Treatment Goals
- To restore the correct skeletal, cartilaginous, and soft tissue relationship pre-surgically
- To align and approximate the intraoral alveolar segments (greater/lesser segments)
- To correct the malposition of the nasal cartilages
- To correct the nasal tip and the alar base on the affected side(s), as well as the position of the philtrum and columella
Contraindications for Treatment
- Severe systemic deficiencies
- Risk of airway obstruction
- Age of infant
- Parental compliance
- Cost
Timing of Intervention
Timing is very important. The ideal time to begin NAM is 1-2 weeks after birth and before 6 weeks of age. At birth there is a high level of hyaluronic acid in the infant, which begins to fall off after 6 weeks of age. The presence of hyaluronic acid in the body makes molding the tissue and bone more easy. This facilitates the:
- Active reduction of the cleft parts
- Enlargement of the affected nostril (alar)
- Lengthening the area under the nose tip (columella)
- Lenthening of the skin under the nose to the upper lip (philtrum)
- Bringing the upper lip segments together
When these facial areas are restored to a more normal size and position the following surgical connection of these cleft parts is vastly more normal in appearance.
Unilateral Nasoalveolar Molding
In unilateral cases, molding time takes approximately four months.
Bilateral Nasoalveolar Molding
In bilateral cases, molding time takes as long as six months.
At the conclusion of the process, the nasal cartilages, columella, philtrum, and alveolar segments should be aligned to facilitate the surgical restoration of normal anatomic relationships.
Evaluation
At 1-2 weeks after birth an interdisciplinary cleft palate team evaluates the infant. A clinical examination is completed to determine whether or not the infant is a good candidate for NAM treatment.
Fitting
Impression
In a hospital setting, an impression is taken of the infant fully awake. A full upper arch impression is taken to capture the intraoral cleft defect, using a soft putty-type polyvinylsiloxane material in an infant acrylic impression tray. A nasal impression is made to aid in the fabrication of a nasal stent and for comparison of the pre and post nasoalveolar molding results.
Molding Plate
A molding plate is then fabricated and inserted. The infant will wear the molding plate 24 hours a day for approximately 4-6 months. The molding plate causes no pain and is attached with small rubber bands taped to the face.
Molding Plate Adjustments
Adjustments to the molding plate/nasal portion are done weekly, or every other week, depending on the progress. Each adjustment is very small, but the process begins to guide the baby's gums, lip, and nasal cavities as they are growing.
Alignment
One Week
One week after the molding plate with button is delivered it is adjusted fr ulceration or pressure sores.
Plate Adjustments
The plate is then adjusted every 2 weeks. Soft lining acrylic is added on one side and the hard acrylic is removed on the opposite side, actively moving the alveolar segments 2-3 mm/visit.
Cheek Taping
Cheek taping exerts an upward and backward force on the molding plate via orthodontic elastic bands; lip tape compresses the lip segments together.
Cleft Closure
The alveolar cleft is closed to less than 3-4 mm, to attain a better anatomical base, resulting in improved nasal support prior to placement of the nasal stent.
Nasal Stent
At this stage, the nose is molded to support the nasal tip and create tissue expanding forces. At each visit, the stent is modified to impart convexity to the alar cartilages.
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