PNAM- Pre naso alveolar molding

Presented By:

Dr. Saili Chandavarkar

Prosthodontics M.D.S. III

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DEFINITION

Cleft palate – A congenital fissure or elongatedopening in the soft and/or hard palate .

OR

An opening in the hard and/or soft palate due toimproper union of the maxillary process and themedian nasal process during the second month ofintra uterine development. GPT 8

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ROLE OF

PROSTHODONTIST Feeding plate

Presurgical nasoalveolar molding

Replacement of teeth

Stabilization of teeth

Stabilization and or achieving ideal arch configuration before surgery

Camouflage for the inadequacy in surgical or orthopedic treatment

Fabrication of speech prosthesis

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A review of literature

1689: 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 presurgicalpreparation of clefts using adhesive tapes binding.

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

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Grayson 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 presurgicalorthopedic 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 premaxillaand expand the posterior segments.

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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

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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 elongation

4. 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.

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Deidre J. Maull et al (1999) conducted a study to determine the effect of presurgical nasoalveolarmolding(PNAM) on long term nasal shape in complete unilateral cleft lip and palate. They concluded that PNAM increases the symmetry of the nose.

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Deirdre 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 NasoalveolarMolding on three-dimensional shape in unilateral clefts. Cleft Palate Craniofac J, September 1999;36(5):391-7.

Nita Viwattanatipa et al (2001) in the presurgicalorthopaedic 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.

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Nita 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.

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Tracy 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.

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Eric Jein-Wein Liou (2004) Their study revealed that thenasal asymmetry was significantly improved afternasoalveolar molding and was further corrected tosymmetry after primary cheiloplasty. To compensate forrelapse and differential growth, the authors recommend(1) narrowing down the alveolar cleft as well as possible bynasoalveolar molding, (2) overcorrecting the nasal verticaldimension surgically, and (3) maintaining the surgicalresults 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.

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Iino 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 astudy to describe a treatment approach for PNAM in unilateralCLCP. This approach uses a plate held in with outriggers,which prevents the cleft-widening effect of the tongue, helpswith tongue tip placement, and utilizes the functionalmovements of the facial musculature to guide and relocate themajor segment medially to its normal position. Nasal moldingis undertaken after most of the lateromedial correction of thealveolar position. They concluded that this technique helps toimprove alveolar position, nasal septum alignment, nasalsymmetry, and nasal tip projection prior to lip repair.

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Sanjay 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 nasoalveolarmolding 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.

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Ziai 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-subjectsstudy in which 11 infants with unilateral lip deformity andvarying degrees of alveolar gaps were treated by NAM. Allpatients 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 andbiomechanical principles of NAM therapy. Long termstudies on NAM therapy indicate better lip and nasal form,reduced oronasal fistula and labial deformities, 60%reduction in need for alveolar bone grafting.

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Marcos 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;59:489–94.

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 extraoralforces. It produces columellar elongation and increase in prolabium length facilitating the primary cheiloplasty and rhinoplasty without scarring.

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Abida 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 lip–cleft 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.

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Judah 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 lip–cleft 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).

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V. Shetty, H. J. Vyas, S. M. Sharma, H. F. Sailer: A comparison of results using nasoalveolarmoulding 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: 28–36.

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.

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Perry 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.

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Habel 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.

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Habel 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 orthopedicsfailed to address include deformity of nasal cartilages inunilateral as well as bilateral clefts of lip and palate anddeficiency of columella tissue in infants with bilateralclefts.

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Matsuo 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.

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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.

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Adam 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 Rationale

Retraction of premaxilla.

Alignment of cleft alveolar segments.

Presurgical elongation of collumella

Up-righting of collumella

Correction of nasal cartilage deformity

Increase in surface area of mucosal lining.

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Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of lip, alveolus and palate. Clin Plast Surg 2004;31:149-58.

Clinical approach

Evaluation by the interdisciplinary cleft palate team. Examination Explanation of treatment goals and procedure to

parents Impression Fabrication of plate Pnam activation Retentive taping Follow up Nasal stent addition Follow up Difference between unilateral and bilateral treatment

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Impression of intraoral cleftMaterial:

Impression compound/Elastomeric impression material

Consistent 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.

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The 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.

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Impression 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.

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Fabrication of the device Pour two casts

Fabrication of prosthesis

Patients permanent record

Cleft 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.

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Methods of fabrication of the plate

Heat 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.

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Molding plate

Borders trimmed

Oral portion-Highly polished.

Should be fairly retentive.

No projection into cleft area.

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Post insertion

considerations Observation: retention, extent posterior,

not too tight fitting, no acrylic in cleft area.

Suckling verification, no gagging.

Molding of the alveolar segments

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Molding of alveolar

segments Desired movement-direct greater segment

inward and lesser segment outward

Selective removal-1 to 1.5 mm

Changes made weekly

Ultimate goal: reduce the gap

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Method to achieve Pnam:

Acrylic removal-where one desires alveolar bone to move

Permasoft addition-where one desires bone to be reduced

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Extraoral retentive button

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Retentive taping

Broader 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 taping

Retention of appliance

Controlled orthopedic effects

Alignment of nasal base region

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Follow up

Weekly basis

Progress of molding appliance monitored

Retention evaluated

Examination for possible sores

Monitoring Change in size of defect

Modification of appliance

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Nasal stent•When the size of the cleft is less than 6 mm. •Causes active nasal cartilage molding.•Should project passively in nostril.

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Base 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 PNAM

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Bilateral CLCP

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Bilateral CLCPPNAM consists of following phases-

1. Alignment of posterior lateral segments while retracting and derotating premaxilla

2. Molding the nasal cartilages by repositioning apices of alar cartilages towards nasal tip

3. Elongation of columella

4. Addition of nasal stents

5. Horizontal prolabial band or saddle is attached across the two acrylic nasal stents.

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Force vector

Downward force-Surgical tape placed on prolabium

Posterior force-from horizontal band

Upward and anterior force-from nasal stents.

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Force vector

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Considerations before

surgery Alignment of alveolar segments, nasal

cartilages, columella and philtrum.

GPP- To close alveolar defect

Timing for surgery: 2-3 months.

Evaluation of infant: Rule of 10.

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Gingivoperiosteoplasty- gpp

Millard and Latham 1990

Between 12-16 weeks of age.

Prior oronasal orthopedics is required.

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Tracy 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 considerations

Lip is taped for several weeks even after surgery

No nasal stent or supporting device is employed.

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Surgical nasoalveolar molding

and columellar elongation

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Complications

Locked-out Segment: most common

• Hard tissue complication-misdirected molding

• Successful alveolar molding but lack of soft tissue support.

• Resulting misshapen corrected orthodontically.

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Thomas Tyalor, Complications associated with presurgical nasoalveolar moiding and columellar elongation. Clinical Maxillofacial Prosthodontics.

Nostril Over-expansion: most serious

• Soft tissue complication-MEGA-NOSTRIL

• Etiology: gap > 6 mm,

• Force vector

• Precautions

• Treatment: wedge

procedure at initial

surgical repair

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Tissue Ulceration

• Etiology

• Precautions

• Treatment: smooth appliance, no sharp areas, aloe vera cream, tissue lubricant.

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Failure to Retain/ wear Appliance During Oronasal Molding

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Failure to Tape Lip Segments

• Consequences: non retentive appliance and very slow progress in closure. Minimize the potential of soft tissue expansion

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Exposure of a Primary Tooth

• Retained or Removed-

• Location, Prognosis, Surgical plan

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Benefits

Allows controlled, predictable repositioning without Lip adhesion surgery or Surgical insertion of pin retained dynamic molding plate

Reduction in size of cleft gap-

One surgical procedure

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Allows surgeon to perform a GPP without need for extensive tissue dissection.

PNAM used in conjunction with GPP –

Avoids additional surgery to bone graft the alveolus

Reduces need for early nasal revision surgery.

EXTREMELY COST-EFFECTIVE

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Additional 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.

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In 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

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Limitations

AGE

CO-OPERATVE PARENTS

LABOUR INTENSIVE

REGULAR VISITS

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Recent Advances: CAD

NAM

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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-S78

The 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.

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Quan 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 Radiol2013;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.

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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 Radiol2013;116:418-426

CONCLUSION

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THANK YOU

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PNAM- Pre naso alveolar molding

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