ORIGINAL ARTICLES

Presurgical Nasoalveolar Orthopedic Molding in Primary Correction of the

Nose, Lip, and Alveolus of Infants Born With Unilateral and Bilateral Clefts
BARRY H. GRAYSON, DDS
COURT B. CUTTING, M.D.

This addendum to the ‘‘State of the Art Dental Treatment of Predental and
Infant Patients With Clefts and Craniofacial Anomalies,’’ by Prahl-Andersen
(Cleft Palate Craniofac J. 2000;37:528–532), offers an extended perspective on
this controversial subject. This article reviews the role of combined nasal and
alveolar (nasoalveolar) molding in the primary correction of the nose, lip, and
alveolus of infants born with unilateral and bilateral clefts. The background of
presurgical nasoalveolar orthopedic molding, the technique, and the literature
are presented. The proposed benefits of treatment from the traditional tech-
niques of presurgical orthopedics have been shown to be unsubstantiated (Ku-
ijpers-Jagtman and Prahl, 1996). A close comparison of the proposed benefits
of earlier forms of presurgical orthopedics, along with those of the current
technique of nasoalveolar molding, is presented.

KEY WORDS: bilateral unilateral cleft lip and palate, gingivoperiosteoplasty, na-
sal stent, nasoalveolar molding, nonsurgical columella elongation,
presurgical orthopedics

The state of the art in clinical methods and the proposed
benefits of presurgical infant orthopedics have changed signif-
icantly from those described by the early proponents of the
technique (McNeil, 1950; Hotz and Gnoinski, 1976; Latham,
1980). In the last decade, it has been shown that correction of
nasal cartilage deformity, stretching of the nasal mucosal lin-
ing, and achievement of nonsurgical columella elongation can
be combined with molding of the alveolar process and gingi-
voperiosteoplasty in patients with clefts and craniofacial anom-
alies (Grayson et al., 1993; Cutting et al., 1998; Grayson et
al., 1999). As in the case of neonatal auricular cartilage (Mat-
suo et al., 1984), active molding and repositioning of the nasal
cartilages take advantage of the plasticity of cartilage in the
newborn infant. The temporary plasticity of nasal cartilage in
the neonatal period is believed to be caused by high levels of
hyaluronic acid, a component of the proteoglycan intercellular
matrix, found circulating in the infant for several weeks after
birth. The combination of nasal and alveolar presurgical infant
Dr. Grayson is Associate Clinical Professor of Surgery (Orthodontics) and
Orthodontist on the Cleft Palate and Craniofacial Anomalies Teams at the In-
stitute of Reconstructive Plastic Surgery at New York University Medical Cen-
ter, New York, New York, and Director of the Lorenz Surgical Orthodontic
Clinical Fellowship and the Stryker-Leibinger Surgical Orthodontic Research
Fellowship Training Programs. Dr. Cutting is Director of the Cleft Palate Team
and Associate Professor at the Institute of Reconstructive Surgery at New York
University Medical Center, New York, New York.
All correspondence should be addressed to: Barry H. Grayson, DDS, Institute
of Reconstructive Plastic Surgery, New York University Medical Center, 560 First
Avenue, New York, New York 10016. E-mail barry.grayson@med.nyu.edu.
orthopedic molding (nasoalveolar molding) has resulted in
measurable long-term benefits to the patient (Cutting et al.,
1998; Santiago et al., 1998; Maull et al., 1999) and in medical
economics (Pfeifer et al., 1998).
UNILATERAL CLEFT LIP AND PALATE
The unilateral cleft lip and alveolar deformity is associated
with significant abnormality in nasal cartilage morphology and
asymmetry of alar base and columella. The lower lateral alar
cartilage is often depressed and concave (Fig. 1a). The goal of
presurgical nasoalveolar molding is to align and approximate
the alveolar cleft segments while at the same time achieving
correction of the nasal cartilage and soft tissue deformity (Fig.
1b). These corrections are achieved by adding a nasal stent to
the labial vestibular flange of a conventional intraoral molding
plate (Fig. 1c). The nasal stent and alveolar molding plate are
adjusted gradually over a period of 3 months to achieve nasal
and alveolar symmetry, nasal tip projection, and contact of the
cleft alveolus just before primary lip, nasal, and alveolar sur-
gical repair (Fig. 1d). The nasoalveolar orthopedic appliance
is held in place with a combination of surgical tapes and elas-
tics applied to the cheeks and cleft lip segments. The presur-
gical reduction in osseous and soft tissue cleft deformity con-
siderably reduces the magnitude of the surgical challenge, re-
sulting in improved surgical outcomes (Fig. 1e and 1f).
The advantages of nasoalveolar presurgical infant orthope-
dics may be considered from a soft tissue perspective as well
as from the usual osseous perspective. The presurgical reduc-

193
194 Cleft Palate–Craniofacial Journal, May 2001, Vol. 38 No. 3

FIGURE 1 Unilateral cleft lip and alveolar deformity. a: Significant abnormality in nasal cartilage morphology and asymmetry of alar base and columella.
The lower lateral alar cartilage is depressed and concave, and the columella is inclined. b: The same infant after presurgical nasoalveolar molding, showing
correction of the nasal cartilage and soft tissue deformity. Close approximation of the relaxed lip segments results in minimum tension in the lip closure.
The alveolar gap has been reduced to passive contact. c: The nasoalveolar molding plate showing a nasal stent extended from the labial vestibular flange
of a conventional intraoral molding plate. d: The nasal stent and alveolar molding plate are adjusted gradually over 3 months to achieve nasal and alveolar
symmetry, nasal tip projection, and contact of the cleft alveolus just before primary lip, nasal, and alveolar surgical repair. The nasoalveolar orthopedic
 Grayson and Cutting, PRESURGICAL NASOALVEOLAR MOLDING IN CLEFT LIP AND PALATE 195

FIGURE 2 Bilateral nasoalveolar molding plate. a: The premaxilla is retracted by using the molding plate in conjunction with external tape and elastics.
Bilateral nasal stents are extended into the nostril aperture from the vestibular flange of the intraoral molding plate. The tip of the nasal stents push forward
on the nasal dome from inside the nose. A soft acrylic band presses back on the lip-columella junction. b: Clinical view (lateral) showing the bilateral
nasoalveolar molding plate in position.

tion in soft tissue and cartilaginous deformity facilitates
achievement of surgical soft tissue repair under minimal ten-
sion and optimal conditions for scar formation. There is also
a reduction in the number and complexity of minor soft tissue
revision surgeries required to maintain acceptable nasolabial
aesthetics as the nose grows (Lee et al., 1999b). The long-term
retention of nasal symmetry achieved by presurgical nasoal-
veolar molding was reported by Maull (1999). Presurgical na-
soalveolar molding was shown to significantly increase sym-
metry of the nose. This increase in symmetry was maintained
into early childhood. Gingivoperiosteoplasty has been shown
to eliminate the need for secondary alveolar bone grafting in
60% of cases treated with presurgical orthopedics (Santiago et
al., 1998). The combined benefits of presurgical nasoalveolar
molding and gingivoperiosteoplasty have been shown to re-
duce the overall cost of therapy from birth to adolescence
(Pfeifer et al., 1998).
Caries in the deciduous dentition were previously reported
to be associated with molding plate orthopedic treatment of
infants with clefts (Bokhout et al., 1996a, 1996b, 1997; van
Loveren et al., 1998; Prahl-Andersen, 2000). These studies
were performed on the same study population of children with
clefts at the University Hospitals in Amsterdam and Rotter-
dam. The orthopedic molding appliances were used from
shortly after birth through 18 months of age. It has been shown
(Van Loveren et al., 1998) that lactobacilli and Streptococcus
mutans required nonshedding surfaces (teeth or acrylic mold-
ing plate) to build up recordable levels. This cleft study pop-
ulation, with a molding plate from birth through the eruption
of the deciduous dentition (18 months), had oral conditions
that were conducive to bacterial colonization. In contrast to
earlier forms of infant orthopedics, unilateral nasoalveolar
molding is concluded by 3 to 4 months of age, and bilateral
nasoalveolar molding is usually completed by 5 months. In
both unilateral and bilateral treatment, the molding plate is not
used after surgery. Therefore, there is a period in which the
mouth is free of all nonshedding surfaces after completion of
orthopedic treatment and before eruption of the deciduous den-
tition at 6 months of age. Thus, children in the nasoalveolar
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.
The effect of presurgical orthopedics on facial growth has
long been of concern and the subject of much clinical research.
Ross (1987) showed in a major multicenter study that there is
no difference in facial growth between cleft patients treated
with or without presurgical orthopedics. Wood et al. (1993,
1997) and Lee et al. (1999b) showed that maxillary growth

appliance is held in place with a combination of surgical tapes and orthodontic elastics applied to the cheeks and cleft lip segments. e: Postoperative frontal
view. The presurgical reduction in soft tissue and cartilaginous deformity facilitates achievement of surgical soft tissue repair under minimal tension and
optimal conditions for scar formation. f: Postoperative basilar view showing nasal tip projection and symmetry.
196 Cleft Palate–Craniofacial Journal, May 2001, Vol. 38 No. 3

FIGURE 3 Bilateral nasal stents entering the nostril aperture. a: Note the horizontal band pressing back at the base of the columella. Tape is applying
force downward on the prolabium. This tape is adhered to the undersurface of the molding plate. b: Clinical view (frontal) showing bilateral nasoalveolar
molding plate in position. The columella is elongated as a net result of pushing forward on the nasal dome, down and back at the base of the columella,
and adhesive traction on the prolabium in a downward direction.

was not inhibited in patients who underwent presurgical or-
thopedic closure of the cleft alveolar gap followed by the pri-
mary gingivoperiosteoplasty described by Millard and Latham
(1990). It is important to recognize that state of the art gin-
givoperiosteoplasty changed in significant ways from its intro-
duction by Skoog (1967) to the more current method of Mil-
lard and Latham. The Skoog technique required extensive sub-
periosteal dissection to achieve soft tissue closure of large alveolar
cleft gaps. The current practice of gingivoperiosteoplasty is pre-
ceded by orthopedic alveolar molding to close the gap and bring
the cleft alveolar segments into passive contact. The strict asso-
ciation of presurgical nasoalveolar molding and alveolar gap clo-
sure allows gingivoperiosteoplasty to be performed, confining
subperiosteal dissection only to the cleft edges. Lee et al. (1999b)
has demonstrated no significant growth disturbance in the first 10
years of growth when the presurgical alveolar gap is reduced to
contact and a conservative Millard-type gingivoperiosteoplasty is
performed in infancy. It is unlikely that the conservative neo-
natal gingivoperiosteoplasty would place this group at any ad-
ditional risk of growth disturbance in the remaining years of
growth when compared with the conventionally treated cleft
population, all of whom should have undergone secondary
bone grafting by the age of 10 years. Thus far, we have not
been able to demonstrate an adverse affect on facial growth to
a mean age of 10 years. Nevertheless, we remain cautious at
this time, because these children have not gone through the
pubertal growth spurt.
BILATERAL CLEFT LIP AND PALATE
The bilateral cleft lip and palate deformity presents addi-
tional challenges for satisfactory surgical repair. The usual sur-
gical approach to the correction of bilateral cleft lip necessi-
tates a two-stage surgical repair of the short or absent colu-
mella and the excessively wide prolabium. Presurgical colu-
mella elongation combined with orthopedic retraction of the

FIGURE 4 Pretreatment and posttreatment views of an infant with bilateral cleft lip and palate. a: Note the nearly absent columella and the depressed
and broad nasal tip. b: The same patient after nasoalveolar molding and nonsurgical columella elongation. Note the presence of normal columella length,
good nasal tip projection, and symmetry of the alar cartilages.
 Grayson and Cutting, PRESURGICAL NASOALVEOLAR MOLDING IN CLEFT LIP AND PALATE
FIGURE 5 The same infant seen in Figure 4b, after primary nasal, labial, and alveolar repair. a: Note the straight line lip closure and absence of scars
in the columella. b: The same patient 3 years and 8 months after primary lip, nose, and alveolar repair.
premaxilla and active alveolar molding has eliminated the need
for the traditional surgical reconstruction of the columella
(Cutting et al., 1998). In the method of nasoalveolar molding
and columella elongation, the posterior lateral alveolar ridges
are molded to an appropriate width to accept the premaxilla.
The premaxilla is retracted by using the molding plate in con-
junction with external tape and elastics.
Bilateral nasal stents are extended into the nostril aperture
from the vestibular flange of the intraoral molding plate (Fig.
2a and 2b). A band of soft acrylic presses against the naso-
labial fold (Fig. 3a and 3b). The combined effect of pushing
the nasal tip forward and pressing back on the nasolabial fold
results in gradual tissue expansion and lengthening of the col-
umella. At the same time, the domes of the lower lateral nasal
cartilages are brought together in the midline, and the intra-
nasal lining is expanded (Fig. 4a and 4b). A surgical correction
of the nose is necessary to remove the fibroadipose tissue that
is deposited between the widely separated nasal dome carti-
lages. The lip repair uses a straight-line approach on either
side. Bilateral gingivoperiosteoplasties are performed if alve-
olar segments are touching at the time of surgery. Tension-free
muscle repair and narrowing of the alar bases is greatly facil-
itated by preoperative premaxillary retraction. The combina-
tion of presurgical nasoalveolar molding and nonsurgical col-
umella elongation allows bilateral cleft lip and nose correction
in a single stage (Fig. 5a and 5b). This has been shown to
result in an improved aesthetic outcome and reduced need for
surgical revision before the age of secondary bone grafting
(Lee et al., 1999a).
As the techniques of presurgical orthopedics have evolved,
so have the proposed benefits from this treatment. Proposed
benefits of traditional intraoral presurgical orthopedics (e.g.,
improved feeding, growth guidance, development of palatal
segments, minimization of treatment at a later age, and nor-
malization of tongue position, resulting in better speech and
positive psychological effect on the parents) were shown to be
not achieved in a recent three-center prospective randomized
clinical trial conducted in the Netherlands (Kuijpers-Jagtman
and Prahl, 1996). In contrast, the current state of the art in
197
presurgical infant orthopedic nasoalveolar molding has five
aims that go beyond the traditional goals of presurgical ortho-
pedics: (1) improved long-term nasal esthetics, (2) reduced
number of nasal surgical procedures, (3) reduced need for sec-
ondary alveolar bone grafts in the majority of patients if gin-
givoperiosteoplasty is included in the protocol, (4) no greater
growth disturbance then is found in cleft patients undergoing
good traditional treatments, and 5) savings in cost to the pa-
tient and society through the reduction in number of surgical
hospital admissions.
REFERENCES
Bokhout B, Hofman FXWM, van Limbeek J, Kramer GJC, Prahl-Andersen B.
Incidence of dental caries in the primary dentition in children with a cleft
lip and/or palate. Caries Res. 1997;31:8–12.
Bokhout B, Hofman FXWM, van Limbeek J, Kramer GJC, Prahl-Andersen B.
Increased caries prevalence in 2.5-year-old children with cleft lip and/or
palate. Eur J Oral Sci. 1996a;104:518–522.
Bokhout B, van Loveren C, Hofman FXWM, Buijs JF, van Limbeek J, Prahl-
Andersen B. Prevalence of Streptococcus mutans and lactobacilli in 18-
month-old children with cleft lip and/or palate. Cleft Palate Craniofac J.
1996b;33:424–428.
Cutting CB, Grayson BH, Brecht L, Santiago P, Wood R, Kwon S. Presurgical
columellar elongation and primary retrograde nasal reconstruction in one-
stage bilateral cleft lip and nose repair. Plast Reconstr Surg. 1998;101:630–
l639.
Grayson BH, Cutting CB, Wood R. Preoperative columella lengthening in bi-
lateral cleft lip and palate. Plast Reconstr Surg. 1993;92:1422–1423.
Grayson BH, Santiago P, Brecht L, Cutting CB. Presurgical naso-alveolar mold-
ing in patients with cleft lip and palate. Cleft Palate Craniofac J. 1999;36:
486–498.
Hotz M, Gnoinski W. Comprehensive care of the cleft lip and palate children
at Zurich University: a preliminary report. Am J Orthod. 1976;70:481–504.
Kuijpers-Jagtman AM, Prahl C. A Study Into the Effects of Presurgical Ortho-
paedic Treatment in Complete Unilateral Cleft Lip and Palate Patients.
Interim Analysis. Nijmegen, The Netherlands: Nijmegen University Press;
1996:23–30.
Latham, RA. Orthodontic advancement of the cleft maxillary segment: a pre-
liminary report. Cleft Palate J. 1980;17:227–233.
Lee C, Grayson BH, Cutting CB, Lin WY. Presurgical nasal molding in bilateral
cleft lip patients—the need for surgical revision before bone grafting age.
The American Association of Orthodontists Annual Session; May 1999a;
San Diego, CA.
198 Cleft Palate–Craniofacial Journal, May 2001, Vol. 38 No. 3
Lee C, Grayson BH, Lin WY, Cutting CB. Long term study of midface growth
in unilateral cleft lip and palate patients following gingivoperiosteoplasty.
Presented at the American Cleft Palate-Craniofacial Association; April,
1999b; Scottsdale, AZ.
Matsuo K, Hirose T, Tonomo T. Nonsurgical correction of congenital auricular
deformities in the early neonate: a preliminary report. Plast Reconstr Surg.
1984;73:38–50.
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. Cleft Palate Craniofac J.
1999;36:391–397.
McNeil CK. Orthodontic procedures in the treatment of congenital cleft palate.
Dent Rec. 1950;70:126–132.
Millard DR, Latham RA. Improved primary surgical and dental treatment of
clefts. Plast Reconstr Surg. 1990:86:856–871.
Pfeifer T, Grayson BH, Cutting CB. Gingivoperiosteoplasty versus alveolar E
bone graft: an outcome analysis of costs in the treatment of unilateral cleft
alveolus. Presented at the 55th Annual Meeting of the American Cleft Palate-
Craniofacial Association; April 1998; Baltimore, MD.
Prahl-Andersen B. State of the art—dental treatment of predental and infant
patients with clefts and craniofacial anomalies. Cleft Palate Craniofac J.
2000;37:528–532.
Ross RB. Treatment variables affecting facial growth in complete unilateral
cleft lip and palate. Part II. Presurgical orthopaedics. Cleft Palate Craniofac
J. 1987;24:24–32.
Santiago PE, Grayson BH, Gianoutsos MP, Kwon SM, Brecht LE, Cutting CB.
Reduced need for alveolar bone grafting by pre-surgical orthopedics and
primary gingivoperiosteoplasty. Cleft Palate Craniofac J. 1998;35:77–80.
Skoog T. The use of periosteum and Surgicel for bone restoration in congenital
clefts of the maxilla. Scand J Plast Reconstr Surg. 1967;1:113–130.
Van Loveren C, Bujis JF, Bokhout B, Prahl-Andersen B, Ten Cate JM. Inci-
dence of mutans streptococci and lactobacilli in oral cleft children wearing
acrylic plates from shortly after birth. Oral Microbiol Immunol. 1998;13:
286–291.
Wood R, Grayson BH, Cutting CB. Gingivoperiosteoplasty and growth of the
midface. Surg Forum. 1993;16:229.
Wood R, Grayson BH, Cutting CB. Gingivoperiosteoplasty and midfacial
growth. Cleft Palate Craniofac J. 1997;34:17–20.