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Review Article

Nasoalveolar molding treatment in presurgical infant

orthopedics in cleft lip and cleft palate patients
N. Retnakumari1, S. Divya2, S. Meenakumari3, P. S. Ajith4
1
Professor and Head of Pedodontics, 2Post Graduate Student of Pedodontics, Government Dental College, Kozhikode, 3Assistant Surgeon
(Pediatrician) Taluk Hospital, Ambalappuzha, Alleppey, 4Consultant Surgeon (Plastic Surgery), General Hospital, Changanassery, Kottayam,
Kerala, India

ABSTRACT
The nasoalveolar molding (NAM) technique is a new approach to presurgical infant orthopedics that reduces the severity of the initial
cleft alveolar and nasal deformity. This technique facilitates the primary surgical repair of the nose and lip to heal under minimal tension,
thereby reducing scar formation and improving the esthetic result. NAM technique is the nonsurgical, passive method of bringing the gum
and lip together by redirecting the forces of natural growth. NAM has proved to be an effective adjunctive therapy for reducing hard and
soft tissue cleft deformity before surgery. This paper reviews the basic principles of NAM therapy, various types of appliances used in this
therapy, protocol followed, and a critical evaluation of the advantages and disadvantages of this technique. Universally authors have agreed
the positive outcome of NAM for better esthetics after cleft lip and palate (CLP) repair, but the long-term effects of this therapy are yet to be
substantiated. Despite a relative paucity of high-level evidence, NAM appears to be a promising technique that deserves further research.

Key words: Cleft lip and cleft palate, nasoalveolar molding, NAM protocol, NAM appliances, presurgical infant orthopedics

Introduction left side is most commonly involved in unilateral CL cases.

Interracial differences exist in the incidence of CLP versus
Cleft lip and palate (CLP) are among the most common types CP. The mean incidence of CLP is 2.1 cases per 1,000 live
of birth defects. Two-thirds of all cases of clefting involve births among Asians, one case per 1,000 live births among
the lip with or without involvement of the palate; whereas, white people, and 0.41 cases per 1,000 live births among
one-third of all cases occur as an isolated deformity of the black people. A high incidence of the CLP is seen in North
palate. Males predominate within the CLP group (60-80% American populations of Asian descent, such as Indians
of cases); whereas, females constitute the majority within of the southwestern United States and the west coast of
the cleft palate (CP) group. CLP deformity is strongly Canada.[1]
associated with bilateral cleft lips (CLs) (86% of cases);
the association decreases to 68% with unilateral CL. The CLP along with nasal deformity is one of the common
anomalies occurring during the embryonic development of
Access this article online face. By the end of the 4th week in gestational period of human
Quick Response Code: embryo, bilateral swellings and nasal placodes develop on
Website:
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the lower part of the frontonasal prominence. The medial and
lateral nasal prominences develop as peripheral thickenings
DOI: of the mesenchymal tissue of the nasal placodes, producing
10.4103/2321-4848.133804 two central depressions, and the nasal pits. Failure of the
nose to develop completely is associated with failure of the

Corresponding Author:
Dr. N. Retnakumari, Professor and Head of Pedodontics, Government Dental College, Kozhikode, Kerala-673008, India.
E-mail: [email protected]

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nasal placodes to develop. Between the 4th and 8th weeks, complete bilateral cleft is the protruding premaxilla. Because
the paired medial nasal prominences fuse with each other, of the lack of connection of the premaxilla with the lateral
with the paired lateral nasal prominences, and with cells in palatal shelves, the premaxilla has not been “reined back”
the maxillary prominences. Successful fusion of the medial into alignment with the lateral arch segments during fetal
nasal and maxillary prominences is essential for continuity development. At the time of birth, the premaxilla protrudes
of the upper lip and primary palate. Failure of fusion of one on a vomerine stem. Uncontrolled growth at the premaxillary
or both medial nasal and maxillary prominences results in suture results in overprojection of the premaxilla, with or
unilateral or bilateral CL, respectively. without rotation, and angulation of the segment. Just as the
premaxilla is not reined back by the lateral palatal shelves,
As the face nears the completion of the “developmental the lateral palatal shelves are not pulled forward by their
critical period”, from approximately the end of the 6th-8th attachment to the premaxilla. Without the intervening
intrauterine week, the lateral palatine processes grow out premaxilla to maintain arch width, the lateral palatal shelves
from the walls of the still common oronasal cavity. Growth collapse toward the midline. The severity of this disruption
of these paired processes is initially medial, but continues of arch morphology varies and will dictate the tension on the
inferolaterally to lie on either side of the developing tongue. repair, the degree of dissection required, and ultimately, the
Nearing the 8th week, palatal shelf elevation begins while final esthetic result unless it is corrected with presurgical
the tongue is depressed downward and forward. Once in orthopedics.[3]
contact, epithelial cells of the palatal shelves degenerate
by programmed cell death uniting the paired processes The traditional treatment of CLP involves multiple surgeries.[4]
in a process known as fusion. Once fusion of the shelves The surgical treatment of CLP has been documented since
of the secondary palate occurs, the mesenchymal cells AD 317, when Chinese general Wei Yang-Chi had his CL
differentiate, and become osteogenic cells contributing to corrected by cutting and stitching the edges together. As
the bony development of the premaxillary, maxillary, and surgical techniques advanced from the 1800s to 1900s, the
palatine portions of the palate. CP results from the failure focus shifted to achieving precise muscle closure, delicate
of fusion of these paired lateral palatine processes as a technique, and a better esthetic result.
result of a defect in any of the three major stages of palatal
formation — palatal shelf outgrowth, elevation, or fusion. The concept of presurgical orthopedic cleft molding was
developed to further improve the esthetic result of lip repair.
Unilateral complete clefts are characterized by disruption of Use of presurgical orthopedics is recorded as early as the
the lip, nostril sill, and alveolus (complete primary palate). 18th century. The auricular cartilage could be molded with
The deformities seen in relation to CL in these cases are permanent results if treatment was started within 6 weeks
cupids bow more or less clearly defined, philtral ridge is of life. During this period there are high levels of maternal
ill-defined if not absent, abnormal shortness of the lip estrogen in the fetal circulation which triggers an increase
compared with its height on the normal side, fernum of the in the hyaluronic acid. Hyaluronic acid alters the cartilage,
vermilion is often hypertrophied, depth of vestibular sulcus ligament, and connective tissue elasticity by breaking down
can be outlined only on noncleft side, the cutaneous portion intercellular matrix. Levels of estrogen start dropping at 6
of the lip is often convex in both vertical and horizontal weeks of age. Matsuo applied this concept for the correction
directions as the underlying muscles which have lost their of nasal deformities in CL patients. It is on this principle
medial insertion tend to draw up into ball of fibers. Nasal that the concept of nasoalveolar molding (NAM) works.
deformities associated are flattening and widening of the It is also suggested that NAM stimulated immature nasal
nostril aperture on cleft side, the columella is slanted chondroblasts, producing an interstitial expansion that
towards the affected side, the alar base is slightly everted, is associated with improvement in the nasal morphology
the anterior nasal spine deviated towards normal side, and (Chondral Modeling Hypothesis, Hamrick 1999).[6] Grayson
tip of the nose is slightly asymmetrical. and Shetye developed the concept of NAM, which combined
a nasal molding stent with a passive, presurgical molding
In bilateral CLP cases, the cupid’s bow is generally absent appliance in treating CLP infants.[7]
and the cutaneous portion often appears as a convex surface
shaped like a lens. There is no trace of philtral ridge and the Terminology
prolabium is usually devoid of properly developed muscle
fibers. The nasal deformities seen are nasal tip flattened and In presurgical orthopedic therapy, orthodontic techniques are
widened, the columella seems too short, and septal cartilage used to mold the maxillary, alveolar, and nasal tissues of an
is often underdeveloped.[2] The most obvious aspect of a infant with a unilateral or bilateral CLP. Other terms used for

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these techniques are neonatal infant orthopedics, presurgical base is sitting in the cleft). “Collapse” refers to a palatal
infant orthopedics, and nasal-alveolar molding. Because displacement of the lateral maxillary segment as predicated
the infant does not yet have teeth, the term orthodontics by the arch configuration of the medial, noncleft dental
would be inaccurate; thus, orthopedics is the preferred ridge. Clefts characterized as “narrow-no collapse” with
term. Presurgical orthopedic devices are a controversial minimal nasal deformity are treated with presurgical taping
topic in cleft treatment. With increasing clinical experience, to prevent widening of the cleft with growth and feeding,
the long-term outcome and the specific role of presurgical prior to a primary CL repair with primary tip rhinoplasty. If a
orthopedics are becoming better defined.[8,9] gingivoperiosteoplasty is to be performed at the same time, a
molding plate can be used to optimize contact of the opposing
What is NAM? alveolar ridges. Clefts characterized as “narrow-collapse” or
“wide-collapse” benefit from presurgical molding to create
NAM is the nonsurgical, passive method of bringing the gum the desired arch form, alveolar contact, and nasal anatomy at
and lip together by redirecting the forces of natural growth. the time of surgery. Clefts characterized as “wide-collapse”
It is nonpainful and easy to use. It also allows for correction or “wide-no collapse” must be assessed closely by the dental
of the flattened nose prior to surgery and facilitates nose members of the cleft team. If they feel that these cases are
repair at the time of lip repair.[10] deficient in arch mesenchyme, presurgical orthopedics is
used to align the arch segments by correcting the collapse,
Presurgical NAM works on the principle of ‘negative but not to close the alveolar cleft since this will result in a
sculpturing’ and ‘passive molding’ of the alveolus and constricted arch. External taping can be used to correct the
adjacent soft tissues. In passive molding, a custom-made alar base position over the maintained arch form. The use
molding plate of acrylic is used to gently direct the growth of presurgical orthopedics or aggressive presurgical taping
of the alveolus to get the desired result later on. While in has eliminated the need for preliminary lip adhesion surgery
negative sculpturing serial modifications are made to the
at most centers.[3]
internal surfaces of the molding appliance with addition or
deletion of material in certain areas to get desired shape of In infants with bilateral clefts of the lip alveolus and
the alveolus and nose.[11] palate, the objective of presurgical NAM includes the
Objectives of NAM technique nonsurgical elongation of the columella, centering of the
• Principal objective of presurgical NAM is to reduce the premaxilla along the midsagittal plane, and retraction of
severity of the initial cleft deformity which is achieved the premaxilla in a slow and gentle process to achieve
by active molding and repositioning of the deformed continuity with the posterior alveolar cleft segments.
nasal cartilages and alveolar processes.[12-14] Additional objectives include a reduction in the width
• Nonsurgical lengthening of the columella.[13-15] of the nasal tip, improved nasal tip projection, and a
• Approximation of lip segments to reduce tension in the decrease in the nasal alar base width.[18] The key point of
tissues after lip repair and thus reduce scarring.[16,17] nasal molding in bilateral clefts is to push the alar domes
• Presurgical NAM is recommended to produce more forward in a sagittal direction for columella lengthening
favorable bone formation by reducing the size of the instead of pushing the domes upward in a cephalic
cleft and improving nasal esthetics.[16,17] direction into a turned-up nasal tip.[19]
• Reduces the need for secondary alveolar bone grafts.[3,14]
Protocol for NAM Therapy
The critical factors for evaluating unilateral complete clefts
are the position of the lesser and greater alveolar segments, The treatment outcome of presurgical NAM therapy
the vertical height of the lateral lip element, and the degree depends on proper case selection, appropriate appliance
of associated nasal deformity. The alveolar (maxillary) design and proper motivation of the caretakers. Once
segments assume one of four positions: the above criteria are met, then the commonly followed
a. Narrow-no collapse; steps in NAM are:
b. Narrow-collapse; • Impression technique
c. Wide-no collapse; and • Fabrication of appliance
d. Wide-collapse. • Insertion of appliance
• Adjustment of appliance
“Wide” is determined by an alveolus position lateral to the • Incorporation of nasal stent
desired alar base position (i.e., with lip closure the alar • Final impression.

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Impression technique soft material. A retention button is fabricated and positioned

Research reports revealed that various impression anteriorly at an angle of 40 degree to the plate. The vertical
techniques were followed by the clinicians in presurgical position of the retention arm should be at the junction of the
NAM therapy. Grayson and Shetye[7] held the infant upside upper and lower lip. The retention button adequately secures
down while taking the impression. The impression tray is the molding plate in the mouth with the help of orthodontic
inserted into the oral cavity. The infant is held in an inverted elastics and tapes. A small opening measuring 6-8 mm in
position to prevent the tongue from falling back and to allow diameter is made on the palatal surface of the molding
fluids to drain out of the oral cavity. The tray is seated until plate to provide an airway in the event that the plate drops
the impression material adequately covers the anatomy down posteriorly. This is the most commonly used NAM
of the upper gum pads. He used a heavy body silicone appliance.[15,20-23] Various materials have been substituted
impression material as it has good tear strength. Prasanth for autopolymerizing resin in fabrication of the appliance
et al.,[20] and Retnakumari et al.,[21] used heavy body silicone by various researchers. They are light-cure polymerizing
impression material for taking impression, and the infant material (Yang et al.[10]), heat-cure polymerizing material
was kept in supine position during the procedure [Figure 1]. (Ma et al.,[4] and Karimi et al.[9]) and thermoplastic base plate
Dubey et al.,[11] kept the baby in mother’s lap with head wax (Upadhyay et al.[24]).
facing downward and her hands supporting baby’s chest
Insertion of appliance
and lap region while making the impression. Yang et al.,[10]
The NAM appliance is secured extraorally to the cheeks and
took alginate impressions using a pretrimmed customized bilaterally by surgical tapes with orthodontic elastic bands
pediatric tray. Utility wax was employed to avoid any sharp at one end [Figure 2]. The elastic on the surgical tape is
edges on the tray and to better adapt to the newborn’s looped on the retention arm [Figure 3] of the molding plate
mouth. The impression was taken with the baby in the most and the tape is secured to the cheeks [Figure 4]. The elastics
upright position, being held by one of the parents. Alginate (inner diameter 0.25 inch, wall thickness heavy) should be
impression when used in thin sections has the disadvantage stretched approximately two times their resting diameter
of breaking away from the tray when the tray is removed for proper activation force of about 100 g. The amount of
from the mouth. Such broken pieces may remain in deeper force could vary depending on clinical objective and the
section of the cleft and may even enter the nasal cavity mucosal tolerance to ulceration. Additional tapes may be
making their removal difficult. Karimi et al.,[9] used red necessary to secure the horizontal tape to the cheeks.[4,7]
impression compound to take the preliminary impression. Some authors advice the application of liquid adhesive on
Splengler et al.,[14] took intraoral and extraoral alginate cheeks to secure the Steri tapes for better retention of the
impression with the patient under general anesthesia. This appliance.[10] Denture adhesive and tape-elastic system has
method is generally not recommended as the patient is been used by Shetty et al.,[23] for the same purpose.
subjected to hospitalization for an impression procedure.
Adjustment of the appliance
Fabrication of NAM appliance The baby is seen weekly to make adjustments to the
The NAM plate described by Grayson and Shetye[7] is made up molding plate to bring the alveolar segments together.
of hard, clear self-cure acrylic and is trimmed with a denture These adjustments are made by selectively removing the
hard acrylic and adding the soft denture base material to
Figure 1: Heavy body silicone impression the molding plate [Figure 5]. At one visit not more than
1 mm of modification of the molding plate should be made.

Figure 2: Tape with elastics at one end

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Figure 3: Attachment of tape on retention stop Incorporation of nasal stent

A silicone nasal conformer suggested by Matsuo and
Hirose[25] can be used as a tool for presurgical nasal molding
when the patient has an incomplete CL. The height of the
conformer can be adjusted by gradually adding some soft
resin or flat silicone sheets on the domes. This is a method
to increase the columella height gradually by adding silicone
sheets to the domes of the nasal stent. It can be used for
presurgical elongation of the columella in incomplete clefts
or postoperative maintenance of the nostril configuration.
There are some limitations in this method. These include
the need for an intact nasal floor (Simonart’s band or lip
adhesion) and the inability to direct the force because the
stent expands circumferentially.

Grayson and Shetye[7] adapted nasal stent to extend from the

Figure 4: Insertion of appliance
anterior flange of an intraoral molding plate. The greatest
advantage of NAM is that it enables the practitioner to apply
force skillfully to shape the nasal cartilage. Because the stent
is extended from a molding plate, an intact nasal floor is not
required. According to the authors, when the alveolar gap
is approximated and the arch is aligned, a nasal molding
device is added to the orthopedic appliance to increase the
columella length as well as to reshape the alar dome. The
stent is made up of 0.36 inch, round stainless steel wire,
and takes the shape of a ‘Swan Neck’. The hard acrylic
component is shaped into a bilobed form that resembles
a kidney. A layer of soft denture liner is added to the hard
acrylic for comfort. The upper lobe enters the nose and gently
lifts forward the dome until a moderate amount of tissue
blanching is evident. The lower lobe of the stent lifts the
Figure 5: Adjustment of appliance by selective relining and grinding nostril apex and defines the top of the columella. The nasal
stent component of the NAM appliance is incorporated when
the width of the alveolar gap is reduced to about 5 mm. The
rationale for delaying the 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; and with the nasal stent, this can be
elevated into a symmetrical and convex form.

In Figueroa’s technique, alveolar and nasal molding are

performed simultaneously using an acrylic plate with rigid
acrylic nasal extension. Rubber bands are connected to
the acrylic plate for gentle retraction of the premaxilla
backward. A soft resin ball attaching to the acrylic plate
across the prolabium is sometimes used to maintain the
The alveolar segments should be directed to its final and nasolabial angle.
optimal position. Care must be taken to prevent the soft
denture material from building up on the height of the The nasal components are made up of 0.028 inch stainless
alveolar crest as this will prevent complete seating of the steel wire projecting forward and upward bilaterally from
molding plate.[4,7,10] the anterior part of the dental plate in Liou’s method.

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The top portion contains a soft resin molding bulb that lengthen the columella and vertically lengthens the often
fits underneath the nasal cartilages for nasal molding. In small prolabium. The horizontal lip tape is added after the
this method also, nasal and alveolar molding was done prolabium tape is in place.[4]
simultaneously.[19]
Splengler et al., in 2006[14] gave the flow chart which shows
Liao et al., conducted a blinded, retrospective study
[26] the protocol followed by them [Figure 7].
of 58 patients with complete bilateral CLP, 27 patients
received Grayson NAM and 31 patients received Figueroa Shetty et al., used the following protocol for presurgical
NAM. Outcomes were compared by analyzing pre- and NAM therapy:[13]
posttreatment facial photographs and clinical charts for
First visit:
efficacy (columella length ratio, alar width ratio, alar base
width ratio, nostril shape, nasal tip angle, nasolabial angle,
Parent education and counseling:
and nasal base angle), efficiency (molding frequency),
• Use of audiovisual aids and live demonstrations
and incidence of complications (facial irritation and oral
• Interaction with parents of older NAM patients
mucosal ulceration). The results showed that Grayson and
• Diet counseling
Figueroa NAM similarly improve nasal deformities and
reduce alveolar gaps; however, the Figueroa technique is Detailed documentation:
associated with less oral mucosal complication and more • Photographs — standard 1:1 ratio frontal and basilar
efficiency. view
• Dentofacial impressions
In bilateral cases, there is a need for two retention arms • Medical evaluation of patients
as well as two nasal stents [Figure 6] which are similar
in shape to the unilateral stent. After adding the nasal Fabrication of NAM appliance:
stents in the bilateral cleft, the attention is focused on • >8-10 mm intersegment distance — alveolar molding
nonsurgical lengthening of the columella. To achieve this • <8-10 mm intersegment distance — NAM
objective, a horizontal band of the denture material is
added to join the left and right lower lobes of the nasal Demonstration of home care instructions:
stent, spanning the base of the columella. This band sits at • Daily appliance care
the nasolabial junction and defines this angle as the nasal • Awareness about possible complications and their
tip continues to be lifted and projected forward. The tape management
is adhered to the prolabium underneath the horizontal
lip tape and stretches downward to engage the retention Telephonic correspondence after 2 days to ascertain parent
arm with elastics. This vertical pull provides a counter and patient compliance
stretch to the upward force applied to the nasal tip of the
Second visit (1 week subsequent to first visit):
nasal stent. Taping downwards on the prolabium helps to
Evaluation of patient and parent compliance.
Figure 6: Nasoalveolar molding (NAM) appliance with two retention
stops and two nasal stents for bilateral cleft lip and palate cases Figure 7: Protocol used for presurgical NAM therapy[13]

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Detailed documentation: strategies include presurgical NAM and active strategies

• Photographs — standard 1:1 ratio frontal and basilar include latham appliance which is an intraoral active
view appliance custom-made on the infant’s plaster cast of
• Dentofacial impressions the palate. It is fixed on the palate by four 0.70 mm
stainless steel pins on each side; a screw activated by the
Treatment outcome and assessment: parent pulls the cleft segments into alignment over 3-6
• Compatibility of appliance and required modifications weeks. Latham appliance facilitates only alveolar molding
• <8-10 mm intersegment distance — initiate NAM without nasal molding. In this article certain appliances
• >8-10 mm intersegment distance — aggressive alveolar described have an active component. They are modified
molding muscle-activated maxillary orthopedic appliance used
by Suri and Tompson[22] in NAM therapy; alveolar molding
Recall visits every 3 weeks: appliance with expansion screw described by Retnakumari
Evaluation of patient and parent compliance. et al.,[21] in their research report; dynamic presurgical nasal
remodeling intraoral appliance designed by Bennun and
Detailed documentation: Figueroa;[28] and self-retentive appliance with orthodontic
• Photographs — standard 1:1 ratio frontal and basilar wire used by Kamlesh Singh et al.,[29] in presurgical infant
view orthopedics.
• Alveolar surface impressions
• Dentofacial impressions recorded prior to primary lip Modified muscle-activated maxillary orthopedic
repair appliance
Suri and Tompson[22] used a plate held in with outriggers,
Treatment outcome and assessment: which prevents the cleft-widening effect of the tongue,
• Compatibility of appliance and required modifications helps with tongue tip placement, and utilizes the functional
• Nasal molding started at the earliest and continued till movements of the facial musculature to guide and relocate
completion the major segment medially to its normal position in unilateral
• Active alveolar molding continued till completion CLP cases. Nasal molding is undertaken after most of the
• Passive alveolar molding started once complete lateromedial correction of the alveolar position. Stainless
approximation of alveolar segment achieved steel wire outriggers are bent in situ, which emerge from
• Fabrication of new appliance every 2 months the cleft between the lip margins, and are gently contoured
• Parents participation in periodic NAM workshops. at an angle upward to end in oblong terminal loops lying
beyond the modiolus region. The loops are bent in such a
Active and passive appliances fashion that their long axes are roughly at right angles to an
In literature there is no clear definition of active and imaginary line extending from the lateral lip commissures
passive appliances used in NAM therapy. The NAM to the superior surface of the helix of the external ear. This
appliances are classified as into pre- or postsurgical, modified technique, which amalgamates nasal molding with
active or passive, and intraoral or extraoral. Active a muscle-activated alveolar molding infant orthopedic plate,
maxillary appliances move alveolar cleft segments in a helps to improve alveolar position, nasal septum alignment,
predetermined manner with controlled forces; whereas nasal symmetry, and nasal tip projection prior to the primary
passive appliances deliver no force, but act as a fulcrum lip and nasal surgical repair.
upon which the forces created by surgical lip closure
contour and mold the alveolar segments in a predictable Dynamic presurgical nasal remodeling
fashion.[22] The newly designed intraoral appliance by Bennun and
Figueroa[28] consists of two elements: A perfectly adapted
Donalb[9] states that active appliances are fixed intraorally conventional acrylic intraoral plate, which is left loose in
and apply traction through mechanical means such as the mouth of the neonate, and a dynamic nasal bumper
elastic chains, screws, and plates. Passive appliances attached to the vestibular flange of the intraoral plate.
maintain the distance between the two maxillary segments, It is placed lateral to the plate midline, in line with the
while external force is applied to the primarily to reposition lip and alveolar cleft. In bilateral cases, two stents are
it posteriorly. used. The nasal stent has a directional component which
is made of a U-shaped wire that can easily be bent. The
Neligan and Buck[27] mentioned that there are two dentofacial two free ends are secured to the plate, and the base of
orthopedics passive and active. According to them, passive the ‘U’ of the directional wire holds a soldered, vertical

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stainless steel bar or stent 2 mm in diameter. A dynamic made self-retentive by adding soft acrylic on its palatal
component, a stainless steel open coil spring (2.2 mm surface in the defect part. There was no need of any extra
diameter), is inserted over the stent. It is used to regulate oral attachment As suggested by Grayson and Shetye[7]
the impact force and to reduce rebound of the nasal for retention of the appliance. The palatal surface of this
extension or bumper. The coil exerts a force of 70 g/m for orthopedic plate was adjusted fortnightly by adding over 1
each millimeter of compression. The coil is approximately mm of hard acrylic along the entire palatal surface, around
3 mm longer than the stent. Full compression of the the soft acrylic, followed by insertion and adaptation of
stent can generate a force up to 210 g/m. A remodeling the palate. Adhesive Steri strip 1/4´ 4 inches was applied
silicone component (bumper) is mechanically attached to extraorally to facilitate approximation of the CL and
the cranial aspect of the open coil spring. It is in direct alveolar segments.
contact with the intranasal soft tissues. It was designed
to avoid soft tissue lesions in the delicate nasal mucosa Karimi et al.,[9] used a prosthesis made with a heat-cure
and to obtain a superior remodeling effect of the nasal acryl with a 3-4 mm extension into the nasal chamber. Most
structures. retention was assumed to be provided form palatal shelves
of maxilla and nose chamber. Pronounced extension into
Active alveolar molding appliance [Figure 8] the nasal chamber was avoided to reduce the risk of airway
A new approach in presurgical infant orthopedics using obstruction. As the details of inner nasal alar anatomy
an alveolar molding plate with an expansion screw (Jack would not be recorded satisfactory; this part of prosthesis
screw) fully opened, incorporated into the appliance. was molded again using tissue conditioner to ensure the
This formed the active component of the appliance for maximal fitness. Five adjustment sessions were performed
retraction of the protruded premaxilla. The anterior in every other day. A week after the prosthesis was delivered
component of the appliance was fabricated with two to the parents, two crossed straps which were secured to a
retention stops. These retention stops facilitated the head cap at the sides were added to augment the posterior
attachment of elastic traps on both sides. The appliance protraction of the displaced premaxillary segment and
was activated by closing the expansion screw and by corresponding soft tissue.
selective grinding and relining with denture base material.
The premaxilla was retracted and the cleft gap was Ijaz [30] designed a custom made orthopedic plate
reduced with the use of this active alveolar molding incorporating a self-cure acrylic ring around the protruding
appliance within 3 months. This enabled better esthetic premaxilla. The plate was made self-retentive by addition
results after surgery by reducing tissue tension and scar of soft acrylic on its palatal surface, filling the cleft area.
formation.[21] This innovative self retentive plate was made up of acrylic
which comprised of two parts; the palatal plate covered
NAM with self retentive plate
the palatal defect and served as a passive obturator and
Ijaz[12] in his study on unilateral CLP cases used a custom-
the anterior part of the plate extended as a ring around the
made orthopedic plate incorporating nasal stent, made
protruded and deviated premaxilla. This ring acted as an
from self-cure acrylic on the labial vestibular flange of the
active part to align and retract the malposed premaxillary
orthopedic plate. The nasoalveolar orthopedic plate was
segment.
Figure 8: Active alveolar molding appliance with expansion screw
The modified appliance used by Kamlesh Singh et al.,[29] is
nearly the same as described by Grayson and Cutting except
that they used an orthodontic wire covered the nasal tip
cartilage, proximity of the lip segments, and convexity in
the alar base with an acrylic bulb to give pressure for active
molding. This appliance does not need any further addition
of acrylic every week, only wire angle is increased a bit to
increase the pressure exerted.

Discussion
NAM is used effectively to reshape the nasal cartilage and
mold the maxillary arch before CL repair and primary
rhinoplasty. Nasal deformity in infants with nasolabial clefts

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persists if it is not actively corrected. The principle objective of the alveolar segments. This only results if there is poor
of presurgical NAM is to reduce initial cleft deformity. This management of the molding process. It may be remedied
enables the surgeon and the patient to enjoy the benefits through corrective molding if recognized early. If the
associated with repair of a cleft deformity. The goals of greater segment is directed posteriorly more quickly
PNAM are to align the intraoral alveolar segments and than the lesser segment advances outward, the cleft may
correct the nasal tip, the alar base, the philtrum, and the close with the lesser segment locked behind the greater
columella. segment.[5,7,31]

Advantages of NAM technique Meganostril/nostril overexpansion

NAM device approximates the alveolar segments as close A potential soft tissue complication would be overexpansion
as possible before surgery and brings the premaxilla of the alar rim as a result of premature stenting before
back into the position of the alveolar arch in bilateral sufficient closure of the cleft gap (5 mm). Again, direction
clef t patients. [14,30] When combined with primar y of tissue expansion and progress must be monitored on a
gingivoperiosteoplasty (GPP), this potentially results weekly basis to avoid this occurrence.[4,5,31]
in a reduced need for alveolar bone grafting during the
mixed dentition period. In addition, there are several Soft tissue irritation
other advantages to using a prosthetic device to place a The most common problems observed during NAM therapy
premaxilla in a more anatomically correct position before are irritation to the oral mucosa, gingival tissue or nasal
surgical closure of the lip. First, soft tissue will be carried mucosa. Intraoral tissues may ulcerate from excessive
with the segment, leading to a decrease in the width of pressure applied by the appliance. These are commonly
the defect.[13,15] Second, a centrally positioned premaxillary found in the oral vestibule and on the labial side of the
segment provides a more ideal base for lip closure.[12,16] It premaxilla. The oral and the nasal cavities of the infant
decreases tissue tension during the surgical procedure, should be carefully examined on each visit for ulceration
and finally, it allows healed soft tissues to rest against and appropriate adjustments should be made to the
a more normal bony anatomy. If the premaxilla is not molding plate to relieve sore spots. The intranasal lining
repositioned in these extreme cases, excessive tension of the nasal tip can become inflamed if too much force is
may develop at the surgical site, which compromises the applied by the upper lobe of the nasal stent. The area under
surgical result. By using orthopedic therapy, a second the horizontal prolabium band can become ulcerated if the
operative session may be eliminated, thereby decreasing band is too tight.[20,21]
total hospitalization time and cost. Besides the intraoral
advantages of NAM, there are also significant benefits Another area of tissue irritation is the cheeks. Extreme care
in helping to correct the external nasolabial deformities. should be taken while removing the cheek tape to avoid any
In unilateral cleft patients, the nasal stent is positioned irritation to the skin. Skin barrier tapes like TegadermTM
so that the columella and septum are molded to a more are recommended. Slight relocation of the position of the
vertical and upright position.[13] This will help correct the tape during treatment is also recommended to provide
deviation of the columella base to the noncleft side. With rest to the tissues in case they become irritated. It is also
careful adjustments, the alar cartilage can be molded recommended that an aloe vera gel be applied to the cheeks
into a more normal convexity and bilateral symmetry when changing tapes.
can be achieved without additional soft tissue surgery
or scarring.[4] Exposure of primary tooth bud
Sometimes exposure of primary tooth bud may occur due
Disadvantages of NAM to the pressure applied during active molding.[31]
The disadvantages mentioned by various researchers are
locked out segment, nostril overexpansion, irritation to skin Obstruction of airway
and mucosa, exposure of primary tooth bud, obstruction of If there is no proper retention, the appliance may dislodge
airway due to dislodgement of NAM appliance, and relapse posteriorly and obstruct airway, for this always a hole should
of the molded cartilages though not entirely to some extent be incorporated in the appliance in center of palatal region
back to the original position. of the molding plate.[4]

Locked out segment Relapse

The most common hard tissue complication associated Pai et al.,[32] has reported that patients who have received
with the presurgical NAM device is misdirected molding NAM therapy has relapse of nostril shape in width (10%),

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Retnakumari, et al.: Nasolveolar molding in presurgical infant orthopedics

Table 1: Studies in relation to nasoalveolar molding (NAM) in unilateral cleft lip and palate
Author Objective Sample size Results Unique aspects
Maull et al.,[33] (1999) To evaluate the long-term 10 patients who had undergone Mean asymmetry index for NAM group was 0.74; Effectiveness of NAM compared with alveolar
effectiveness of presurgical NAM NAM, 10 patients who had whereas, control group was 1.21 molding
(PNAM) undergone alveolar molding alone
Pai et al.,[32] (2005) To assess nostril symmetry and 57 patients treated with NAM Infants with PNAM improved symmetry of the nose Assessed the relapse of the corrections achieved
alveolar cleft width in infants in width, height, and columella angle, as compared to with NAM at 1 year of age
with unilateral cleft lip and palate their presurgical status. There was some relapse of
following PNAM nostril shape in width (10%), height (20%), and angle of
columella (4.7%) at 1 year of age
Ezzat et al.,[6] (2007) To evaluate the outcome of PNAM Twelve patients with UCLP There was a statistically significant decrease in both PNAM therapy decreases intersegment alveolar cleft
treated from 1997 to 2003 intersegment alveolar cleft distance and columella distance while permitting an increase in posterior
deviation (P<0.05). There was also a statistically maxillary arch width. The improvement of the height
significant increase in cleft nostril height, maxillary width, of the cleft nostril was correlated with the time the
and columella width (P< 0.05). Moreover, although appliance was applied
there was no statistically significant reduction of the
affected nostril width, it demonstrated on average
1.7-mm reduction after PNAM therapy. The length of the
time the patient utilized the appliance and post molding
nostril height were found to have a statistically significant
positive correlation (P<0.05).
Aboul Hassan et al.,[15] To evaluate the outcome of PNAM Fifteen patients, with average Narrowing of the interalveolar distance by more than Very short period of activation - 55 days
(2010) therapy age 2 weeks 3.3 mm after PNAM. The nasal deviation angle improved
by >25 degrees in all cases. Pre-NAM alveolar distance
average is 7.333+1.291 post NAM alveolar distance
average is 4.067+0.961
Ijaz[12] (2011) To introduce an effective, simple, 32 neonates (18 males and Anterior cleft gap was reduced to 11.065 mm showing The appliance being self-retentive is comfortable to
and cost-effective NAM appliance 14 females), age ranging from a post moulding reduction of 2.215 mm. The intercanine wear. Extraoral attachments are not needed
3 days to 12 days width however, showed a reduction of 1.718 mm after
moulding. Intermolar width, more or less remained the
same (0.156 mm) after NAM. Angular measurement was
made to record derotation or alignment of major cleft
alveolar segment. With this appliance, the major segment
showed 7.359 degree rotation after alveolar moulding
Clark et al.,[16] (2011) To evaluate the long-term 20 patients PNAM and Clinically, the improvement in the PNAM group was most Long-term follow-up
effectiveness of presurgical NAM 5 patients non-PNAM therapy evident in nasal and lip anatomy. However, there were
no statistically significant differences between the two
groups on each of the measurements on three-dimensional
facial images and dental models
Shetty et al.,[13] (2012) Comparison of results using NAM in Group I (n=15) treated with Group I patients demonstrated 81, 198, 69, and 145% Although the results in group II patients were inferior
cleft infants treated within 1 month NAM within 1 month of age; improvement in intersegment distance, nasal height, nasal to those of group I patients the relative improvement
of life versus those treated after group II (n=15) treated with dome height and columella height respectively; whilst in nasal dome height (69%), intersegment distance
this period NAM between 1 and 5 months group II patients demonstrated 51, 33, 21, and 38% (51%), columella height (38%), and nostril height
of age. Control: Group III improvement for the same. At 18 months, group I patients (21%) deserves a mention. This improvement
(n=15) comprised of noncleft closely resembled group III patients validates the use of NAM in infants that present for
18-month-old children treatment as late as 5 months of age

height (20%), and angle of columella (4.7%) at 1 year Conclusion

of age.
The NAM technique has been significantly shown to improve
It is imperative that parents become active members of the the surgical outcome of CLP patients compared with other
treatment team. If the appliance is lost or not worn, a cleft techniques of presurgical orthopedics. NAM has proved
gap that had been closed early during molding therapy may to be an effective adjunctive therapy for reducing hard
widen again as the infant places his or her tongue into the and soft tissue cleft deformity before surgery. However,
cleft. Compliance is an essential factor with this method of it is important that parents or caregivers become active
members of the treatment team. Similarly, it is crucial
treatment.
that members of the cleft team provide the parents and
caregivers adequate training, education, active support, and
Many studies [Tables 1 and 2] have been performed to assess
encouragement during NAM treatment. Lack of parent or
the outcome of NAM. Universally authors have agreed the caregivers’ compliance and commitment results in less than
positive outcome of NAM for better esthetics after CLP are ideal clinical outcomes. Despite a relative paucity of high-
repaired. But the long-term effects of this therapy are yet level evidence, NAM appears to be a promising technique
to be substantiated. that deserves further study. The long-term effectiveness of

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Table 2: Studies in relation to nasoalveolar molding (NAM) in bilateral cleft lip and palate
Author Objective Sample size Results Unique aspects
Splengler et al.,[14] To evaluate the outcome of presurgical NAM 8 patients with average age Intraoral measurements demonstrated that there was Very long treatment time of
(2006) (PNAM) therapy of 34 days a statistically significant reduction of the premaxillary 212 days
protrusion and deviation. There was also a significant
reduction in the width of the larger cleft. Extraoral
measurements revealed that there was a significant
increase in the bi-alar width and in the columella
length and width. Moreover, there was a significant
improvement in columella deviation. Finally, the nostril
heights of both sides were increased
Mishra et al.,[34] (2010) To evaluate the role of PNAM in correction of cleft 23 cases having either Nostril height was more in patients of experimental group Unilateral cleft lip had more
lip nasal deformity for patients with unilateral and unilateral or bilateral cleft lip (P=0.18), while nostril width and alar perimeter were not reduction in alveolar gap than
bilateral clefts of the lip and palate changed significantly. Children with NAM had significant bilateral group
lengthening of columella (P=0.02). Patients of unilateral
cleft lip had more reduction in alveolar gap (P=0.08) than
bilateral group (P=0.15)
Ijaz[30] (2010) To introduce a simple, self-retentive, and cost- 35 subjects (27 males, Retraction of premaxillary segment to be 3.80±1.3 mm. Self-retentive plate, cost-effective,
effective presurgical infant orthopedic plate with 8 females) with a median age Derotation of the premaxilla was recorded as 5.41±7.4 avoids traumatic, and cumbersome
anterior ring of 7 days (1-13 days) degrees; whereas, septum deviation was 1.67±1.48 use of appliance
degree. The increase in columella as well as prolabium
length recorded was 2.24 and 1.85 mm, respectively.
Intercanine width was increased by 0.78 mm after
moulding. The intermolar width however showed an
increase of 1.02 mm. The downward movement of
premaxilla measured from the cast was 2.92±2.3 mm
Liao et al.,[26] (2013) To compare outcomes of two NAM techniques 27 received Grayson NAM, Grayson and Figueroa NAM did not differ in treatment Both Grayson and Figueroa NAM
(Grayson and Figueroa techniques) 31 received Figueroa NAM efficacy for columella length ratio, alar width ratio, alar similarly improve nasal deformities
base width ratio, nostril shape, nasal tip angle, nasolabial and reduce alveolar gaps;
angle, and nasal base angle. Grayson NAM was less however, the Figueroa technique is
efficient, that is, required more adjustments (10.8±4.1 associated with less oral mucosal
vs 7.6±1.5, P=0.001), and had a higher incidence of oral complication and more efficiency
mucosal ulceration (26 vs 3%, P<0.05)

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Source of Support: Nil, Conflict of Interest: None declared.
bilateral cleft nose deformity. Plast Reconstr Surg 2013.

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