MANAGEMENT OF CONGENITAL ABNORMALITIES OF SOFT PALATE

PRESURGICAL NASOALVEOLAR MOLDINGPresented By:Dr. Saili ChandavarkarProsthodontics M.D.S. III

1DEFINITIONCleft palate A congenital fissure or elongated opening in the soft and/or hard palate . OR An opening in the hard and/or soft palate due to improper union of the maxillary process and the median nasal process during the second month of intra uterine development. GPT 8

2ROLE OF PROSTHODONTISTFeeding platePresurgical nasoalveolar moldingReplacement of teethStabilization of teethStabilization and or achieving ideal arch configuration before surgeryCamouflage for the inadequacy in surgical or orthopedic treatmentFabrication of speech prosthesis

3PRESURGICAL NASOALVEOLAR MOLDING:4A review of literature1689: Hoffman demonstrated use of facial binding to narrow the cleft and prevent post surgical dehiscence.

1790: Desault used a similar technique to retract the maxilla before surgical repair in bilateral clefts.

1844: Hullihen stressed the importance of presurgical preparation of clefts using adhesive tapes binding.

Esmarch and Kowalzig used a bonnet and strapping to stabilize the premaxilla after surgical retraction

5Grayson BH, Shetye PR, Cutting CB. Presurgical nasoalveolar molding treatment in cleft lip and palate patients. Clin. Journal, 2005; vol (1):4-7.1927: Brophy demonstrated passing of a silver wire through both ends of the alveolus and tightening to narrow the cleft.

1950: McNeil started the modern school of presurgical orthopedic treatment in CLCP. He used a series of plates to actively mold the segments into desired position.

Burston popularized this technique

1975: Georgiad and Latham introduced a pin retained active appliance to simultaneously retract the premaxilla and expand the posterior segments.

6Grayson BH, Shetye PR, Cutting CB. Presurgical nasoalveolar molding treatment in cleft lip and palate patients. Clin. Journal, 2005; vol (1):4-7.1993: Grayson et al described a new technique to presurgically mold the alveolus, lip and nose in infants with CLCP.1998: Cutting et al described PNAM in detail

7Grayson BH, Shetye PR, Cutting CB. Presurgical nasoalveolar molding treatment in cleft lip and palate patients. Clin. Journal, 2005; vol (1):4-7.1999:Grayson in his article listed four benefits of PNAM:1. PNAM enables surgeon to perform a gingivoperiosteoplasty; 2. Presurgical alignment and correction of deformity in nasal cartilage minimize the extent of primary nasal surgery required;3. In bilateral cleft deformity, nonsurgical columella elongation4. PNAM used in conjugation with a modified surgical approach, allows for a single initial surgical procedure to address lip-nose alveolar complex and its deformity.

8Grayson BH, Shetye PR, Cutting CB. Presurgical nasoalveolar molding treatment in cleft lip and palate patients. Clin. Journal, 2005; vol (1):4-7.Deidre J. Maull et al (1999) conducted a study to determine the effect of presurgical nasoalveolar molding(PNAM) on long term nasal shape in complete unilateral cleft lip and palate. They concluded that PNAM increases the symmetry of the nose.

9Deirdre J. Maull, Barry H. Grayson, Court B. Cutting, Larry L. Brecht, Fred L. Bookstein, Deljou Khorrambadi, Jon A. Webb, Dennis J. Hurwitz. Long-term effects of Nasoalveolar Molding on three-dimensional shape in unilateral clefts. Cleft Palate Craniofac J, September 1999;36(5):391-7.Nita Viwattanatipa et al (2001) in the presurgical orthopaedic phase used an obturator and active lip strapping followed by a naso-alveolar molding appliance. The first surgical procedure involved the gingivoperiosteoplasty, lip and nasal reconstruction, all in one operation. They concluded that this coordinated treatment brought about better early esthetics of the soft tissue lip and nose.

10Nita Viwattanatipa, Palakom Surakulprapa, Bowornsilp Chowchuen. Bilateral cleft lip and cleft palate. Srinagarind Med J 2001;16(1):54-60.Tracy M. Pfeifer et al (2002) conducted a study to compare the financial impact of two treatment approaches to the unilateral cleft alveolus, the recently advocated NAM and gingivoperiosteoplasty at time of lip repair were compared with traditional approach of secondary alveolar bone graft. They concluded that the treatment of unilateral cleft alveolus by NAM and gingivoperiosteoplasty results in substantial cost savings compared with treatment by secondary alveolar bone graft.

11Tracy M. Pfeifer, Barry H. Grayson, Court B. Cutting. Nasoalveolar molding and gingivoperiosteoplasty versus alveolar bone graft: An outcome analysis of costs in the treatment of unilateral cleft alveolus. Cleft Palate Craniofac J, January 2002;39(1):26-9.Sue Yang et al (2003) brought to light that as a result of the PNAM appliance, the primary surgical repair of the nose and lip heals under minimal tension, thereby reducing scar formation and improving the esthetic result.

12Eric Jein-Wein Liou (2004) Their study revealed that the nasal asymmetry was significantly improved after nasoalveolar molding and was further corrected to symmetry after primary cheiloplasty. To compensate for relapse and differential growth, the authors recommend (1) narrowing down the alveolar cleft as well as possible by nasoalveolar molding, (2) overcorrecting the nasal vertical dimension surgically, and (3) maintaining the surgical results using a nasal conformer.

Sue Yang, Eric J. Stelnicki, Misook N. Lee. Use of nasoalveolar molding appliance to direct growth in newborn patient with complete unilateral cleft lip and palate. Pediatric Dentistry 2003;25(3):253-6. Eric Jein-Wein Liou, Murukesan Subramanian, Phil K. T. Chen, C. Shing Huang. The progressive changes of nasal symmetry and growth after nasoalveolar molding: A three-year follow-Up study. Plast Reconstr Surg, September 15, 2004;114:858-64.Iino Mitsuyoshi et al (2004) reported a new preoperative nasoalveolar molding for infants with unilateral cleft lip and palate. The nasal stent of PNAM is made of cobalt chrome wire with a 3mm diameter loop in the middle of the stent which enables precise manual control of the force and direction of the stent with considerable ease. In addition, this wire is easy to make, prepare and keep clean.

13Iino Mitsuyoshia, Wako Masahikob, Fukuda Masayukia. Simple modified preoperative nasoalveolar moulding in infants with unilateral cleft lip and palate. British Journal of Oral Maxillofacial Surgery 2004;42:578-80.Sanjay Suri and Bryan D Tompson (2004)23 conducted a study to describe a treatment approach for PNAM in unilateral CLCP. This approach uses a plate held in with outriggers, which prevents the cleft-widening effect of the tongue, helps with tongue tip placement, and utilizes the functional movements of the facial musculature to guide and relocate the major segment medially to its normal position. Nasal molding is undertaken after most of the lateromedial correction of the alveolar position. They concluded that this technique helps to improve alveolar position, nasal septum alignment, nasal symmetry, and nasal tip projection prior to lip repair.

14Sanjay Suri, Bryan D. Tompson. A modified muscle-activated maxillary orthopedic appliance for presurgical nasoalveolar molding in infants with unilateral cleft lip and palate. Cleft Palate Craniofac J, May 2004;41(3):225-9.Betty Chen Jung Pai et al (2005)25 conducted a study that concluded that infants with presurgical nasoalveolar molding had improved symmetry of the nose in width, height, and columella angle, as compared to their presurgical status. There was some relapse of nostril shape in width, height, and angle of columella at 1 year of age.Ziai MN et al (2005)27 conducted a study which concluded that, in patients with cleft lip and palate with natal/neonatal teeth who require NAM, the tooth must be removed to facilitate the fabrication and placement of the device.

15Ziai MN, Bock DJ, Da Silveira A, Daw JL. Natal teeth: A potential impediment to naso alveolar molding in infants with cleft lip and palate. J Craniofac Surj, Mar 2005; 16(2):262-6.Betty Chen-Jung Pai, Ellen Wen-Ching Ko, Chung-Shing Huang, Eric Jen-Wen Liou. Symmetry of the nose after presurgical nasoalveolar molding in infants with unilateral cleft lip and palate: A preliminary study. Cleft Palate Craniofac J, November 2005;42(6):658-63.Marcos Jaeger et al (2007)30 developed a within-subjects study in which 11 infants with unilateral lip deformity and varying degrees of alveolar gaps were treated by NAM. All patients obtained significant reduction of the alveolar gap. The appliance also facilitated primary nasal positioning, significantly improving nasal symmetry and nostril shape.

Barry H. Grayson and Pradip R. Shetye (2009)33 discussed the appliance design, clinical management and biomechanical principles of NAM therapy. Long term studies on NAM therapy indicate better lip and nasal form, reduced oronasal fistula and labial deformities, 60% reduction in need for alveolar bone grafting.

16Marcos Jaeger, Jefferson Braga-Silva, Daniel Gehlen, Yuki Sato, Ronald Zuker, David Fisher. Correction of the alveolar gap and nostril deformity by presurgical passive orthodontia in the unilateral cleft lip. Ann Plast Surg 2007;59:48994.Barry H. Grayson, Pradip R. Shetye. Presurgical nasoalveolar moulding treatment in cleft lip and palate patients. Indian J Plast Surg 2009;42(Suppl.S1):56-61.Abida Ijaz, Arsalah Raffat, Junaid Israr (2010)37 conducted a study to introduce a simple, self-retentive and cost effective presurgical infant orthopaedic plate with anterior ring to retract and align the grossly protruded and deviated pre-maxilla and to perform the nasoalveolar moulding in order to facilitate initial lip repair. 35 subjects with bilateral CLCP were treated with custom made orthopaedic plate with an acrylic ring around the protruded premaxilla for around 3 months. They concluded that the orthopaedic plate causes significant retraction of premaxillary segment without applying extraoral forces. It produces columellar elongation and increase in prolabium length facilitating the primary cheiloplasty and rhinoplasty without scarring.

17Abida Ijaz, Arsalah Raffat, Junaid Israr. Nasoalveolar molding of bilateral cleft of the lip and palate infants with orthopaedic ring plate. J Pak Med Assoc July 2010; 60(7):527-31.Judah S. Garfinkle et al (2011)39 conducted a study to compare the nasal morphology of patients treated with presurgical nasoalveolar molding. They concluded that patients with bilateral cleft lipcleft palate treated at their institution with nasoalveolar molding and primary nasal reconstruction, performed at the time of their lip repair attained normal nasal morphology through 12.5 years of age.

18Judah S. Garfinkle, Timothy W. King, Barry H. Grayson, Lawrence E. Brecht, Court B. Cutting. A 12-Year anthropometric evaluation of the nose in bilateral cleft lipcleft palate patients following nasoalveolar molding and cutting bilateral cleft lip and nose reconstruction. Plast Reconstr Surg April 2011;127(4):1659-67.V.Shetty et al (2012)42 conducted a study to evaluate the effects of nasoalveolar moulding (NAM) in complete unilateral cleft lip and palate infants presenting for treatment at different ages; propose a new NAM protocol in these patients; improve the predictability of NAM. This study validates the use of NAM in infants presenting late for treatment (at 18 months).

19V. Shetty, H. J. Vyas, S. M. Sharma, H. F. Sailer: A comparison of results using nasoalveolar moulding in cleft infants treated within 1 month of life versus those treated after this period: development of a new protocol. Int. J. Oral Maxillofac. Surg. 2012;41: 2836.Perry van der Heijden et al (2013)47 performed a systematic review of the literature with the intention of performing a meta-analysis. They concluded that results of studies of nasoalveolar molding are inconsistent regarding changes in nasal symmetry; however, there is a trend towards a positive effect.

20Perry van der Heijden, Pieter U. Dijkstra, Cees Stellingsma, Bernard F. van der Laan, Astrid G.W.Korsten-Meijer, Sieneke M. Goorhuis-Brouwer. Limited evidence for the effect of presurgical nasoalveolar molding in unilateral cleft on nasal symmetry: A call for unified research. Plast Reconstr Surg January 2013;131(1):62e-71e.What is PNAM?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 introduction of concept of nasoalveolar molding, repair of a large cleft required multiple surgeries between birth and 18 years of age, putting the child at risk for psychological and social adjustment problems. 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. 21Habel A, Sell D. Management of cleft lip and palate, Archives of diseases in childhood 1996;74:360-4.Principle of 'Negative sculpturing' and 'Passive molding' of the alveolus and adjacent soft tissues. Passive molding: a custom made molding plate of acrylic is used to gently direct the growth of the alveolus to get the desired result later on. 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.22Habel A, Sell D. Management of cleft lip and palate, Archives of diseases in childhood 1996;74:360-4.Some of the problems that traditional infant orthopedics failed to address include deformity of nasal cartilages in unilateral as well as bilateral clefts of lip and palate and deficiency of columella tissue in infants with bilateral clefts. 23Matsuo K. Repair of cleft lip with nonsurgical correction of nasal deformity in the early neonatal period. Plast Reconst Surg 1989;83:25-31.PNAM takes advantage of the flexibility of the cartilaginous septum in the first few weeks after birth(caused by high levels of hyaluronic acid found circulating in infants). At this time, it is relatively easy to apply external traction and by means of controlled forces rotate the lower part of the premaxilla to a more surgically advantageous position.24 Matsuo K. Repair of cleft lip with nonsurgical correction of nasal deformity in the early neonatal period. Plast Reconst Surg 1989;83:25-31. Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of lip, alveolus and palate. Clin Plast Surg 2004;31:149-58.The purpose of the traction is not to produce a normal dental arch form but to facilitate approximation of the alveolar cleft segments while at the same time achieving correction of the nasal cartilage and soft tissue deformity. PNAM improves nasal asymmetry and deficient nasal tip projection associated with bilateral cleft lip and palate.25Adam L. Spengler, Carmen Chavarria, John F. Teichgraeber, Jaime Gateno, James J. Xia. Presurgical nasoalveolar molding therapy for the treatment of bilateral cleft lip and palate: A preliminary study. Cleft Palate Craniofac J, May 2006;43(3):321-8.Objectives and RationaleRetraction of premaxilla.Alignment of cleft alveolar segments. Presurgical elongation of collumellaUp-righting of collumellaCorrection of nasal cartilage deformity Increase in surface area of mucosal lining. 26Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of lip, alveolus and palate. Clin Plast Surg 2004;31:149-58.27

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Clinical approachEvaluation by the interdisciplinary cleft palate team.Examination Explanation of treatment goals and procedure to parentsImpressionFabrication of platePnam activationRetentive tapingFollow upNasal stent additionFollow upDifference between unilateral and bilateral treatment

29Impression of intraoral cleft

Material: Impression compound/Elastomeric impression materialConsistent results have ben obtained fastest setting time polysiloxane material with the Base: catalyst ratio being 2:1. Light body wash not used : registration of minute details is not necessary and it may cause gagging.Irreversible hydrocolloid never used: poor tear strength creates possibility of having small pieces break free occlude nasal passage or respiratory tree. It also does not provide two reliable cast from same impression.

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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. 31The 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.32Impression of the nasal region:It is not necessary but may be helpful in comparing the pre and post orthopedic molding results. Obtained in clear polyvinylsiloxane.Cotton plugs with floss used to prevent material lodging into deep nostrils.Not used for fabricating the nasal stent.33

Fabrication of the devicePour two castsFabrication of prosthesisPatients permanent recordCleft region of palate and alveolus is filled with wax.Cast is lubricated with thin layer of petroleum jelly.

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Soft ,resilient, slowly polymerising acrylic resin is added to the undercut areas of the cast. Remainder of the oral molding plate is fabricated from clear methyl methacrylate.

35Methods of fabrication of the plateHeat processed method: waxed in 2 layers of baseplate wax then packed and lab processed. Sprinkle on: porosity, cloudy. Preferred method: thick consistency loaded in syringe, expressed onto the cast in lines. Ensure uniform coverage. Before the material begins to set place it in pressure pot at approx. 32 psi,198 F, 10 mins. Reduces bubbles and residual free monomer.36

Molding plate

Borders trimmedOral portion-Highly polished.Should be fairly retentive.No projection into cleft area.

37Post insertion considerationsObservation: retention, extent posterior, not too tight fitting, no acrylic in cleft area.

Suckling verification, no gagging.

Molding of the alveolar segments

38Molding of alveolar segmentsDesired movement-direct greater segment inward and lesser segment outwardSelective removal-1 to 1.5 mmChanges made weeklyUltimate goal: reduce the gap

39Method to achieve Pnam: Acrylic removal-where one desires alveolar bone to movePermasoft addition-where one desires bone to be reduced

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Extraoral retentive button

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Retentive tapingBroader base tape-0.5*1.5 inch

Thin suture strips-0.25*4 inch

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Small red orthodontic elastics-0.25 inch diameter.Elastics- Stretched to twice the original length

Force vector: posterior and superior.

Timings for changing taping

Adhesive and Adhesive relieving agents

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Use of retentive tapingRetention of applianceControlled orthopedic effectsAlignment of nasal base region

44Follow up Weekly basisProgress of molding appliance monitoredRetention evaluatedExamination for possible soresMonitoring Change in size of defectModification of appliance

45Nasal stent

When the size of the cleft is less than 6 mm. Causes active nasal cartilage molding.Should project passively in nostril.46Base of nasal stent: above the retentive button

Orientation: nasal tip and the dome on the cleft side are projecting toward the cleft side and not upward. It will also serve to bring the columella into more midline position.

Outer Permasoft veneering. Blanching occurs at the nasal tip as infant suckles and activates the appliance. It also exerts a reciprocal intraoral molding force against the alveolar segments.

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Unilateral clefts PNAM49

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Bilateral CLCP51

Bilateral CLCPPNAM consists of following phases-Alignment of posterior lateral segments while retracting and derotating premaxillaMolding the nasal cartilages by repositioning apices of alar cartilages towards nasal tipElongation of columellaAddition of nasal stentsHorizontal prolabial band or saddle is attached across the two acrylic nasal stents.52Force vectorDownward force-Surgical tape placed on prolabium

Posterior force-from horizontal band

Upward and anterior force-from nasal stents.

53Force vector54

Considerations before surgeryAlignment of alveolar segments, nasal cartilages, columella and philtrum.GPP- To close alveolar defectTiming for surgery: 2-3 months.Evaluation of infant: Rule of 10.

55Gingivoperiosteoplasty- gppMillard and Latham 1990Between 12-16 weeks of age.Prior oronasal orthopedics is required. 56Tracy M. Pfeifer, Barry H. Grayson, Court B. Cutting. Nasoalveolar molding and gingivoperiosteoplasty versus alveolar bone graft: An outcome analysis of costs in the treatment of unilateral cleft alveolus. Cleft Palate Craniofac J, January 2002;39(1):26-9.Post surgical considerationsLip is taped for several weeks even after surgeryNo nasal stent or supporting device is employed. 57Surgical nasoalveolar molding and columellar elongation58

ComplicationsLocked-out Segment: most commonHard tissue complication-misdirected moldingSuccessful alveolar molding but lack of soft tissue support.Resulting misshapen corrected orthodontically.

59Thomas Tyalor, Complications associated with presurgical nasoalveolar moiding and columellar elongation. Clinical Maxillofacial Prosthodontics.Nostril Over-expansion: most serious Soft tissue complication-MEGA-NOSTRILEtiology: gap > 6 mm,Force vectorPrecautionsTreatment: wedge procedure at initial surgical repair

60Thomas Tyalor, Complications associated with presurgical nasoalveolar moiding and columellar elongation. Clinical Maxillofacial Prosthodontics.Tissue UlcerationEtiologyPrecautionsTreatment: smooth appliance, no sharp areas, aloe vera cream, tissue lubricant.

61Thomas Tyalor, Complications associated with presurgical nasoalveolar moiding and columellar elongation. Clinical Maxillofacial Prosthodontics.Failure to Retain/ wear Appliance During Oronasal Molding

62Thomas Tyalor, Complications associated with presurgical nasoalveolar moiding and columellar elongation. Clinical Maxillofacial Prosthodontics.Failure to Tape Lip SegmentsConsequences: non retentive appliance and very slow progress in closure. Minimize the potential of soft tissue expansion

63Thomas Tyalor, Complications associated with presurgical nasoalveolar moiding and columellar elongation. Clinical Maxillofacial Prosthodontics.Exposure of a Primary ToothRetained or Removed-Location, Prognosis, Surgical plan

64Thomas Tyalor, Complications associated with presurgical nasoalveolar moiding and columellar elongation. Clinical Maxillofacial Prosthodontics.BenefitsAllows controlled, predictable repositioning without Lip adhesion surgery or Surgical insertion of pin retained dynamic molding plateReduction in size of cleft gap-One surgical procedure

65Allows surgeon to perform a GPP without need for extensive tissue dissection.PNAM used in conjunction with GPP Avoids additional surgery to bone graft the alveolusReduces need for early nasal revision surgery.EXTREMELY COST-EFFECTIVE

66Additional force from nasal stent provides final push that allows alveolar segments to meet.

Intra-oral molding plate provides foundation that enhances function of nasal stent.

67In Bilateral cleft patient, PNAM combined with columellar elongation Eliminates need of columellar elongation surgery.No scar at lip-nose-columella.Improves the infants ability to feed

68Limitations AGE

CO-OPERATVE PARENTS

LABOUR INTENSIVE

REGULAR VISITS

69Recent Advances: CAD NAM70

Correction of maxillary deformity in infants with bilateral cleft lip and palate using computer-assisted design. Xin Gong, DDS, MDS, and Quan Yu, DDS, MDS Oral Surg OralMed Oral Pathol Oral Radiol 2012;114(suppl 5):S74-S78The treatment planning and appliance design were accomplished with a CAD technique, which enabled accurate analysis of the movement amount in multiple planes. The digital 3D model of the upper denture was constructed using laser scanning to make the diagnosis and measurement of the BCLP alveolar morphology.The NAM treatment objective could be simulated on Rapidform 2006 software. The guiding principle is the application of constant low-grade pressure to reshape and reposition anatomic structures. This method of treatment requires attention with CAD to detail that is at times 1 mm in dimension. The alveolar segments should be directed to their final and optimal positions. Force and direction could properly be controlled.71

Correction of maxillary deformity in infants with bilateral cleft lip and palate using computer-assisted design. Xin Gong, DDS, MDS, and Quan Yu, DDS, MDS Oral Surg OralMed Oral Pathol Oral Radiol 2012;114(suppl 5):S74-S7872

Correction of maxillary deformity in infants with bilateral cleft lip and palate using computer-assisted design. Xin Gong, DDS, MDS, and Quan Yu, DDS, MDS Oral Surg OralMed Oral Pathol Oral Radiol 2012;114(suppl 5):S74-S7873

Correction of maxillary deformity in infants with bilateral cleft lip and palate using computer-assisted design. Xin Gong, DDS, MDS, and Quan Yu, DDS, MDS Oral Surg OralMed Oral Pathol Oral Radiol 2012;114(suppl 5):S74-S7874Quan Yu, Xin Gong, Gang Shen evaluated the effectiveness of computer-aided designed nasoalveolar molding (CAD-NAM) on maxillary alveolar morphology in infants with unilateral cleft lip and palate (UCLP). 15 infants with UCLP treated by CAD-NAM therapy composed the treatment group, and the control group consisted of 15 infants with non-presurgically treated UCLP. The maxillary morphology was analyzed by Rapidform XOR3 software. CAD presurgical nasoalveolar molding effects on the maxillary morphology in infants with UCLP. Quan Yu, Xin Gong, Gang Shen. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:418-426

This study suggests a trend toward morphological improvement in maxillary alveoli of infants with UCLP treated with CAD-NAM. The CAD-NAM effectively reduced the cleft gap, corrected the maxilla midline, and improved the sagittal length of the maxilla. The alveolar height decreased significantly after the treatment, which indicated that the traction force of the appliance may have obstructive effects on the vertical growth of the alveolar bone.

75CAD presurgical nasoalveolar molding effects on the maxillary morphology in infants with UCLP. Quan Yu, Xin Gong, Gang Shen. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:418-426

CONCLUSION76 THANK YOU77