Cleft Palate Habilitation

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Cleft Palate Habilitation
Shefali Singla and Manjot Kaur

Department of Prosthodontics, Dr. H.S.J. Institute of Dental Sciences and Hospital, P.U., Chandigarh, India

Presurgical Orthopaedics is any treatment that alters the position of the segments of cleft maxilla in infancy prior to lip and
palate reconstruction. There are different approaches, with different mechanics, seeking and achieving different end results.
This article describes PNAM, a current approach to the traditional method of presurgical infant orthopaedics for patients with
unilateral and bilateral clefts of lip and palate. The goal of PNAM is to align and approximate the alveolar cleft segments while
at the same time achieving correction of nasal cartilage and soft tissue deformity. [Indian J Pediatr 2008; 75 (7) : 703-708]
E-mail: shefali_singla

Key words : Cleft palate; Cleft lip; Presurgical orthopaedics; Presurgical nasoalveolar molding (PNAM)

Cleft lip and palate are the commonest congenital                   secondary adaptations of otherwise normal structures,
malformations with incidence ranging from 1 in 750 to 1             there is the added influence of treatment. Whether the
in 1000 live births. 1 Although cleft lip and palate are            influence is favorable or unfavorable to the pattern of
distinct and separate congenital abnormalities, they often          facial growth is dependent on the clinician’s knowledge as
occur concomitantly.2 These deformities occur when                  well as technical ability in designing and carrying out a
mesenchymal connective tissues from different                       treatment plan.
embryologic structures fail to meet and merge with each
                                                                       Those responsible for cleft palate habilitation should
other. Cleft lip is the result of failure of fusion of medial
                                                                    ensure that the young patients are receiving treatment
nasal process with maxillary process.It may be unilateral
                                                                    that will secure the bone development, tooth position, and
or bilateral and may extend into alveolar process. Cleft
                                                                    soft tissue support to allow the use of conservative
palate on the other hand, is the result of either the lateral
                                                                    prosthetic replacements.
palatine shelves to fuse with each other, or its fusion with
the nasal septum or with primary palate. A complete cleft
lip and palate is a severe malformation which contributes                       PRESURGICAL ORTHOPAEDICS
to multiple functional deficiencies with direct influence on
mastication, hearing, speech, facial growth, feeding and
breathing. This aberrant growth pattern also presents with          This concept was introduced at University of Glasgow by
a great deal of personal, social and psychological                  Kerr McNeil in 1954 as an adjunctive neonatal therapy
morbidity.                                                          aiming at nonsurgical reduction of the size of the alveolar cleft.3
                                                                    The rationale behind “Maxillary Orthopedics” as
   Genetic and environmental factors are implicated,                described by McNeil, Burston and Rosenstein is that early
although exact etiology of cleft lip and palate is not              segment alignment will allow the maxillary halves to
known. The cleft is apparent by the third month of fetal            develop normally even though a normal bony union is
development. It is during the remaining period of growth            not present.
and development, which extends untill adolescence, that
the cleft exerts a secondary effect upon the whole of the              The primary purpose of the appliance prior to lip closure is
middle third of the face and leads to the classical                 not to proliferate tissue or initiate growth but to guide the
deformities.                                                        maxillary segments into proper spatial position with eachother
                                                                    and with the mandibular arch. After the maxillary appliance
   In addition to the altered appearance and function               has the segments in good alignment, the plastic surgeon
resulting from the cleft (primary defect) and the                   restores lip continuity. The molding pressure of the
                                                                    surgically closed cleft lip, along with the appliance helps
                                                                    to create an ideal arch form.
Correspondence and Reprint requests : Dr. Shefali Singla, Reader,
                                                                    Advantages of Presurgical Orthopedics
H.No. 2864-A, Sector: 42-C, Chandigarh.
[Received September 13, 2006; Accepted January 21, 2008]            Surgical benefits : Main advantage of presurgical

Indian Journal of Pediatrics, Volume 75—July, 2008                                                                                703
                                                 S. Singla and Manjot Kaur

orthopaedics is that it allows a surgical cleft closure             Some of the problems that traditional approach failed
without tension and mobilization of the surrounding soft         to address include deformity of nasal cartilages in
tissue.                                                          unilateral as well as bilateral clefts of lip and palate and
                                                                 deficiency of collumella tissue in infants with bilateral
   • In complete unilateral clefts of primary and
secondary palate, the defective oropharyngeal
musculature allows unrestricted lateral and superior                 A new approach to the traditional method of
rotation of the maxillary segments in a medial and inferior      presurgical infant orthopaedics for patients with
direction and recontour the greater segment, restoring a         unilateral or bilateral clefts of lip, alveolus and palate is
normal premaxillary-maxillary arch relationship and thus         Presurgical Nasoalveolar Molding (PNAM) 6 which takes
facilitating surgical repair of cleft lip.4                      advantage of the flexibility of the cartilaginous septum in
                                                                 the first few weeks after birth(caused by high levels of
   • In case of bilateral clefts, the premaxilla is rotated
                                                                 hyaluronic acid found circulating in infants). At this time,
superiorly and anteriorly and the maxillary segments are
                                                                 it is relatively easy to apply external traction and by
retruded and rotated medially and superiorly. Repair of
                                                                 means of controlled forces rotate the lower part of the
lip without first repositioning the segments of the maxilla
                                                                 premaxilla to a more surgically advantageous position.
would lock the premaxilla outside the maxillary segments
                                                                 The purpose of the traction is not to produce a normal
in a forward position. This allows the lower lip to fall
                                                                 dental arch form but to facilitate approximation of the
behind the premaxilla, retruding the mandible, allowing
                                                                 alveolar cleft segments while at the same time achieving
overdevelopment of the premaxillary alveolar area and
                                                                 correction of the nasal cartilage and soft tissue deformity.
creating an excessive overbite. An Orthopedic feeding
                                                                 PNAM Improves nasal asymmetry and deficient nasal tip
appliance facilitates the correction by expanding the
                                                                 projection associated with bilateral cleft lip and palate.7
maxillary buccal segments and retruding the premaxilla
with or without external strappings. The surgical                  Principal objectives8 of Presurgical Nasoalveolar
correction of the lip can now be performed over a more           Molding are;
normal skeletal base, with far better aesthetic results.
                                                                 • Retraction of premaxilla.
   • The constant gentle pressure of the appliance against       • Presurgical elongation of collumella through the
the palatal tissues serves as a stimulus for the growth of         application of tissue expansion principles.
underlying bone. This results in a narrowing of the palatal      • Correction of nasal cartilage deformity.
cleft and greatly benefits surgical repair.                      • Alignment of cleft alveolar segments.
                                                                 • Increase in surface area of nasal mucosal lining.
   • A definite surgical advantage of orthopaedic
                                                                 • Up-righting of collumella and achieving close
treatment is marked narrowing of lip cleft i.e., less
                                                                   approximation of cleft lip segments at rest, results
extensive freeing of tissue from anterior surface of maxilla
                                                                   from gentle application of forces through NAM
would be required to obtain tension free repair. This
means less future interference with maxillary growth.5
There would be less worry that the repair might                     According to Grayson of NYU Medical Centre, New
breakdown postoperatively.                                       York, a traditional approach to treatment of clefts might
                                                                 only bring the lip segments together, relying on the
   • Another advantage is reduction in width of the cleft
                                                                 tension set up by the lips to approximate the alveolar
in the alveolar process which means that there is more
                                                                 processes.9 Since lip repair is achieved under tension,
chance of the segments forming a butt joint in the alveolar
                                                                 there is also a broad and noticeable scar. Repairing the lip
process region and possibility of an over contracted upper
                                                                 alone does not address the nasal asymmetry present in
arch after lip repair is therefore, reduced.
                                                                 their children. Furthermore, while the gum pads may
   • Since lip surgery following presurgical orthopaedics        eventually come together, a gap will be present in the
is delayed until optimal maxillary alignment is achieved         bone which requires alveolar bone grafting at a later
(usually about age of 3-6 months with unilateral complete        stage.
clefts), the aesthetic result of lip surgery is enhanced
                                                                    Grayson10,11 suggested use of intraoral molding therapy
because growth has provided tissues which are of
                                                                 presurgically to bring gum pads together and make
increased size, more vascular and easier to manipulate.
                                                                 gingivoplasty possible which obviates the need for a bone
    • Aid to plastic surgeon – The orthopedic repositioning      graft in 60% cases.11
of the premaxillary region of the greater segment, and the
                                                                    The addition of nasal molding,using a stent radiating
repositioning of the premaxilla restore the skeletal base
                                                                 from intraoral molding appliance, reshapes the deformed
under the nose and lip to a more normal position and
                                                                 cartilage in children with bilateral clefts and elongates the
permit a more aesthetic reconstuction of the cleft lip. The
                                                                 deficient columella.
better the original correction of the lip, the less likelihood
there is of secondary surgical correction.5                         An impression is taken when the baby is 7-14 days old

704                                                                     Indian Journal of Pediatrics, Volume 75—July, 2008
                                                        Cleft Palate Habilitation

by the orthodontist in the operation room with an
anaesthetist “standing by” to monitor the baby and help
with breathing, if there is a concern. A plaster cast (Fig. 1a)
is made from the impression and then intraoral mold
(appliance, Fig. 1b) is fabricated by the technician.The
appliance (Fig.2) is fitted within a couple of days and
secured with plastic skin/bone tape and steristrips and
orthodontic elastics (Fig.3). By gradually changing the
shape of the molding plate, the bones of upper jaw are
brought into a normal, symmetyrical configuration,
closing the gap where the cleft occurs. Each week for 3-4
months, the molding plate is adjusted by about 1mm. The
appliance also serves as an artificial palate, closing the
roof of mouth, so that it is easier for infant to feed. Baby                 Fig.3. Bilateral Nasal Stent in Patient’s mouth
will not be able to suck but will be able to squeeze the teat
between the gum pads and the appliance, allowing to                   maintain nasoalveolar molding results.12
feed itself with out the mother having to squeeze the
                                                                          In a Bilateral case , a normal length of collumella is
bottle. In the first few weeks after birth, the cartilage in
                                                                      created presurgically with an approach based on concept
nose is very malleable and a permanent change can be
                                                                      of tissue expansion. It involves use of bilateral nasal stents
achieved by holding it in a new position.
                                                                      emanating from the intraoral molding plate into each
   Nasal stent is a specially formed extension of hard and            nostril. With gradual adjustment, the stents direct the tip
soft acrylic or a wire component, which rises from the                of nose forward and press back on the lip-collumella
forward edge of molding plate into the nose (Fig. 3).                 junction resulting in tissue expansion and elongation of
                                                                      collumella (Fig. 5a, b, c). The nasal stents support the
   In a Unilateral case, stent lifts the nasal tip on the
                                                                      nasal tip and create tissue expanding forces that are
                                                                      directed to collumella and nasal lining. This nonsurgically
                                                                      created collumella is free of scar tissue and consequently,
                                                                      the nose can continue to mature and grow in a normal
                                                                         Infants with PNAM had improved nasal symmetry in
                                                                      width, length and collumella angle, as compared to their
                                                                      presurgical status. There was some relapse of nostril
                                                                      shape in width (10%), height (20%) and angle of columella
                                                                      (4.7%) at one year of age.13
                                                                         To produce continuity of alveolar bones, Dr.
                                                                      Cutting11,14 suggested Gingivoperiosteoplasty(GPP) at the
              (A)                                (b)                  time of primary surgical repair. After opening the
Fig. 1. (a) Plaster cast (b) Appliance fabricated on the cast         gumpads to find where the bones end, tease the
                                                                      gingivoperiosteum off the bony surface and repair it in a
                                                                      normal relationship with other side. Bone replaces the
                                                                      hematoma in the gap. Just prior to the surgery,the wire
                                                                      component will be removed but acrylic plate will stay in
                                                                      until the palate surgery at 10-14 months.
                                                                        ADVANTAGES of this new method of Presurgical
                                                                      orthopedics may be considered from a soft tissue
                                                                      perspective as well as from osseous perspective.

  Front view                               Side view                  • The major intraoral benefit of PNAM is its ability to
                                                                        guide the alveolar segments into a normal position
                 Fig. 2. Bilateral Nasal Stint                          prior to surgery .

collapsed cleft side (Fig. 4a, b, c) and elevates to give a           • The reduction of cleft gap width facilitates the primary
normal shape to the cartilage and create symmetry to the                gingivoperiosteal closure of defect.
nose. Slight overcorrection of alar cartilage done on cleft              •     The combined action of nasoalveolar molding
side using pressure exerted by nasal stent is indicated to            plate and nonsurgical approximation of lip segments with

Indian Journal of Pediatrics, Volume 75—July, 2008                                                                              705
                                                      S. Singla and Manjot Kaur

Fig. 4a. Schematic representation of orthopedic molding of maxillary arch in an infant with a unilateral cleft of lip and palate. As the cleft
         defect closes with time, lateral arch dimension is maintained which produces optimal maxillary arch symmetry.

Fig. 4b. Conventional NAM appliance held in place with                    Fig. 4c. Unilateral nasal stent extending from labial vestibular
         combination of surgical tapes and orthodontic elastics                    flange of a conventional NAM plate.
         applied to cheeks and cleft lip segments.

Fig. 5a. Schematic representation of maxillary arch of an infant with complete bilateral cleft of lip and palate before, during and after
         completion of Premaxilla retraction therapy. Note that lateral arch dimension is maintained.

706                                                                               Indian Journal of Pediatrics, Volume 75—July, 2008
                                                      Cleft Palate Habilitation

                                                                      segments and premaxilla to form a normal maxillary arch.
                                                                         • Nasolveolar molding with nonsurgical collumella
                                                                      elongation eliminates the need for surgical lengthening in
                                                                      a single stage and avoids scarring at the base of nose.
                                                                        • Nasolveolar molding also results in stretching of
                                                                      nasal lining, which allows the surgeon to approximate the
                                                                      domes of lower cartilages with less resistance.10
                                                                         • In contrast to earlier forms of infant orthopaedics,
                                                                      unilateral nasolveolar molding is concluded by 3 to 4
                                                                      months of age and bilateral nasolveolar molding is
                                                                      usually completed by 5 months. In both, unilateral and
                                                                      bilateral treatment, the molding plate is not used after
Fig. 5b. Schematic representation of premaxilla being retracted by    surgery. Therefore, there is a period in which mouth is
         using molding plate in conjunction with external tape and
                                                                      free of all non-shedding surfaces after completion of
                                                                      orthopedic treatment and before eruption of deciduous
                                                                      dentition at 6 months of age. Thus, children in
                                                                      Nasolveolar molding population , who have had 3 to 5
                                                                      months of orthopedic appliance wear, are not likely to be
                                                                      at elevated risk for caries when compared with other
                                                                      children with clefts.11
                                                                         Grayson and Cutting11 in 2001 stated five aims of
                                                                      presurgical infant orthopedic nasoalveolar molding that
                                                                      go beyond the traditional goals of presurgical
                                                                      • Improved long term nasal esthetics.
                                                                      • Reduced number of nasal surgical procedures.
                                                                      • Reduced need for secondary alveolar bone grafts in the
                                                                        majority of patients if gingivoperiosteoplasty is
                                                                        included in the protocol.
                                                                      • No greater growth disturbance than is found in cleft
                                                                        patients undergoing good traditional treatment.
                                                                      • Savings in cost to the patient and society through the
Fig. 5c. Bilateral nasal stents extending into the nostril aperture     reduction in number of surgical hospital admissions.
         from vestibular flange of intraoral molding plate. Tips of
         nasal stents push forward on nasal dome from inside the
         nose. Soft acrylic band at base of collumella presses back                         CONCLUSION
         on lip-collumella junction.

surgical tape also results in a predictable correction of             A rational approach to the value of a clinical treatment
alveolar, nasal cartilage and soft tissue deformities.                requires that it be clearly delineated and defined.
                                                                      Presurgical Orthopedics aims to place the maxillary
   • As a result of nasolveolar molding, the primary                  segments in a more advantageous position for normal
surgical repair of nose and lip heals under minimal                   growth and development and also produces a better
tension, thereby reducing scar formation.                             skeletal base for the plastic surgeon, paving the way for a
   • In unilateral cleft deformity, a significant benefit of          more aesthetic lip repair. Not all Presurgical Orthopedic
nasoalveolar molding is the repositioning of collumella               treatments are same nor do they have same goal. Different
and septum from an oblique position into an upright and               approaches and different end results have confused the issues.
more midline orientation, which results in improved                   Such adjunctive treatment as passive feeding plates, post
nasal tip projections and alar cartilage symmetry. With               surgery dental arch control, alveolar repair, bone grafting
careful attention given to the soft tissue molding each               or periosteoplasty are side issues that require a separate
week, excellent bilateral symmetry may be developed.                  evaluation.

   • In bilateral patients, Presurgical nasolveolar molding             Recent clinical studies support the role of PNAM in
helps to lengthen the collumella, to reposition the apex of           correcting nasal cartilage deformity and alveolar
alar cartilage towards the tip, and to align the alveolar             malposition prior to primary surgical repair. Cleft lip and
                                                                      nose repair is aesthetically delicate surgery. Even the very
Indian Journal of Pediatrics, Volume 75—July, 2008                                                                              707
                                                        S. Singla and Manjot Kaur

best of our current surgical endeavours fall short of                      6. Matsuo K. Repair of cleft lip with nonsurgical correction of
clinical perfection. So it follows that any supportive                        nasal deformity in the early neonatal period. Plast Reconst
                                                                              Surg 1989; 83 : 25-31.
technique that can provide a small but consistent
                                                                           7. Spengler AL, Chavarria C. Presurgical nasoalveolar molding
improvement in surgical outcome, must be given the                            therapy for treatment of bilateral cleft lip and palate. Cleft
consideration.                                                                Palate- Craniofac J 2005; 43 : 321-328.
                                                                           8. Grayson BH, Maull D. Nasoalveolar molding for infants born
   When the optimum development of the face has been                          with clefts of lip,alveolus and palate. Clin Plast Surg 2004; 31
achieved by way of multidisciplinary approach,                                : 149-158.
definitive prosthodontic treatment may consist of little                   9. Grayson BH, Maull D. Nasoalveolar molding for infants born
more than fixed partial denture replacement for missing                       with clefts of lip, alveolus and palate. Clin Plast Surg 2004; 92:
                                                                          10. Grayson BH, Santiago PE, Brecht LE, Cutting CB. Presurgical
                                                                              Nasoalveolar molding in infants with cleft lip and palate. Cleft
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708                                                                              Indian Journal of Pediatrics, Volume 75—July, 2008

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