vestibular shield
of the appliance.
• Tip of nasal stent is pointed in the direction of the medial wall of
the defective nostril.

29. • The upper lobe enters the nose
and lightly elevates the dome until
a reasonable amount of tissue
blanching is apparent.
• The lower lobe elevates the nostril
apex and delineates the top of the
columella.
• The alar rim, stretched at birth
will demonstrate a little laxity,
and with the nasal stent, this is
elevated into a proportioned and
convex form.

30. • Major surgical closure of the lip and nose are performed
between 3 and 5 months of age.
• As the alveolar segments are in approximation, a gingivo-
periosteoplasty (GPP)is simple to perform, which avoids
widespread dissection and not affecting growth of the mid-
face.

31. TIMING OF WEAR
• The type of cleft the child has (unilateral or bilateral) will
determine the amount of time that the child will need to use
the NAM.
• On average, a unilateral cleft will require the NAM for
around three months while a bilateral baby might be required
to wear it for up to five or six months.

32. POST INSERTION EVALUATION
• Observation: retention, posterior extension, verification for
not too tight fitting & no acrylic in cleft area.
• Infant suckling evaluation, absence of gagging.
• Molding of the alveolar segments

33. FOLLOW UP
• Weekly basis
• Progress of molding appliance is monitored
• Retention is evaluated
• Examination for possible sores
• Monitor Changes in size of defect
• Modification of appliance, if needed

34. ACTIVE AND PASSIVE APPLIANCES
• Appliances are classified
into active or passive or
semi-passive depending on
forces required.
• Active appliances are fixed
intra-orally and apply
traction through mechanical
means such as elastic
chains, screws, and plates.
• Active maxillary appliances
use controlled forces to
move the alveolar cleft
segments in a predetermined
manner.

35. • Passive appliances maintain the
distance between the 2 maxillary
segments while external force is
applied primarily to reposition
the segments posteriorly.
• External taping of the lip, head
cap with elastic straps across the
prolabium, or a surgical lip
adhesion applies external forces.
• Passive appliances act only as a
hinge on which the forces
produced by surgical lip closure,
shape and mold the alveolar
segments in an expected manner.

36. COMPLICATIONS
• Irritation of the oral mucosal.
• If there is more force application by the upper lobe of the nasal
stent, it may cause inflammation of intranasal lining of the nasal
tip.
• If the lower lobe is not positioned correctly notching can occur
along the alar rim.
• If the band is too tight, the region under the horizontal prolabium
band may become ulcerated.
• Loss of valuable treatment time if parent’s compliance is poor.
• The risk of dislodgement of the molding plate which may
obstruct the airway.
• Possibility that the posterior limit of the NAM plate may drop
down onto the tongue if the arms are taped too horizontally or
with inadequate activation.
• Pressure from molding plate may cause premature emergence of
the labial surface of maxillary deciduous central incisors

37. JOURNALS

38. A MODIFIED PRESURGICAL
ORTHOPEDIC (NASOALVEOLAR
MOLDING) DEVICE IN THE TREATMENT
OF UNILATERAL CLEFT LIP AND PALATE
• Chitravelu Siva Subramanian1, N. K. K. Koteswara Prasad1, Arun B.
Chitharanjan1, Eric Jein Wein Liou2
• 2016 European Journal of Dentistry

39. • Nasoalveolar molding (NAM) can be done effectively to
reshape the nasal cartilage and mold the maxillary
dentoalveolar arch before surgical cleft lip repair and primary
rhinoplasty.
• Presurgical NAM helps as an adjunct procedure to enhance
the esthetic and functional outcome of the surgical
procedures.
• This device helps in reducing the number of frequent visits
the patient needs to take to the craniofacial center.

40. • A female baby who was 45
days old reported to the
craniofacial center with
unilateral cleft lip and
palate.
• After clinical examination,
NAM was planned for the
patient.
• The parents were informed
about treatment procedure
and the duration, with more
emphasis placed on their
daily involvement during
the active phase of the
NAM procedure

41. • The parents were asked not to feed the baby at least 3 h before
taking impression. Impression was taken with the child secure in the
mother’s lap.
• Primary impression of the maxillary arch was taken with silicone
impression material in a special pediatric impression tray.

42.  The plate was
fabricated on the
cast after the
undercut areas were
blocked with utility
wax.
 The plate was made
of self-cure acrylic
material.
 The plate should be
at least 2 mm in
thickness to provide
rigidity during the
NAM procedure.

43. APPLIANCE FABRICATION
• Nasal stent was made in 0.032-inch titanium molybdenum alloy
(TMA) wire, the retentive part was acrilyzed in the plate during the
plate fabrication.

44. • The plate is placed in the infant’s mouth, and from the wire, a coil is
made which is 3–4 mm in diameter.
• The upper part of the wire reaches the dome of the nose which is
bent into bean shape to incorporate acrylic bulb.
• The acrylic bulb is coated with soft acrylic for ease of insertion and
also to prevent irritation during activation.

45. APPLIANCE INSERTION AND TAPING
• All the surfaces of the plate are smoothed any rough surface,
or hard edges may irritate the soft tissues and may cause
ulcerations.
• The plate was placed in the mouth and checked for fitting.
• Properly seated appliance will have the plate seated in the
mouth and the nasal stent soft acrylic placed in the medial
alar wall of the nose on the affected side.
• The baby was kept under observation for the initial few
minutes to check for the stability of the plate.
• Steri strips are placed from one side of the cheeks to the other
side.
• After this procedure, the parents were asked to bottle feed the
baby to ensure there is no gag reflex.

47. APPLIANCE ADJUSTMENT
• The baby was seen once in 2 weeks for appliance adjustment.
• The plate is adjusted to facilitate the approximation of the
alveolar process.
• The nasal stent is adjusted to align the nasal dome, improve
nasal projection, and increase the length of the columella.
• The adjustment of the nasal stent is done with orthodontic
pliers.
• The parents were advised to clean the plate every day and
keep the plate clean.

48. DISCUSSION
• In this technique, NAM device was modified by making the nasal
stent with TMA wire.
• The advantage of TMA wire is that it is more resilient, and hence,
activation can be done once in 2 weeks unlike the other technique
where activation of the nasal bulb has to be done once in a week.
• This causes added burden for the parents who come from far
distances to come with the baby once a week.
• Further, the nasal stent made with TMA wire can be adjusted with
orthodontic pliers, and the activation does not take long chairside
time, which in turn increases the compliance of the baby during
the activation period.

49. CONCLUSION
• In India, the numbers of cleft cases are significantly high, so
it is imperative to develop and modify procedures to make
the treatment cost-effective and ease the burden of the child
so that will help to improve the psychological well-being of
the growing child and enable the child to become part of the
society.

50. Facilitating CAD/CAM nasoalveolar molding
therapy with a novel click-in system for nasal
stents ensuring a quick and user-friendly
chairside nasal stent exchange
• Florian D. Grill 1, Lucas M. Ritschl1, Hannes Dikel2,
Andrea Rau3, Maximilian Roth 1, Markus Eblenkamp2,
Klaus-Dietrich Wolff1, Denys J. Loeffelbein1,4 & Franz X.
Bauer2

51. AIM
• Nasoalveolar molding (NAM) improves nasal symmetry with a
nasal stent, because of dentoalveolar growth or cleft reduction,
the nasal stent has to be mounted onto a new plate.
• This procedure elongates visiting hours for patients and parents
or requires second treatment sessions.
• This study introduces a quick-lock additive manufacturing
solution for chairside nasal stent exchange called RapidNAM.
• A novel taping retention pin designed that enables nasal stent
insertion.

52. MATERIALS
• Patients with unilateral CLP were included in this study. Plaster
models were digitalized and measured by two independent
observers.
• Two methods of CAD/CAM-molding therapies were compared:
(i) conventional adhesion of a nasal stent (CAD/CAM NAM);
(ii) quick-lock system in which the nasal stent was transferred to
another plate (RapidNAM).
• The quick-lock system minimizes wire adaptations, since the
preexisting stent can be reused.
• The new nasal stent development seems a feasible solution to
minimize visiting hours This new nasal stent system combines
traditional elements of NAM with CAD/CAM-technology.

53. Virtual RapidNAM plate with
retention pin and screw thread.
Corresponding nut with
retentions for buccal tapings.

54. Caudal view of the retention pin with the retention groove and
profile view. The wire (black) can be clipped into the retentive slot

55. Dorsal view of a RapidNAM
plate with attached nasal stent.
Frontal view of a RapidNAM plate
with attached nasal stent

57. • In total, 14 healthy newborns requiring treatment of unilateral
CLP were included in the study.
• In this, two groups were formed: one group had been previously
treated with conventionally CAD/CAM-intraoral molding plates
that were designed digitally whereas the other group with
RapidNAM.
• The casts were digitalized with a 3D triangulation scanner with a
resolution of 20 µm (3Shape D500, 3Shape; Copenhagen,
Denmark). Both techniques involved the use of a stainless steel
wire construction and a nasal bulb made of resin pattern.
• For nasal stent activation, the treatment groups attended weekly
clinical controls. For extraoral tapings, the Grayson technique was
used
METHODS

58. RESULTS
• In this pilot study, 7 newborns with CLP were included who
had been treated previously with CAD/ CAM-NAM.
• In the RapidNAM-cohort, 7 newborns with CLP were treated
with the novel nasal stent system.
• For comparison purposes, the impressions of the CAD/CAM
NAM cohort were re-measured digitally.
• One patient dropped out of NAM treatment because of
parental difficulties in applying daily tapings, so that a
regular drinking-plate was used instead.

59. • The results of this study show that both approaches significantly
elevate the nostril on the cleft side with an increase in height of
more than 60% and 75%.
• This is a much greater increase than on the non-affected nostril on
the other side.
• Furthermore, the columella angle was noticeably raised in both
groups, whereas the initial values differed between the two groups.
• The preceding CAD/CAM-cohort started out with a mean of 18.3°
that changed to 47.3°.
• The initial angle of the RapidNAM-group was higher with a mean
of 40.7° at the beginning and 53.9° at the end of treatment.
• The columella was lengthened in the CAD/CAM-NAM group by
55% and in the RapidNAM-group by 31%.

60. DISCUSSION
• When choosing to use CAD/CAM-technology in NAM
therapy, the advantage of the new pin and nasal stent
retention design is the easy exchangeability when a new
plate is required.
• The presented solution overcomes previous CAD/CAM-
approaches that needed manual stent attachments.
• Since all RapidNAM-plates have a pin with the same
dimensions, a previously fitting nasal stent can be removed
by unwinding the screw and can be transferred onto the next
plate.
• 3D photography can help additionally to capture the soft-
tissue relationships, especially during different facial
movements for a suitable pin positon, when the plate has to
be designed at a later time.

61. CONCLUSION
• The introduced quick-lock system for CAD/CAM-NAM
devices is the combination of traditional NAM with additive
manufacturing. The integration of the pin is part of the
RapidNAM algorithm which is very time-efficient.
• The exchange of the previously fitted nasal stent to another
plate is fast and only needs minor corrections thus reducing
treatment hours.

62. EFFECTIVENESS OF
NASOALVEOLAR MOLDING IN
THE UNILATERAL CLEFT LIP
AND CLEFT PALATE
• Gabriela Edith Castillo Mariqueo, Eduardo Enrique Almeida
Arriagada,y Teresita del Pilar Iturriaga Bustos,z Sergio
Mun˜oz Navarro,§ and Gerardo Enrique Espinoza Espinoza
• The Journal of Craniofacial Surgery Volume 29, Number 6,
September 2018

63. AIM
• The aim of the present study was to determine the
effectiveness of the Grayson nasoalveolar molding appliance
in reducing the gap between the alveolar segments in cases of
unilateral cleft lip and palate.

64. MATERIALS AND METHODS
• The study design was quasi-experimental, with
measurements taken before and after surgery and no control
group.
• The author studied medical records and models of a sample
of 52 patients with complete unilateral cleft lip and palate
who were discharged after treatment using Grayson
nasoalveolar molding appliance.
• Treatment was considered effective when the final gap was
3mm or less.

65. • Patel and Goya and Espana et al reported that Grayson NAM
appliance was effective in reducing the initial gap.
• In the present study, good effectiveness was observed in
patients in age range of 1 to 4 weeks at the start of treatment.
• The duration of treatment was reflected in the number of
checkups necessary before discharge; the majority of patients
needed 18 or more treatment sessions, and the effectiveness
was greater in the group with treatment lasting 17 weeks or
less.

66. • The effectiveness of Grayson NAM appliance was highest in the
group with initial gap of 8 to 12mm between the alveolar segments;
the differences with other gap ranges were statistically significant.
• These results are consistent with the research carried out by
Grayson himself, who suggested that the NAM appliance is
indicated for complete unilateral or bilateral cleft lip and palate
with an initial gap of up to 14mm for good results.
DISCUSSION

67. • One limitation of this study was the fact that there was no
control group with which to compare the results obtained in
the study group; however, the before and after comparison
serves as a good means of assessing the effectiveness of the
treatment.
• Another limitation was that the study did not consider both
the steps of presurgical orthopedic treatment, since only
correction of the maxillary arch was included and not
changes in the nose.
• One way of continuing this line of research would be to
include patients with bilateral cleft lip and palate, to assess
the improvement in the nasal deformity as part of the
effectiveness indicator, and to add a final, long-term
measurement once the lip has been reconstructed.

68. RESULTS:
• The authors observed that the Grayson nasoalveolar molding
appliance was effective in 69.23% of patients.
• The results of this study support the hypothesis that patients
with unilateral cleft lip and palate benefit from use of the
Grayson NAM appliance to reduce the gap between the
alveolar segments to 3mm or less prior to primary closure.

69. CONCLUSION:
• Grayson NAM appliance presents good effectiveness in
reducing the gap between the alveolar segments in patients
with unilateral cleft lip and palate, especially in cases with a
gap of 8 to 12mm.

70. PRESURGICAL NASAL MOLDING WITH A
NASAL SPRING IN PATIENTS WITH MILD-
TO-MODERATE NASAL DEFORMITY WITH
INCOMPLETE UNILATERAL CLEFT LIP
WITH OR WITHOUT CLEFT PALATE-
CASE REPORT
• Supakit peanchitlertkajorn, dds, mds1,2,3
• The cleft palate-craniofacial journal 1-5

71. AIM
• The goal is to improve nasal deformity prior to primary repair
in infants born with incomplete unilateral cleft lip with or
without cleft palate by the design, construction, and application
of a spring.

72. INDICATION
• Infants born with incomplete unilateral cleft lip with or without
palate are indicated for this molding technique.
• The anterior alveolar cleft, if present, should not exceed 3 mm
(no significant alveolar molding required).

73. FABRICATION OF NASAL SPRING
• A piece of 0.02500 stainless steel
wire is used to form a spring.
• The spring is activated by bending
the active arm of the spring
anteriorly (approximately 30 in
relation to the frontal plane).
• This creates a gentle force to
elevate the alar of nose and
eventually achieves a more
symmetrical nose.
• The spring can be further adjusted
at subsequent follow-up visits by
bending the active arm of the
spring approximately 10 further.

74. • The spring is also tied with a piece of 6-inch long dental floss
to prevent an accidental swallowing of the spring in case of a
spring dislodgment.
• Parents are instructed to clean the spring every 12 hours, how
to apply the tape and use of the safety floss.
• The patient should be seen every 2 to 4 weeks for follow-up
care and adjustments.
• The improvement in the nasal symmetry can be observed
after a few weeks of treatment.
• The total treatment usually lasts 2 to 3 months.

75. • Two patients born with incomplete unilateral cleft lip with or
without palate were referred to our clinic for routine presurgical
NAM.
• Parents were presented with options for either a traditional NAM
plate or a nasal spring and lip taping.
• These parents chose nasal spring as a treatment due to easier
application and less frequent visits.
• A nasal spring was fabricated and delivered along with lip taping
in their initial visits.
• This can be done because oral impression is not required, and the
fabrication of a spring is a quick and simple process.
• The improvement in nasal symmetry is usually achieved within 2
to 3 months depending on the initial severity of the nasal
deformity.
• The patients were then scheduled for their primary surgical repair
after nasal symmetry was achieved or significantly improved.
CASE REPORT

76. CASE #1
• A 9-day-old patient presented with an incomplete unilateral
cleft lip without cleft palate.
• Patient presented with a collapsed nostril on the affected side
• Parents decided to pursue a treatment with the nasal spring.
The patient underwent nasal molding for 11 weeks.
• The nasal symmetry had improved significantly
• The patient received a primary surgical repair after nasal
molding.
• A favorable nasolabial outcome was achieved. No
complication was reported during the course of treatment.
The total number of treatment visits for the nasal molding
was 4.

78. CASE #2
• A 7-day-old patient presented with an incomplete unilateral
cleft lip and alveolus without cleft palate.
• The patient presented with a moderate nasal asymmetry
• The patient received a presurgical nasal molding with nasal
spring for 3 months. The nasal symmetry has improved
significantly patient then had a surgical repair of the lip after
the molding.
• Postsurgical outcomes shows favorable nasolabial aesthetics
with a good nasal symmetry.
• The adjustments needed during follow-up visits are simplified,
significantly reducing the time required to do adjustments, and
increasing the interval between appointments.
• This could lead to an overall reduction in burden of care.

80. DISCUSSION
• The initial nasal deformity can be improved with presurgical
NAM.
• After the molding, the more severe degree of nasal deformity
presented at birth can be reduced to a degree that favorable
nasal outcomes can be expected regardless of primary nasal
reconstruction.
• Chang et al. (2010) demonstrated that nasal symmetry in
patients who underwent NAM and primary nasal
construction is superior to those with NAM alone (without
primary nasal repair) or those with primary nasal
reconstruction alone (without NAM).
• They also found that nasal symmetry is better achieved in the
long term for patients with NAM alone when compared to
those with primary nasal repair alone.

81. • The original design of the presurgical NAM is an intensive
process, requiring an oral impression and time-consuming
laboratory work.
• A nasal spring is designed to minimize these issues. The spring
can be fabricated within a short amount of time due to the
simplicity of the spring design, making it cost effective. It can be
delivered during the initial visit.
• The spring is well tolerated by patients and requires significantly
less compliance from parents.
• The nasal spring is adjusted gradually to improve nasal features
by correcting the shape and position of a lower lateral alar
cartilage.

82. • When the nasal molding with the nasal spring, it reduce the
need for surgical revision of the nose.
• This makes presurgical molding with nasal spring a viable and
practical option to improve the initial cleft nasal deformity
among patients born with unilateral incomplete cleft lip with
or without cleft palate, to facilitate surgical reconstruction, and
to obtain favorable surgical outcomes.
• With the advent of 3-D imaging technology, it might be
possible to digitally design and 3-D print nasal springs to
further simplify the fabrication process.

83. CONCLUSION
•Nasal spring presurgically improves nasal symmetry
in patients with incomplete unilateral cleft lip with or
without cleft palate.
•The nasal spring is simpler in design and
construction, making it cost-effective.
•The nasal spring requires less adjustment time and
follow-up visits.

84. MODIFICATIONS IN PRESURGICAL
NASOALVEOLAR MOLDING TREATMENT
OF BILATERAL CLEFT LIP AND PALATE
PATIENTS WITH SEVERELY
MALPOSITIONED PREMAXILLAE
• Serap Titiz, MS1 and Isil Aras, DDS, PhD2
• The Cleft Palate-Craniofacial Journal

85. AIM
• The aim of this study was to evaluate a modified presurgical
nasoalveolar molding (PNAM) treatment for patients with bilateral
cleft lip and palate (BCLP) with severely malpositioned premaxillae.

86. METHOD
• An impression of the infant’s maxilla was made using customized
infant trays with a heavy-body silicone material
• The modified PNAM appliance consisted of the retention arm, the
prefabricated retraction apparatus, the nasal stent, and the lip
hanger fixed to the premaxilla with a band
• The retraction apparatus was designed for holding the elastic
bands and manufactured from biphenyl-free high-density
polyethylene polymers.
• The retention arm was manufactured in a mold that were
developed using autopolymerization of acrylic resin.

87. • A 0.036-in stainless steel wire at the bottom of the retention arm was
bent to fit the crest of the alveolar ridge.
• During the acrylic curing, care was taken to ensure that the acrylic
body only wrapped the lateral maxillary segments.
• When the length of the cleft was reduced to less than 6 mm, the nasal
stent was fixed to the sulcus on the retention arm via the acrylic body.
Modified (PNAM)
appliance. Retraction apparatus.
The mold developed for
production of the retention
arm.
Retention arm.
Matching of the retraction
apparatus & retention
arms on the model.
Lip hanger

88. Insertion of the Appliance and Lip Taping
• Correction of the deviation of the premaxilla.
• A combination elastic band system was used to correct the
deviation of the premaxilla.
• The elastic band combination surrounded the premaxilla was
fixed to the contralateral buccal region of the deviated premaxilla
• Thus, the premaxilla was aligned with the midline. Horizontal
band support was used to avoid flaring of the premaxilla during
these movements.

90. RETRACTION OF THE PREMAXILLA.
• Retraction was initiated after aligning the premaxilla with the
midline.
• To provide force on the posterior aspect of the premaxilla, hooks
were bent in the edges of a 0.023-in stainless steel straight wire
according to the size of the premaxilla and were fixed to the
prolabium with a band.
• The lip hanger was sutured to the band to avoid separation of the
lip hanger from the band due to saliva.
• According to the amount of force desired, 1/8 light elastic bands
were attached to the anterior, median, or posterior hooks of the
retraction apparatuses, and the appliance was placed into the
mouth of the patient.

91. • The elastic bands were stretched and placed onto the lip
hanger
• Subsequently, the elastic band system placed on the retention
arm was fixed to the buccal region at a 45 degree angle with
2 folds of stretching.
• The molding plate was modified at weekly intervals to obtain
sufficient space for the premaxilla via selective removal of
acrylic and addition of a soft acrylic.

92. • The modified PNAM appliance used in the study is an active NAM
method. The appliance body plays an anchoring role for retraction
of the premaxilla
• The elastic between the retraction apparatus and the lip hanger
retracts the premaxilla and applies a force onto the PNAM
appliance at the anterior aspect.
• The modified PNAM apparatus acted as a class 2 lever. The
retention arms served as a power arm, and the posterior part of the
plate became a fulcrum.
• The angulations and length of the retention arms were very
important for the retention of the PNAM appliance.
• The presence of wire within the retention arms enabled the
pedodontist to adjust the appliance in a clinical setting.
DISCUSSION

93. • In babies with severely malpositioned premaxillae, the
modified PNAM treatment provides improvement in the
premaxillary deviation within 8 to 10 days.
• In patients treated in clinics, the modified PNAM technique
provided premaxillary retraction within a mean of 3 to 4 weeks
in newborns with severely malpositioned premaxillae.

94. • Nasal molding was continued for an additional month for
columellar lengthening when necessary.
• Approximately 2 months of modified PNAM treatment was
required for patients with severely malpositioned premaxilla.
• Due to rapid retraction, a columellar length of 5 to 7 mm was
obtained even in severe cases. Grayson suggested that in patients
with BCLP, the columella should be presurgically lengthened up to
4 to 7 mm (Grayson et al., 1999).
• The short duration of treatment has increased the cooperation of the
families.
• This article described an efficient method for derotating and
retracting the premaxilla in substantially difficult cases.

95. CONCLUSION
• The modified PNAM technique performed in the current
study reduced the conventional 4- to 5-month period required
for deviation correction and retraction of severely
malpositioned premaxilla in patients with BCLP by
approximately 2 months and produced an adequate
columella.

97. CONCLUSION OF THE JC
 NAM technique has been significantly shown to improve the
surgical outcome of CLP patients compared with other
techniques of presurgical orthopedics.
 NAM has proved to be a simple yet effective adjunctive therapy for
reducing hard and soft tissue cleft deformity before surgery.
However, it is crucial that members of the cleft team provide the
parents and caregivers adequate training, education, active support,
and encouragement during NAM treatment.
 Lack of parent or caregivers’ compliance and commitment results
in less than ideal clinical outcomes.
 Despite the relative paucity of high-level evidence, NAM appears
to be a promising technique that deserves further study.

98. THANK YOU