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 @yahoo.com
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
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
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
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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
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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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