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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 206-209

The impact of presurgical nasoalveolar molding on the surgical and quality of life outcome: A case report with 1-year follow-up

Department of Preventive, Riyadh Elm University, Riyadh, Saudi Arabia

Date of Submission19-Apr-2020
Date of Decision21-May-2020
Date of Acceptance30-Aug-2020
Date of Web Publication12-Nov-2020

Correspondence Address:
Dr. Fatmah Nasser Almotawah
Department of Preventive, Riyadh Elm University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_24_20

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Since its introduction in 1996, the use of presurgical nasoalveolar molding (P-NAM) has been a controversial topic. While P-NAM has become routine in many cleft centers, there have been others who have refused to adopt it. Difficulties cited have included the apparent lack of parent co-operation and perceived challenges in parent compliance. This report looks at both the esthetic postsurgical outcomes and the impact the procedure has on the overall oral health-related quality of life. The report looks at not only the procedure of P-NAM but also examines the steps a multidisciplinary team would need to take in order to make the experience beneficial to both the surgeon and the parent.

Keywords: Cleft lip and palate, oral health-related quality of life, presurgical nasoalveolar molding

How to cite this article:
Almotawah FN. The impact of presurgical nasoalveolar molding on the surgical and quality of life outcome: A case report with 1-year follow-up. Saudi J Oral Sci 2020;7:206-9

How to cite this URL:
Almotawah FN. The impact of presurgical nasoalveolar molding on the surgical and quality of life outcome: A case report with 1-year follow-up. Saudi J Oral Sci [serial online] 2020 [cited 2022 Aug 15];7:206-9. Available from: https://www.saudijos.org/text.asp?2020/7/3/206/300591

  Introduction Top

Orofacial clefting (OFC) is a wide range of disorders starting from complete fissuring of the upper lip with or without the palate to fissuring of the palate alone. OFC can be seen alone or as part of a syndrome or anomalies.[1],[2] The use of presurgical nasoalveolar molding (P-NAM) was first described by Barry Grayson in 1996.[3] His concept was based on the work of Japanese scientists who had shown that in the first few weeks after birth the neonate retains high levels of hyaluronidase, which makes the cartilage moldable.[3],[4]

Unlike active measures such as Latham screws, P-NAM relies completely on passive force to achieve the molding of the cleft. There have been several studies that have shown that P-NAM reduces the amount to cleft gap to be reduced by the surgeon and results in reduced postoperative complications and better immediate esthetic outcomes.[5],[6] There has, however, been a reluctance to adopt P-NAM as a standard of cleft care.[7] While surgeon preference has played a role, another factor that is often cited is the lack of parent co-operation.[1],[7] P-NAM requires the use of tapes and elastics that can result in irritation to the infant.[1] When there is inadequate peri-oral hygiene, this can also result in the formation of rashes and extreme discomfort to the child.[1]

This case report looks at the factors that can improve the parent experience during the P-NAM procedure. The report follows the patient from the time of first presentation (28 days) up to the infant's first birthday. The paper seeks to describe not only the steps of P-NAM but also the factors influencing the parents' acceptance of the procedure.

The study was reviewed by the institutional review board or REU and deemed to be exempt from ethical approval.

  Case Report Top

Presentation and history

A 28-day-old female patient with bilateral cleft lip and palate visited the dental clinics with parents after being referred to a pediatric dentist for the placement of a P-NAM appliance. The patient is the second child of related healthy parents with unremarkable family history. The baby was born after a full-term healthy pregnancy.

The medical history of the child revealed no underlying medical conditions or syndromes. Clinical examination revealed bilateral cleft lip and palate [Figure 1].
Figure 1: The 28-day-old patient in the first visit

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The quality of life was measured using structured interviewing; the patient's parents reported a difficulty in feeding and the patient was underweight (below the 5th percentile at 28 days).

Treatment plan

The initial examination revealed a cleft of over 5 mm in the hard palate: 2 mm on the left alveolus and 3 mm on the right alveolus. The patient was treatment planned for a P-NAM appliance that would serve two purposes. In addition to closing the hard tissue gaps to enable the surgeon to better close the gap, it was also hoped that the plate would help her feed and gain weight to reach the proper and safe weight to perform surgery under general anesthesia.

Fabrication of the plate

The impression was made using a two-stage technique.[8] An initial impression greenstick compound was used to fabricate the tray. This was then washed with Impression was taken using heavy putty [Figure 2]. The patient was help upright during the procedure to avoid any aspiration of the materials [Figure 3]. A stone cast was made and the undercuts were blocked. The appliance was fabricated using self-cured polymethyl methacrylate resin, keeping with the technique and design as previously described. The cured appliance was placed in warm water for 20 min to remove excess monomer. The appliance was trimmed and polished, and the tissue surface was prepared for the placement of denture relining material [Figure 4]. The plate with the relining material was placed in the child's mouth, and the mother was asked to feed the baby with milk to achieve adequate border molding [Figure 5]. The patient was recalled for relining of the plate every 2 weeks.
Figure 2: Heavy putty impression

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Figure 3: Patient help upright during taking impression to avoid aspiration

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Figure 4: (a) Stoned cast after blocking the undercuts. (b) Cured appliance

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Figure 5: The plate placed in the child's mouth, asked the mother to feed the baby to achieve adequate border molding

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Parent instructions and counseling

The parents were instructed on the use of the plate. They were also counseled regarding potential complications and were shown pictures to enable them to spot rashes early [Figure 6]. They were also shown how to clean the mouth and peri-oral area post feeding.
Figure 6: The rashes on the child's skin

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Surgery and change to feeding plate

The child underwent primary lip repair at the age of 4 months at which time the P-NAM was discontinued and replaced by a feeding plate [Figure 7]. Palate repair was scheduled to be conducted at 14 months.
Figure 7: The child after primary lip repair

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  Discussion Top

The mechanism and technical role of PNAM in cleft lip and palate has been extensively addressed in literature.[6],[7] Despite this, the parental perceptions of PNAM and methods of improving oral health-related quality of life have received relatively little attention in literature.[4],[9] We aimed to not only document the technical aspects of PNAM but also highlight the impact that the placement of the plate can have on the parents.

It has been shown that although there is a positive feeling about PNAM in parents who complete the process, the dropout rates remain high.[5],[6],[10] In our case, we decided to implement a formal conceptual strategy to help parents cope with the anticipated difficulties associated with P-NAM.[1]

In addition to showing parents the pictures of successful outcomes with PNAM, the parents were informed early about the potential complications such as rashes and irritability. Previous studies have shown that these are the most common complaints reported by the parents.[1],[4],[9]

The 1st month after birth is critical not only to the molding process but also to the acceptance of the plate by the child.[3] The patient was seen as soon as possible and followed up at regular intervals. One of the greatest challenges to taking an early impression is the technique used. The two-stage impression technique with a custom-made special tray has been shown to be a safe way to make chairside impressions.[8]

The need for parental support mechanisms has also been highlighted by studies looking into the impact of P-NAM on the quality of life.[1],[4],[7] In our case, the parents and child were given a dental home in the university hospital dental clinic. They were given anticipatory guidance at each weekly visit to help them cope with the potential complications of P-NAM. This approach is based on coping theories and has been previously documented in literature.[1] In our case, there were rashes due to the use of the tape, but the guidance provided to the parent meant that they were prepared to cope with it when it occurred.

In this case, we were able to get a significant closure in the nasal gap, which allowed the surgeon to perform a stable closure of the cleft. Perhaps, just as importantly, we were able to ensure parent compliance throughout the process.

  Conclusion Top

The successful implementation of P-NAM is a multidisciplinary process that includes not only the interaction between the surgeon and the pediatric dentist but also the interaction between the parent, the pediatric dentist, and the dental support team.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sischo L, Broder HL, Phillips C. Coping WITH cleft: A conceptual framework of caregiver responses to nasoalveolar molding. Cleft Palate Craniofac J 2015;52:640-50.  Back to cited text no. 1
Chang SY, Lonic D, Pai BC, Lo LJ. Primary repair in patients with unilateral complete cleft of lip and primary palate: Assessment of outcomes. Ann Plast Surg 2018;80:S2-6.  Back to cited text no. 2
Flores RL, Shetye PR. The Nasoalveolar Molding (NAM) Treatment Protocol. Vol. 56. United States: The Cleft Palate-Craniofacial Journal : Official Publication of the American Cleft Palate-Craniofacial Association; 2019. p. 1124-5.  Back to cited text no. 3
Alanazi FN, Alhayyan WA, Pani SC. Impact of presurgical nasoalveolar molding on the parental perceptions of oral health-related quality of life of children with cleft lip and palate. J Contemp Dent Pract 2020;21:152-55.  Back to cited text no. 4
Altuǧ AT. Presurgical nasoalveolar molding of bilateral cleft lip and palate infants: An orthodontist's point of view. Turk J Orthod 2017;30:118-25.  Back to cited text no. 5
Maillard S, Retrouvey JM, Ahmed MK, Taub PJ. Correlation between nasoalveolar molding and surgical, aesthetic, functional and socioeconomic outcomes following primary repair surgery: A systematic review. J Oral Maxillofac Res 2017;8:e2.  Back to cited text no. 6
Sischo L, Chan JW, Stein M, Smith C, van Aalst J, Broder HL. Nasoalveolar molding: Prevalence of cleft centers offering NAM and who seeks it. Cleft Palate Craniofac J 2012;49:270-5.  Back to cited text no. 7
Pani SC, Hedge AM. Impressions in cleft lip and palate-A novel two stage technique. J Clin Pediatr Dent 2008;33:93-6.  Back to cited text no. 8
Broder HL, Wilson-Genderson M, Sischo L. Oral health-related quality of life in youth receiving cleft-related surgery: Self-report and proxy ratings. Qual Life Res 2017;26:859-67.  Back to cited text no. 9
Shay PL, Goldstein JA, Paliga JT, Wink J, Jackson OA, Low D, et al. A comparative cost analysis of cleft lip adhesion and nasoalveolar molding before formal cleft lip repair. Plast Reconstr Surg 2015;136:1264-71.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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