PRE-SURGICAL NASO-ALVEOLAR MOLDING IN

INFANTS WITH UNILATERAL AND

BILATERAL CLEFT LIP AND PALATE

CRISTINA M. LAURETA DMD CP Ortho, FAPO

CLEFT LIP AND PALATE (CLAP)

Most common congenital malformation of the head and neck

One of the facial clefts described by TESSIER

epocrates

Tessier classification of Facial Clefts

Plastische erasmusmc

TYPES OF CLEFTING

Lip defects unilateral incomplete complete bilateral incomplete complete

Palate defects unilateral incomplete complete bilateral incomplete complete

CLAP : INCIDENCE

Worldwide Average of 0.7/1000 births

race #/1000 births

caucasian 1.0

asian 2.0

japanese / taiwanese

2.23

chinese 1.2

filipino 1.94

blacks 0.5

PHILIPPINES

7107 islands Population 99.9 M

(2010 estimate) Birth rate

2,565,434/yr Cleft rate 1.94/1000 or 1 in every 500

5,130 newborn with

clefts / year Approx 4,000 cleft babies / yr

(survival rate)

Cleft lip/palate 1 / 1,000 births › 50 percent of all clefts› more common in Asians, American Indians› less frequent in African-Americans› 13 percent of cases with other birth defects› more often in male children

Cleft palate 1 / 2,000 births › 30 percent of all clefts› all racial groups have similar risk› more often in female children

Isolated cleft lip 20 percent of all clefts

(Blanco-Davila 2003, Das 1995, Owens 1985, Shaw 1991, Amer. Acad. Otolaryngology- Head and Neck surgery).

CLAP: ETIOLOGY & RISK FACTORS Genetics; Family History Maternal use of medications / exposure

to substances Maternal disease Maternal characteristics and behavior

age

obesity stress smoking alcohol poor nutrition

CLAP: ETIOLOGY & RISK FACTORS

MULTIFACTORIAL THEORY Genetic predisposition to clefting that

is acted upon by environmental factors

Patients with CLAP + /- syndrome 200+ syndromes

CLAP: EARLY DETECTION

3D ultrasound Pre-natal testing

CLAP: UNILATERAL

Deviated septum

Wide gap on upper lip

Lower lateral cartilage depressed & concave

Very short columella Wide gap between segments

Spayed alar base

CLAP: BILATERAL

Columella short / absent

Nasal tip widened and flattened

Premaxilla protruded and rotated upward

CLAP : MANAGEMENT INTERDISCIPLINARY TEAM

APPROACH

MEDICAL

DENTAL

1888toys.com

AUXILLARY HEALTH PERSONNEL

TIMING OF TREATMENT

ORTHODONTICS SURGERY

1 – 3 mos PRE SURGICAL Orthopedics(NAM/ALVEOLAR Molding)

3 – 6 mos Lip repair (Rule of 3 10’s)

12 – 18 mos

Palate repair

4 yrs PREVENTIVE Orthodontics

Velopharyngeal Incompetence (VPI) Surgery; Lip and Nose revisions

5 yrs

6 yrs

7 – 11 yrs Expansion and Crossbite correction

Alveolar bone grafting; Lip and Nose revisions

12-16 yrs COMPREHENSIVE Orthodontics

17 yrs ++ Orthognathic Surgery;Other Esthetic procedures

CLAP : MANAGEMENT

PASSIVE APPLIANCES : OBTURATORS FEEDING PLATES

ACTIVE APPLIANCES : NAM , DPNR, Latham Device

CLAP: MANAGEMENT

INDICATIONS:

Prolonged feeding

Nasal regurgitation

Excessive wind

thinyes.com

OBTURATORS

CLAP: MANAGEMENTADVANTAGES: Faster feeding Baby can drink

more milk Prevents buccal

segment collapse Aids normal dev’t

of speech, deglutition Psychological lift to

parents/ caregivers

King, 1986

Excessive wind

OBTURATORS

INFANT ORTHOPEDICS

Advantages Facilitates primary lip and nose surgery Prevents collapse of segments after

surgery Harmonizes facial growth Improves speech Improves feeding Psychological support for parents King 1986, Friede and

Katsaros 1997

NAM TREATMENT GOALS

Restore the correct skeletal, soft tissue cartilagenous relationship pre-surgically

Align and approximate alveolar segments (greater and lesser alveolar segments)

Correct the malposition of nasal cartilages Correct the nasal tip and alar base on

affected side/s Position philtrum and lengthen columella

NAM TIMING ideal time to begin NAM is 1-2 weeks ,

before 6 weeks of age

At birth high level of hyaluronic acid that begins to taper off after 6 wks of age

HA makes molding the tissue and bone easier- active reduction of the cleft parts, enlargement of affected nostril

NAM TIMING

“In neonates, the blood levels of maternal estrogens are high during the first days

of life, giving neonate tissue elastic properties at the time of delivery.

The elasticity of tissues is due to increased blood levels of hyaluronic acid , which cause intercellular material to remain disconnected.

(Hardingham and Miur, 1972; Kenny, et al. 1973)

NAM PATIENT EVALUATION

at 1 to 2 wks infant is evaluated if he/she is a

good candidate for NAM

Parent evaluation

Childrens Hosp LA

NAM CONTRAINDICATIONS

Severe systemic deficiencies Risk of airway obstruction Age of infant Parental compliance Cost

NAM and OBTURATOR

OBTURATOR

NASAL CONFORMERS

LIP / CHEEK TAPING Exerts an upward and backward force

on the molding plate via elastic bands Compresses lip segments together In UL CLAP direction of taping runs from greater alveolar segment to lesser alveolar segment

GAS

LAS

NAM : APPLIANCE DELIVERY

Molding plate - Patient is comfortable, no pain , can feed - Worn 24/7 until just before lip

surgery - Can be attached by small elastics or tape to face or with denture

adhesive

Lubricate nasal bulb with petroleum jellyApply denture adhesive on plate

NAM: FOLLOW UP weight feeding – frequency and amount compliance tissue condition (extra- and intra-oral) hygiene (patient and appliance) problems Do necessary adjustments

LIP / CHEEK TAPING

change tapes every 2 – 3 days wet the tape for easy removal

NASAL ADJUSTMENT Acrylic bulb of nasal conformer is

adjusted at weekly intervals by adding acrylic or bending the wire

Slight blanching of ala of nose immediately on insertion but should disappear

PLATE ADJUSTMENTS Weekly appointments to guide the

alveolar segments Acrylic is added on 1 side and removed

on the opposite side

GAS GASLAS

LAS

_+

09 03 10 10 21 10

NAM : COMPLICATIONS SOFT TISSUE - mucosal irritation - intraoral bleeding - tissue fungal infections - tissue irritation - mega-nostril - impingement of nasal epithelium - nasal bleeding

Levy-Bercowski, et al. 2009

NAM : COMPLICATIONS

HARD TISSUE - asymmetric T-shaped arch

COMPLIANCE ISSUES - broken appointments - removal on NAM by tongue - removal of NAM by hands

Levy-Bercowski, et al. 2009

NAM: BENEFITS well- aligned tissues prior to primary lip

and nasal repair – helps surgeon achieve better and more predictable outcome with less scar tissue formation

Improvement results in less surgeries necessary for excessive scar tissue, oronasal fistula, nasal and labial deformities

(Lee, Grayson and Cutty 1994, Maull et al 1999)

NAM: BENEFITS

Long term studies show that nasal shape is more stable with less scar tissue; better lip and nasal form

Less incidence of crossbites and arch collapse with pre-surgical orthopedics

O’Donnel 1973

ROLE of PARENTS

It is ultimately the parents’ task to place the device into the baby’s

mouth and secure it with surgical tapes over the cheeks.

This process often takes multiple trials to complete and requires one parent to stabilize an often crying uncooperative infant, while the other places the NAM into the mouth

ROLE of PARENTS

Parents have to learn the manual skills involved in completing the

task (i.e. proper lip strapping, cleaning of appliance, and insertion and positioning of the appliance in the patient’s mouth)

They must also learn to tolerate their infant’s temporary discomfort while focusing on the potential long-term benefits of the molding therapy

THANK YOU