NASOALVEOLAR MOLDING

BASICS OF NASOALVEOLAR
MOLDING

NAM IN UNILATERAL CLCP

NAM IN BILATERAL CLCP

ADVANTAGES OF NAM

COMPLICATIONS OF NAM
DISADVANTAGES OF
TRADITIONAL INFANT
ORTHOPAEDICS
Deformity of the nasal cartilages in
unilateral and bilateral cleft lip and
palate

Deficiency of the length of the collumela
in bilateral cleft lip and palate
Technique
It mainly uses acrylic stents attached
to a vestibular shield of a oral molding
plate to mold the nasal cartillages into
a more normal form and position
during the neonatal period
This takes advantage of the
malleability of the immature nasal
cartilages and its ability to maintain a
permanent correction in form.

In addition the collumela is also non
surgically corrected using tissue
expansion principles.

This correction is achieved by gradual
expansion of the nasal stents and
application of tissue expanding elastic
forces that are applied to the prolabium
Objectives of Nasoalveolar
Molding
Active molding and repositioning of
the deformed nasal cartilages and
alveolar process

Correction of the deficient collumela
mainly in bilateral cases.
Correction of unilateral oronasal
cleft deformity
The lower lateral alar cartilage is
depressed and concave in the alar
rim and is separated from the contra
lateral cartilage high in the nasal tip
The nasal tip is displaced and
depressed and there is also resultant
overhang of the nostril apex
The collumela and nasal septum are
inclined with the base deviated to the
non cleft side.

In addition the orbicularis oris fibres in
the lateral lip segments contracts into a
bulge with some fibres running
superiorly over the cleft towards the
nasal tip
OBJECTIVES OF PNAM
To correct and align and approximate
the intra oral alveolar segments
To correct the deformed nasal
cartilages
To correct the nasal tip and alar base
on the affected side.
To correct the position of the philtrum
and collumela.
These corrections are achieved using
an intra oral molding plate,with a nasal
stent rising from the labial vestibular
flange.
Procedure
Impressions of the infant are made
using an elastomeric impression
material
Impressions of the cleft are useful in
assessing pre and post alveolar
molding results and also in fabrication
of the nasal stent.
Fabrication of molding plate
A molding plate is fabricated using
conventional acrylic resin



The molding plate is secured to the
palate and alveolar process through
external strapping (surgical adhesive
tapes) to the cheeks and to an acrylic
extension from the oral plate between
the lips below the cleft.
Modification of the molding
plate
The molding plate is modified at
weekly intervals to gradually
approximate the alveolar segments
and reduce the size of the cleft gap.
This is achieved by removal of acrylic
resin in areas where alveolar
segments are to move and application
of soft liner in areas where alveolar
bone is to be reduced.

The ultimate aim of he selective
removal and addition of the acrylic
material is to align the alveolar
segments and to achieve the closure of
the alveolar cleft gap

This is similar to the Zurich type
molding plate described by Hotz (1969)
The effectiveness of the molding
therapy is enhanced by supporting the
palatal tissues and by taping the lip
segments together across the cleft.

Maintaining the tight lip apposition with
the external tape provides orthopaedic
benefits and reduces the consequent
scar.

The lip adhesion alone provides
uncontrolled orthopaedic effects but the
lip tape adhesion along with the molding
plate produces controlled approximation
of the alveolar segments.
Taping the lip segments also helps the
alignment of the nasal base region by
bringing the collumela towards the mid
saggital plane and by improving the
symmetry of the nostril apertures.

NASAL STENT
When the alveolar cleft width has
reduced to less than 6 mm then the
nasal stent is added to the molding
plate so that nasal cartilage molding
may start
Any attempt to close the deformity if
the cleft is large may result in
undesirable increase in the size of
lateral nasal wall
The nasal stent is a projection of acrylic
from the labial flange of the molding
plate.
Through gradual addition of acrylic the
sent is positioned underneath the apex
of alar cartilage on the cleft side
The dome of the alar cartilage is
elevated to normal position and
symmetry.
The stent should be located midway
between the middle of the cleft lip
segments
At the tip of the stent soft liner is added
so that tissue breakdown does not
occur when positive pressure is added
to the nasal lining.
The stent performs as a custom tissue
expander for cleft side of the collumela
The elevation of the nasal tip on the
cleft side will also increase the patency
of the nostril aperture.
Through gradual modification of the
nasal stent the shape of the
cartilaginous septum,alar cartilage tip
and lateral and medial crus are carefully
molded to resemble the normal shape
of these structures.
when properly taped temporary
blanching of the tissue overlying the tip
of the nasal stent occurs as the infant
suckles and activates the appliance.
Elevation of the nasal soft tissue results
in an intra oral molding plate that is
conducted down the nasal stent results
in more effective molding of the alveolar
segments.
Lip taping is still continued after the
placement of the nasal stent
At the closing of moulding the
collumela, philtrum and alveolar
segments should be aligned to facilitate
the surgical restoration of normal
anatomic relationships.
GOALS
To approximate the gingival tissues on
either side of the cleft.
However a successful surgical result
is obtained when a small cleft remains
between the segments.
PNAM allows a single surgical repair
of the deformity of the nasolabial
complex with successful results.
Advantages of PNAM
Ability to guide the alveolar segments
to a more normal position prior to
surgery.
Reduction of the cleft gap facilitates
the primary gingivoperiosteal closure
of the cleft defect,because there is a
greater probability that a complete
osseous bridge formation will happen
when cleft width is reduced.
The combined action of the
nasoalveolar molding plate and non
surgical lip approximation with surgical
taping results in a predictable correction
of the nasal,alveolar and soft tissue
deformities.
As a result under surgical repair the lip
and nose heals under minimal tension
with no or minimal scar formation.
Benefits in unilateral clefts
Restoration of the collumela from a
more oblique to a midline position
which also results in improved
projection of the nasal tip and alar
cartilage symmetry.
The collumela base is no longer
deviated to the non cleft side as it
uprights and takes up normal
convexity.
The nasal cartilage on the cleft side is
fashioned to be similar to the one of the non
affected side as the alar cartilage is molded
to a more normal convex shape.

The nasal tip is directed anteriorly and
upwards , this is possible because tissue
expansion allows to include the inherent
tissue defects n the cleft side.

All these are achieved without surgery and
reduce the need for additional soft tissue
surgeries and alveolar bone grafting . Thus
reducing consequent trauma and tissue
scarring.
BILATERAL ORO NASAL
CLEFTS
The lower cartilages have failed to
migrate to the nasal tip to stretch the
collumela
Pro labium also lacks muscle
thickness and is positioned directly
behind the collumela.
The alar cartilages are positioned
along the alar margin and are
stretched over the cleft in a flared
fashion.

The premaxilla is suspended from the
tip of the nasal septum where as the
lateral segments remain behind.
OBJECTIVES
Lengthen the collumela

Reposition the alar cartilages towards
the tip

Align the alveolar segments and pre
maxilla to form a more normal
maxillary arch.
Soft tissue and cartilaginous correction
are achieved through a conventional
molding plate.
The nasal stents also stretch the lower
nasal lining,thereby allowing the domes
of the lateral lateral cartilages to be
approximated under minimal tension
during surgical repair.
The device and its stents are secured
with adhesive surgical tapes and
elastics.
PROCEDURE
Impressions are taken using
elastomeric impression material
Molding plate is fabricated that
encompasses the lateral alveolar
segments and pre maxilla.
The everted pre maxilla is positioned
between the lateral alveolar segments
by modification of the molding plate.
A surgical adhesive tape and elastics is
used to secure the molding plate
actively against the alveolar process
and pre maxilla.
Through modifications of the internal
molding plate and elastic forces applied
by the elastics attached to the adhesive
tapes the pre maxilla is placed in a
keystone position between the lateral
alveolar segments.
The molding plate is adjusted weekly to
position the alveolar segments as the
pre maxilla is retracted.
The pre maxilla is positioned by
modifying the molding plate by adding
soft resin liners anterior to the pre
maxilla and removal posterior to the pre
maxilla.
Second stage
Approximately three weeks after
fabrication of the plate.


Nasal stents are built up from the
anterior of the oral molding plate to
enter the nasal aperture.

The nasal stent elevate the nasal
cartilages and prevent the downward
pull by the tapes placed on the pro
labium
A horizontal pro labial band pulls back
on the collumela at the base of the
nasolabial fold.

The bands force is used to preserve the
nasolabial angle at the junction of the
collumela base and the philtrum as the
collumela is lengthened.
.

The nasal stent supports the nasal tip and
exerts tissue expanding forces that are
directed to the collumela and nasal lining

The stents are also modified to give convexity
to the alar cartilages.

The stent also advance the medial and lateral
crus of the alar cartilages into the nasal tip
while lengthening the collumela.


Nasal stent is bifid with a superior and
inferior lobe.

The superior lobe enters the nostril and
pressing up and forward against the
nasal lining behind the dome of alar
cartilage.

The lower lobe is positioned under the
apex of the nostril aperture,pressing up
against the soft tissue triangle.


Surgical tape attached from the
prolabium to the anteroinferior part of
the molding plate pulls down and
reshapes the collumela.
Attached across the nasal stent is the
horizontal prolabial band that pushes against
the collumela and further lengthens it.
The prolabial band is made of a chain of
elastics and coated with a denture liner to
prevent ulceration of the tissue
It is contoured on the tissue to restrict the
width of the collumela.
It is attached to metal pins on the molding
plate (nasal stents) and stretched.
How is the collumela
lengthened ?
The stretching force applied by the
adhesive tape.
The horizontal posteriorly directed
froce by the elastic band ( pro labial
band)
Upward and anterior force applied to
the nasal tip by the nasal stent.
One of the biggest benefits of builateral
nasoalveolar molding is the lengthening
of the collumela.
About 4mm to 7mm lengthening of
collumela can be achieved by this
procedure.
Nasoalveolar molding without
collumelar lengthening may require
surgical correction.
Surgical correction may result in scar
tissue and may damage the anatomy of
the nasolabial complex.
This also improves the esthetics of the
nasolabial complex.


It stretches the nasal lining and allows
the surgeon to approximate the domes
of the lower alar cartilages with lesser
dificulty.
COMPLICATIONS
Soft tissue breakdown may occur in
areas of modification of the plate if
they are not properly polished
Ulceration may developed and this
can be prevented by adding tissue
lubricant or by proper polishing of the
plate.
If tapes and elastics are not applied
then the plate will not be adequately
retained
If the appliance is lost or not worn then
the previously closed cleft area may
relapse due to tongue pressure.
Occasionally the labial surface of the
central incisor may erupt prematurely
due to molding pressure.
Ectopic tooth bud may be seen on the
lateral aspect of the pre maxillary
segment which might have to removed
to prevent aspiration.
CONCLUSION
Pre surgical reduction of alveolar cleft
allows the surgeon to perform a
gingivoparietoplasty.
This procedure reduces the need for
alveolar bone grafts in more than 60%
of cases in mixed dentition.


The pre surgical alignment and
correction and alignment of nasal
structures reduces the need for primary
nasal surgery and thereby reducing the
scar formation and more consistent post
operative results.
In bilateral cases the need for
secondary elongation of collumela by
surgery is eliminated and consequent
scar formation at the lip collumela
junction is prevented.
NAM combined with a modified surgical
procedure addresses the needs of the
lip-nasal-alveolar complex in a single
surgery and reduces the number of
surgeries an individual has to undergo
in a life time.
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