nasal symmetry achieved by nasoalveolar ......05 jpda vol. 23 no. 01 jan-mar 2014 nasal symmetry...

JPDA Vol. 23 No. 01 Jan-Mar 201405

NASAL SYMMETRY ACHIEVED BY NASOALVEOLARMOLDING IN CLEFT LIP AND PALATE PATIENTS- ALITERATURE REVIEW

Aiyesha Wahaj1 BDS

OBJECTIVE: To review the significance of Nasoalveolar Molding in achieving Nasal Symmetry in Cleft lip andPalate patients before Lip repair.METHODOLOGY: A Data search was performed based on available electronic data base, hand search articles andbooks since 1994-2010. This included Cochrane data base, medline, pubmed, research journals, and papers. Thetotal of nearly 900 articles were found related to naso alveolar molding among which filtered results showed with302 randomized control trials. Inclusion criteria included both unilateral and bilateral cleft lip and palate cases whohad presurgical nasoalveolar molding with nasal stents ; prior to primary lip repair ,whilst the exclusion criteria wassyndromic patients, ,interrupted treatment timings, more than six months of age, immunocompromised, autoimmunediseases ,previous history of lip or nasal surgery before nasoalveolar molding for any reasons. Overall 28 studiesmet the basic inclusion criteria.RESULTS: Nasal symmetry is preferably well acheived by Nasoalveolar Molding.KEY WORDS: Unilateral Cleft lip Palate, Bilateral Cleft lip Palate, Nasoalveolar Molding, Rhinoplasty,Gingivoperiostoplasty, Cheiloplasty.HOW TO CITE: Wahaj A, Ahmed I, Erum G. Nasal Symmetry Achieved By Nasoalveolar Molding In Cleft LipAnd Palate Patients- A Literature Review. J PAk Dent Assoc. 2014;23(1):05-10

INTRODUCTION

resurgical infant orthopedics has been used as anevident mode of treatment from early centuries.Through Hofman et al, Desault, Hullihan, Brophy,

Mcneil, Matsuo and Grayson modifications are beingmade in order to correct the cleft alveolar arch. All aimswere to reduce the alveolar cleft width along with nasalsymmetry. Nasal symmetry reflects the proportionaterelationship among nasal alar base width, columellarlength and nasal tip; steps being taken to improve thecleft region along with maintaining harmonious nasalmorphology to enhance facial esthetics. Previously theonly way for achieving nasal symmetry was by surgicalmeans but with the advent of nasoalveolar molding

before surgery, it significantly enhances the result ofsurgeries and reduces the side effects of early surgeries.It was started from simple bonnet band, then silicontubes with further advancement of molding acrylic plates. Intraoral acrylic molding plate was later constructedwith added nasal stents covered with soft lining to reducethe alveolar gap with nasal symmetry. Although thetechnique is the extension of previous methodologieswhere silicon tubes was used to mold the nostrils1. Allthe above studies were conducted to achieve midfacialregion symmetry of which nasal anatomy and morphologyis the basic component along with alveolar arch widthand gap reduction. Sequential molding of Nasoalveolarregion helps to prevent early side effects prior to lipsurgery and hence gaining maximum benefits of lipsurgery and later the Periogingivoplasty. Correction ofcleft lip and palate with concomitant nasal symmetry inorder to establish physiological oronasal functionalityis necessary for good facial growth. Therefore the primaryaim of this review was to gather the results obtained byusing nasoalveolar molding and how they all accountedto be a part of nasal symmetry.

P

1. Post Graduate Fellowship Residency completed. Orthodontics Department .Dr.Ishrat-ul-Ebad Khan Institute Of Oral Health Sciences-Dow University Of Health Sciences.Karachi-Pakistan.2. Head Of Department and Associate Professor. Orthodontics Department. Dr.Ishrat-ul-Ebad Khan Institute Of Oral Health Sciences-Dow University Of health Sciences.Karachi-Pakistan.3. Associate Professor. Orthodontics Department . Dr.Ishrat-ul-Ebad Khan InstituteOf Oral Health Sciences-Dow University Of health Sciences. Karachi-Pakistan.Corresponding author: “Dr. Aiyesha Wahaj” < [email protected] >

Imtiaz Ahmed2 BDS, FCPS, M.ORTHRCS

SYSTEMATIC REVIEW

Gul-e-Erum3 BDS, FCPS, M.ORTHRCS

JPDA Vol. 23 No. 01 Jan-Mar 2014 06

Nasal Symmetry Achieved By Nasoalveolar MoldingIn Cleft Lip And Palate Patients- A Literature Review

METHODOLOGY

A Data search was performed based on availableelectronic data base, hand search articles and bookssince1994-2010. This included Cochrane data base,Medline, pubmed, research journals, and papers. Thetotal of nearly 900 articles were found related to nasoalveolar molding among which filtered results showed 302 randomized control trials.

The search strategy was based on PICO includingsearch terms such as, unilateral and bilateral cleft, infantorthopedic treatment, nasoalveolar molding, acrylic platewith nasal stents and nasal symmetry. The Inclusioncriteria included both unilateral and bilateral cleft lipand palate cases who had presurgical nasoalveolarmolding, with nasal stents for nasal molding, prior toprimary lip repair, whilst the exclusion criteria wassyndromic patients, interrupted treatment timings, morethan six months of age, immunocompromised,autoimmune diseases, and previous history of lip ornasal surgery before nasoalveolar molding for anyreasons.

Overall 28 studies met the basic inclusion criteria.The Randomized trials filtered during study period wereemphasizing more on surgical means, their sample sizewas not consistent, and highlighting surgical outcomesmore as compared to orthodontic follow up. Furthermost of them were mentioning the word not detailrandomization only their name suffix.

STATISTICAL ANALYSIS

Wahaj A / Ahmed I / Erum G


REVIEW

Cleft lip palate is a multivariant deformity whichpresents with distinct characteristics both phenotypicallyand genotypically. The unilateral cleft lip and palatepresents as a wide nasal base and cleft at upper lipsegments .The affected lower lateral nasal cartilage isdisplaced laterally and inferiorly which results in adepressed nasal dome with the appearance of an increasedasymmetric alar rim, an oblique columella and an overhanging nostril apex. If there is a cleft of palate, thenasal septum will deviate to the non cleft side with anassociated shift of nasal base and tip. While the bilateral

cleft lip palate presents morphologically with procumbentor rotated premaxilla, increase alar base width and thelip segments2,3,4 the prolabium and columella appears tobe deficient because of nasal tip flattening and lack ofprominence. Also lower lateral alar cartilages are flaredand concave. Normally they should be convex.

Previously the primary method of achieving nasalsymmetry was by surgical means. Nasal moldingpresurgically reduced significantly the significant sideeffects of early surgeries like scarring, midfacial retrusionetc. This was started from simple bonnet band, silicontubes and later molding acrylic plates. Intraoral acrylicmolding plate was later constructed with added nasalstents covered with soft lining to reduce the alveolar gapwith nasal symmetry. The stent is made up of .036 guageround stainless steel wire shaped bilobed form. Softdenture lining material is used to avoid nasal mucosalinjury. The stent and the acrylic plates are secured byelastic loops over a retention arm extending from theanterior flange of the plate. The position of retentionarm is40° down from the horizontal plane to achieveproper activation and to increase stabilization of acrylictray5,6,7.Assembly and position of stents differs and mayvary from patient to patient. Generally in unilateral cleftsthere is one retention arm with stent but in case withbilateral cleft there are two retention arms with two nasalstents8,9,10.Thus the nasolabial junction continues to belifted and projected forward. This also uplifts the nostrilapex and ultimatly defining the top of columella11,12,13.

Various analyses were done in which the differenceswere being measured and compared in order to describesymmetry along with concomittent correction achieved.Later presurgical and postsurgical comparisons weremade amongst them. This included : Height of nostril,Nostril width , Columella angle on cleft side ,Nasal tipprojections, Nasal tip symmetry, Alar rim symmetrymeasured between alar base noncleft side with respectiveto cleft side, Columellar base width and symmetry withrespective to noncleft side or alar base cleft side, Lengthof columella and Width of alveolar cleft. The abovemeasurements were discussed in studies shown belowin table 1; all the following discussed studies showedvarious parametric measurements for determining nasalsymmetry after nasoalveolar molding.

Descriptive studies enlightened that the maxillaryalveolar segment molding simultaneously support andhold the deformed nasal cartilage which sequentiallycorrects the central nasal tip projection and cause

Nasal Symmetry Achieved By Nasoalveolar MoldingIn Cleft Lip And Palate Patients- A Literature ReviewWahaj A / Ahmed I / Erum G


lengthening of deficient columella 2,24,25 it has been shownthat the Slight over correction of alar base on the cleftside obtained by using pressure exerted by the nasalstent maintains nasoalveolar molding results 26,27,28. Cleftlip repair is often performed at approximately 3 monthsof age when the risk of anaesthesia related complicationsdiminishes. This may be delayed however if the patientis undergoing presurgical nasoalveolar molding. At endof naso alveolar molding various measurements havebeen taken to identify the differences .Three dimensionalstudies showed effects related to facial forms withpercentage distribution. Overall face form improvedwith columella29%, labial tubercle51% ,lower lip29%,lateral aspect of face19%, tip of nose25%and laterallyto columella directly below nares29% Uppernose81%,alardome5%, columellaheight30%, lateral wall ofnostril30%. Cleft side alar curvature showed largedecrease in size80% 5,6.

Research evaluation also enumerates the combinedsurgical procedures and comprehensively illustrated theirresults achieved. Nasal symmetry is subsequentlyachieved by primary cheiloplasty. Technique is performedby using methods as Triangular flap method, RotationalAdvancement flap method or Hotz plate. Kim et alevaluated and discussed the effects of nasoalveolarmolding and cheiloplasty 16. Closure of cleft gap duringalveolar molding was usually due to backward bandingof whole part of greater segment. They addressed nasaldeformity in both unilateral and bilateral clefts primarilyby combined cheilorhinoplasty performed by openmethods approach with delicately repositioning of loweralar rim cartilage 17,18. To improve nasal tip, nasalheight / width and the post operative nasal form afternasoalveolar molding; lip repair methods usingCronin’s Triangular flap method results in significantimprovement 19.All these studies were aimed to achievednasal symmetry post surgically. Nasoalveolar moldingwas the primary method to achieve approximatepositioning and symmetry.

Evaluation in studies of bilateral cleft lip and palateshowed that nasoalveolar molding significantly causeimprovement in columellar lengthening and hencedecreased the chances of later nasal surgeries. Lee andSato Yuki et al emphasized the nasoalveolar moldingas esthetically beneficial and discussed the role indecreasing later surgical need 20,23.Columella lengthshowed relapse in bilateral cleft because of differentialgrowth pattern between the columella and rest of nose

in first and second post-operative years. This was reportedand found to be 1.9mm. According to growth evaluationdata, columella started to increase in length in third yearpost operatively whereas the rest of nasal growth wassignificantly increased in height year by year. In apreliminary study conducted by Betty et al shows thatin Unilateral cleft lip and palate cases relapse in nostrilwidth and height is10% and 29% respectively and angleof columella [5%] at 1year of age 14.Deirdre, Maull, Grayson et al elaborated in their threedimensional study on nasal morphology by digital surfacescanning which pertains presurgical nasoalveolar molding

to be significant and increases nasal symmetry 15.Nasoalveolar Molding was started before the age of sixweeks and correction was done till age of 3 or 4 monthsat which time the primary lip surgery and nasal surgeryis performed. This associated with increase in symmetryand was reported to be maintained up to early childhood.In this context the mean symmetry index was significantto be p<0.05. Detailed considerate analysis withmeasurements reflect that the nasal symmetry achievedby various methods reveal better results in both unilateraland bilateral cleft lip palate cases. Presurgicalorthopaedics brings better maxillary correction.Levy et al discussed the complications with thenasoalveolar molding procedure. Broken appointmentsand Removal by Tongue is reported variably amongwhich tissue irritation and removal by tongue is thepredominant factor. These are collectively overwhelmingconditions but subsequently found to be out weightedby the benefits achieved later 21. Further Pfeifer et al inhis study compared the cost analysis and predictabilyfound that Nasoalveolar Molding have subsequentlyreduced the need of later surgeries 22.fig1 showingpercentage distribution graph:

Fig 1: Graph showing percentage distribution of complications



CONCLUSION

Unilateral and Bilateral Cleft lip and palate havedifferent morphology. Nasoalveolar molding is a pre-surgical treatment used to improve the surgical repairfor both Unilateral and Bilateral Cleft lip and palatecases. Surgical repair alone cannot correct the multipleproblems encountered with the deformities that resultsfrom cleft of the lip and palate. Nasal symmetry ispreferably well achieved by Nasoalveolar Moldingpresurgically in all the above reviewed studies andshowed to be beneficial. An acrylic orthopedic appliancewith nasal stents is made to approximate the cleft andmold the nose, and hence, reducing the amount of surgicalcorrection required during treatment. This methodsymmetrically molds tissues prior to surgery whichincluded closed approximation of alveolar gap, nostrilshape and width improvement. Also nasal tip projectionwith columellar lengthening and alar rim symmetry helpsto improve over all nasal symmetry.

RECOMMENDATION

All the above discussed studies concomitantly haveLimitations as more objective statistical analysis isrequired to predict three dimensional shape changes;also adult groups serving control are not of the same agegroup. Further there is no Long term data available withadequate follow up times related to surgical maneuversor detailing. Randomized trials and systemic reviewsare needed. Currently research studies show inconsistentsample size, and highlighting surgical outcomes moreas compared to orthodontic follow up.

REFERENCES

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15.Maull DJ, Grayson BH, Cutting CB, Brecht LL,Bookstein FL, Khorrambadi D, Webb JA, Hurwitz DJ.Long-Term Effects of Nasoalveolar Molding on Three-Dimensional Nasal Shape in Unilateral Clefts.Cleftpalate-Craniofac J.1999;36:391-97.16. Kim etal. Effect of presurgical nasoalveolar molding(PNAM) appliance and cheiloplasty on alveolar moldingof complete uni la tera l c lef t l ip and pala tepat ients .Korean J or thod.2003; 33:234-245.17. Thomas C. Primary rhinoplasty by open approachwith repair of bi la teral complete c lef t l ip .J Craniofacial Surg.2009;20:1715-8.18. Thomas C. Primary rhinoplasty by open approachwith repair of unilateral complete cleft l ip.J Craniofac Surg.2009;20:1711-4.19. Nakamura N, Sasaguri M, Nozoe E, Nishihara K,Hasegawa H, Nakamura S.Postoperative Nasal Formsafter Presurgical Nasoalveolar Molding Followed byMedial -Upward Advancement of Nasolabia lComponents with Vestibular Expansion for Childrenwith Unilateral Complete Cleft Lip and Palate.Cleftpalate-Craniofac J.2009;67:2222-2231.20. Lee CT, Garfinkle JS, Warren SM, Brecht LE,Cutting CB, Grayson BH. Nasoalveolar MoldingImproves Appearance of Children with Bilateral CleftLip-Clef t Pa la te . P las t ic & Recons t r SurgJ:2008;122:1131-37.21. Levy-Bercowski D, Abreu A, DeLeon E, LooneyS, Stockstill J, Weiler M, Santiago PE. Complications

and solutions in presurgical nasoalveolar moldingtherapy. Cleft Palate-Craniofac J.2009;46:521-8.22.Pfeifer TM, Grayson BH, Cutting CB. NasoalveolarMolding and Gingivoperiosteoplasty Versus AlveolarBone Graft: An Outcome Analysis of Costs in theTreatment of Unilateral Cleft Alveolus. Cleft Palate-Craniofac J.2002;39:26-9.23. Sato Yuki etal. The Effects of Nasoalveolar Moldingfor Cleft Lip and Palate .Japanese Journal of Plastic&Reconstr Surg J.2005;48:255-62.24. Keçik D, Enacar A. Effects of Nasoalveolar MoldingTherapy on Nasal and Alveolar Morphology inUnilateral Cleft Lip and Palate. Journal of CraniofacSurg.2009;20 (6):2075-2080.25. Mitsuyoshi I, Masahiko W, Masayuki F. Simplemodified preoperative nasoalveolar molding in infantswith unilateral cleft lip and palate. Br J of Oral andMaxillofac Surg.2004;42:578-580.26. Vachiramon AT, Groper JN, Gamer S. A rapidsolution to align the severely malpositioned premaxillain bilateral cleft lip and palate patients.Cleft PalateCranio fac J.2008;45:229-31.27. Millard DR Jr. Embryonic rationale for the primarycorrection of classical congenital clefts of the lip andpalate. Ann R Coll Surg Engl.1994;76:150-160.28. Deng XH, Zhai JY, Jiang J, Li F, Pei X, Wang HT.A clinical study of presurgical nasoalveolar moldingin infants with complete cleft lip and palate. ChineseJournal of Stomatology.2005;40:144-6.


nasal symmetry achieved by nasoalveolar ......05 jpda vol. 23 no. 01 jan-mar 2014 nasal symmetry...

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