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Review Article

Nasoalveolar molding treatment in presurgical infant

orthopedics in cleft lip and cleft palate patients
N. Retnakumari1, S. Divya2, S. Meenakumari3, P. S. Ajith4
1
Professor and Head of Pedodontics, 2Post Graduate Student of Pedodontics, Government Dental College, Kozhikode, 3Assistant Surgeon
(Pediatrician) Taluk Hospital, Ambalappuzha, Alleppey, 4Consultant Surgeon (Plastic Surgery), General Hospital, Changanassery, Kottayam,
Kerala, India

ABSTRACT
The nasoalveolar molding (NAM) technique is a new approach to presurgical infant orthopedics that reduces the severity of the initial
cleft alveolar and nasal deformity. This technique facilitates the primary surgical repair of the nose and lip to heal under minimal tension,
thereby reducing scar formation and improving the esthetic result. NAM technique is the nonsurgical, passive method of bringing the gum
and lip together by redirecting the forces of natural growth. NAM has proved to be an effective adjunctive therapy for reducing hard and
soft tissue cleft deformity before surgery. This paper reviews the basic principles of NAM therapy, various types of appliances used in this
therapy, protocol followed, and a critical evaluation of the advantages and disadvantages of this technique. Universally authors have agreed
the positive outcome of NAM for better esthetics after cleft lip and palate (CLP) repair, but the long-term effects of this therapy are yet to be
substantiated. Despite a relative paucity of high-level evidence, NAM appears to be a promising technique that deserves further research.

Key words: Cleft lip and cleft palate, nasoalveolar molding, NAM protocol, NAM appliances, presurgical infant orthopedics

Introduction left side is most commonly involved in unilateral CL cases.

Cleft lip and palate (CLP) are among the most common types
of birth defects. Two-thirds of all cases of clefting involve
the lip with or without involvement of the palate; whereas,
one-third of all cases occur as an isolated deformity of the
palate. Males predominate within the CLP group (60-80%
of cases); whereas, females constitute the majority within
the cleft palate (CP) group. CLP deformity is strongly
associated with bilateral cleft lips (CLs) (86% of cases);
the association decreases to 68% with unilateral CL. The
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DOI:
10.4103/2321-4848.133804
Interracial differences exist in the incidence of CLP versus
CP. The mean incidence of CLP is 2.1 cases per 1,000 live
births among Asians, one case per 1,000 live births among
white people, and 0.41 cases per 1,000 live births among
black people. A high incidence of the CLP is seen in North
American populations of Asian descent, such as Indians
of the southwestern United States and the west coast of
Canada.[1]
CLP along with nasal deformity is one of the common
anomalies occurring during the embryonic development of
face. By the end of the 4th week in gestational period of human
embryo, bilateral swellings and nasal placodes develop on
the lower part of the frontonasal prominence. The medial and
lateral nasal prominences develop as peripheral thickenings
of the mesenchymal tissue of the nasal placodes, producing
two central depressions, and the nasal pits. Failure of the
nose to develop completely is associated with failure of the

Corresponding Author:
Dr. N. Retnakumari, Professor and Head of Pedodontics, Government Dental College, Kozhikode, Kerala-673008, India.
E-mail: dr.retnakumari@gmail.com

36 Archives of Medicine and Health Sciences / Jan-Jun 2014 / Vol 2 | Issue 1

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Retnakumari, et al.: Nasolveolar molding in presurgical infant orthopedics
nasal placodes to develop. Between the 4th and 8th weeks,
the paired medial nasal prominences fuse with each other,
with the paired lateral nasal prominences, and with cells in
the maxillary prominences. Successful fusion of the medial
nasal and maxillary prominences is essential for continuity
of the upper lip and primary palate. Failure of fusion of one
or both medial nasal and maxillary prominences results in
unilateral or bilateral CL, respectively.
As the face nears the completion of the “developmental
critical period”, from approximately the end of the 6th-8th
intrauterine week, the lateral palatine processes grow out
from the walls of the still common oronasal cavity. Growth
of these paired processes is initially medial, but continues
inferolaterally to lie on either side of the developing tongue.
Nearing the 8th week, palatal shelf elevation begins while
the tongue is depressed downward and forward. Once in
contact, epithelial cells of the palatal shelves degenerate
by programmed cell death uniting the paired processes
in a process known as fusion. Once fusion of the shelves
of the secondary palate occurs, the mesenchymal cells
differentiate, and become osteogenic cells contributing to
the bony development of the premaxillary, maxillary, and
palatine portions of the palate. CP results from the failure
of fusion of these paired lateral palatine processes as a
result of a defect in any of the three major stages of palatal
formation — palatal shelf outgrowth, elevation, or fusion.
Unilateral complete clefts are characterized by disruption of
the lip, nostril sill, and alveolus (complete primary palate).
The deformities seen in relation to CL in these cases are
cupids bow more or less clearly defined, philtral ridge is
ill-defined if not absent, abnormal shortness of the lip
compared with its height on the normal side, fernum of the
vermilion is often hypertrophied, depth of vestibular sulcus
can be outlined only on noncleft side, the cutaneous portion
of the lip is often convex in both vertical and horizontal
directions as the underlying muscles which have lost their
medial insertion tend to draw up into ball of fibers. Nasal
deformities associated are flattening and widening of the
nostril aperture on cleft side, the columella is slanted
towards the affected side, the alar base is slightly everted,
the anterior nasal spine deviated towards normal side, and
tip of the nose is slightly asymmetrical.
In bilateral CLP cases, the cupid’s bow is generally absent
and the cutaneous portion often appears as a convex surface
shaped like a lens. There is no trace of philtral ridge and the
prolabium is usually devoid of properly developed muscle
fibers. The nasal deformities seen are nasal tip flattened and
widened, the columella seems too short, and septal cartilage
is often underdeveloped.[2] The most obvious aspect of a
Archives of Medicine and Health Sciences / Jan-Jun 2014 / Vol 2 | Issue 1
complete bilateral cleft is the protruding premaxilla. Because
of the lack of connection of the premaxilla with the lateral
palatal shelves, the premaxilla has not been “reined back”
into alignment with the lateral arch segments during fetal
development. At the time of birth, the premaxilla protrudes
on a vomerine stem. Uncontrolled growth at the premaxillary
suture results in overprojection of the premaxilla, with or
without rotation, and angulation of the segment. Just as the
premaxilla is not reined back by the lateral palatal shelves,
the lateral palatal shelves are not pulled forward by their
attachment to the premaxilla. Without the intervening
premaxilla to maintain arch width, the lateral palatal shelves
collapse toward the midline. The severity of this disruption
of arch morphology varies and will dictate the tension on the
repair, the degree of dissection required, and ultimately, the
final esthetic result unless it is corrected with presurgical
orthopedics.[3]
The traditional treatment of CLP involves multiple surgeries.[4]
The surgical treatment of CLP has been documented since
AD 317, when Chinese general Wei Yang-Chi had his CL
corrected by cutting and stitching the edges together. As
surgical techniques advanced from the 1800s to 1900s, the
focus shifted to achieving precise muscle closure, delicate
technique, and a better esthetic result.
The concept of presurgical orthopedic cleft molding was
developed to further improve the esthetic result of lip repair.
Use of presurgical orthopedics is recorded as early as the
18th century. The auricular cartilage could be molded with
permanent results if treatment was started within 6 weeks
of life. During this period there are high levels of maternal
estrogen in the fetal circulation which triggers an increase
in the hyaluronic acid. Hyaluronic acid alters the cartilage,
ligament, and connective tissue elasticity by breaking down
intercellular matrix. Levels of estrogen start dropping at 6
weeks of age. Matsuo applied this concept for the correction
of nasal deformities in CL patients. It is on this principle
that the concept of nasoalveolar molding (NAM) works.
It is also suggested that NAM stimulated immature nasal
chondroblasts, producing an interstitial expansion that
is associated with improvement in the nasal morphology
(Chondral Modeling Hypothesis, Hamrick 1999).[6] Grayson
and Shetye developed the concept of NAM, which combined
a nasal molding stent with a passive, presurgical molding
appliance in treating CLP infants.[7]
Terminology
In presurgical orthopedic therapy, orthodontic techniques are
used to mold the maxillary, alveolar, and nasal tissues of an
infant with a unilateral or bilateral CLP. Other terms used for
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Retnakumari, et al.: Nasolveolar molding in presurgical infant orthopedics
these techniques are neonatal infant orthopedics, presurgical
infant orthopedics, and nasal-alveolar molding. Because
the infant does not yet have teeth, the term orthodontics
would be inaccurate; thus, orthopedics is the preferred
term. Presurgical orthopedic devices are a controversial
topic in cleft treatment. With increasing clinical experience,
the long-term outcome and the specific role of presurgical
orthopedics are becoming better defined.[8,9]
What is NAM?
NAM is the nonsurgical, passive method of bringing the gum
and lip together by redirecting the forces of natural growth.
It is nonpainful and easy to use. It also allows for correction
of the flattened nose prior to surgery and facilitates nose
repair at the time of lip repair.[10]
Presurgical NAM works on the principle of ‘negative
sculpturing’ and ‘passive molding’ of the alveolus and
adjacent soft tissues. In passive molding, a custom-made
molding plate of acrylic is used to gently direct the growth
of the alveolus to get the desired result later on. While in
negative sculpturing serial modifications are made to the
internal surfaces of the molding appliance with addition or
deletion of material in certain areas to get desired shape of
the alveolus and nose.[11]
Objectives of NAM technique
• Principal objective of presurgical NAM is to reduce the
severity of the initial cleft deformity which is achieved
by active molding and repositioning of the deformed
nasal cartilages and alveolar processes.[12-14]
• Nonsurgical lengthening of the columella.[13-15]
• Approximation of lip segments to reduce tension in the
tissues after lip repair and thus reduce scarring.[16,17]
• Presurgical NAM is recommended to produce more
favorable bone formation by reducing the size of the
cleft and improving nasal esthetics.[16,17]
• Reduces the need for secondary alveolar bone grafts.[3,14]
The critical factors for evaluating unilateral complete clefts
are the position of the lesser and greater alveolar segments,
the vertical height of the lateral lip element, and the degree
of associated nasal deformity. The alveolar (maxillary)
segments assume one of four positions:
a. Narrow-no collapse;
b. Narrow-collapse;
c. Wide-no collapse; and
d. Wide-collapse.
“Wide” is determined by an alveolus position lateral to the
desired alar base position (i.e., with lip closure the alar
38 Archives of Medicine and Health Sciences / Jan-Jun 2014 / Vol 2 | Issue 1
base is sitting in the cleft). “Collapse” refers to a palatal
displacement of the lateral maxillary segment as predicated
by the arch configuration of the medial, noncleft dental
ridge. Clefts characterized as “narrow-no collapse” with
minimal nasal deformity are treated with presurgical taping
to prevent widening of the cleft with growth and feeding,
prior to a primary CL repair with primary tip rhinoplasty. If a
gingivoperiosteoplasty is to be performed at the same time, a
molding plate can be used to optimize contact of the opposing
alveolar ridges. Clefts characterized as “narrow-collapse” or
“wide-collapse” benefit from presurgical molding to create
the desired arch form, alveolar contact, and nasal anatomy at
the time of surgery. Clefts characterized as “wide-collapse”
or “wide-no collapse” must be assessed closely by the dental
members of the cleft team. If they feel that these cases are
deficient in arch mesenchyme, presurgical orthopedics is
used to align the arch segments by correcting the collapse,
but not to close the alveolar cleft since this will result in a
constricted arch. External taping can be used to correct the
alar base position over the maintained arch form. The use
of presurgical orthopedics or aggressive presurgical taping
has eliminated the need for preliminary lip adhesion surgery
at most centers.[3]
In infants with bilateral clefts of the lip alveolus and
palate, the objective of presurgical NAM includes the
nonsurgical elongation of the columella, centering of the
premaxilla along the midsagittal plane, and retraction of
the premaxilla in a slow and gentle process to achieve
continuity with the posterior alveolar cleft segments.
Additional objectives include a reduction in the width
of the nasal tip, improved nasal tip projection, and a
decrease in the nasal alar base width.[18] The key point of
nasal molding in bilateral clefts is to push the alar domes
forward in a sagittal direction for columella lengthening
instead of pushing the domes upward in a cephalic
direction into a turned-up nasal tip.[19]
Protocol for NAM Therapy
The treatment outcome of presurgical NAM therapy
depends on proper case selection, appropriate appliance
design and proper motivation of the caretakers. Once
the above criteria are met, then the commonly followed
steps in NAM are:
• Impression technique
• Fabrication of appliance
• Insertion of appliance
• Adjustment of appliance
• Incorporation of nasal stent
• Final impression.
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Retnakumari, et al.: Nasolveolar molding in presurgical infant orthopedics
Impression technique
Research reports revealed that various impression
techniques were followed by the clinicians in presurgical
NAM therapy. Grayson and Shetye[7] held the infant upside
down while taking the impression. The impression tray is
inserted into the oral cavity. The infant is held in an inverted
position to prevent the tongue from falling back and to allow
fluids to drain out of the oral cavity. The tray is seated until
the impression material adequately covers the anatomy
of the upper gum pads. He used a heavy body silicone
impression material as it has good tear strength. Prasanth
et al.,[20] and Retnakumari et al.,[21] used heavy body silicone
impression material for taking impression, and the infant
was kept in supine position during the procedure [Figure 1].
Dubey et al.,[11] kept the baby in mother’s lap with head
facing downward and her hands supporting baby’s chest
and lap region while making the impression. Yang et al.,[10]
took alginate impressions using a pretrimmed customized
pediatric tray. Utility wax was employed to avoid any sharp
edges on the tray and to better adapt to the newborn’s
mouth. The impression was taken with the baby in the most
upright position, being held by one of the parents. Alginate
impression when used in thin sections has the disadvantage
of breaking away from the tray when the tray is removed
from the mouth. Such broken pieces may remain in deeper
section of the cleft and may even enter the nasal cavity
making their removal difficult. Karimi et al.,[9] used red
impression compound to take the preliminary impression.
Splengler et al.,[14] took intraoral and extraoral alginate
impression with the patient under general anesthesia. This
method is generally not recommended as the patient is
subjected to hospitalization for an impression procedure.
Fabrication of NAM appliance
The NAM plate described by Grayson and Shetye[7] is made up
of hard, clear self-cure acrylic and is trimmed with a denture
Figure 1: Heavy body silicone impression
Archives of Medicine and Health Sciences / Jan-Jun 2014 / Vol 2 | Issue 1
soft material. A retention button is fabricated and positioned
anteriorly at an angle of 40 degree to the plate. The vertical
position of the retention arm should be at the junction of the
upper and lower lip. The retention button adequately secures
the molding plate in the mouth with the help of orthodontic
elastics and tapes. A small opening measuring 6-8 mm in
diameter is made on the palatal surface of the molding
plate to provide an airway in the event that the plate drops
down posteriorly. This is the most commonly used NAM
appliance.[15,20-23] Various materials have been substituted
for autopolymerizing resin in fabrication of the appliance
by various researchers. They are light-cure polymerizing
material (Yang et al.[10]), heat-cure polymerizing material
(Ma et al.,[4] and Karimi et al.[9]) and thermoplastic base plate
wax (Upadhyay et al.[24]).
Insertion of appliance
The NAM appliance is secured extraorally to the cheeks and
bilaterally by surgical tapes with orthodontic elastic bands
at one end [Figure 2]. The elastic on the surgical tape is
looped on the retention arm [Figure 3] of the molding plate
and the tape is secured to the cheeks [Figure 4]. The elastics
(inner diameter 0.25 inch, wall thickness heavy) should be
stretched approximately two times their resting diameter
for proper activation force of about 100 g. The amount of
force could vary depending on clinical objective and the
mucosal tolerance to ulceration. Additional tapes may be
necessary to secure the horizontal tape to the cheeks.[4,7]
Some authors advice the application of liquid adhesive on
cheeks to secure the Steri tapes for better retention of the
appliance.[10] Denture adhesive and tape-elastic system has
been used by Shetty et al.,[23] for the same purpose.
Adjustment of the appliance
The baby is seen weekly to make adjustments to the
molding plate to bring the alveolar segments together.
These adjustments are made by selectively removing the
hard acrylic and adding the soft denture base material to
the molding plate [Figure 5]. At one visit not more than
1 mm of modification of the molding plate should be made.
Figure 2: Tape with elastics at one end
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Retnakumari, et al.: Nasolveolar molding in presurgical infant orthopedics
Figure 3: Attachment of tape on retention stop
Figure 4: Insertion of appliance
Figure 5: Adjustment of appliance by selective relining and grinding
The alveolar segments should be directed to its final and
optimal position. Care must be taken to prevent the soft
denture material from building up on the height of the
alveolar crest as this will prevent complete seating of the
molding plate.[4,7,10]
40
Incorporation of nasal stent
A silicone nasal conformer suggested by Matsuo and
Hirose[25] can be used as a tool for presurgical nasal molding
when the patient has an incomplete CL. The height of the
conformer can be adjusted by gradually adding some soft
resin or flat silicone sheets on the domes. This is a method
to increase the columella height gradually by adding silicone
sheets to the domes of the nasal stent. It can be used for
presurgical elongation of the columella in incomplete clefts
or postoperative maintenance of the nostril configuration.
There are some limitations in this method. These include
the need for an intact nasal floor (Simonart’s band or lip
adhesion) and the inability to direct the force because the
stent expands circumferentially.
Grayson and Shetye[7] adapted nasal stent to extend from the
anterior flange of an intraoral molding plate. The greatest
advantage of NAM is that it enables the practitioner to apply
force skillfully to shape the nasal cartilage. Because the stent
is extended from a molding plate, an intact nasal floor is not
required. According to the authors, when the alveolar gap
is approximated and the arch is aligned, a nasal molding
device is added to the orthopedic appliance to increase the
columella length as well as to reshape the alar dome. The
stent is made up of 0.36 inch, round stainless steel wire,
and takes the shape of a ‘Swan Neck’. The hard acrylic
component is shaped into a bilobed form that resembles
a kidney. A layer of soft denture liner is added to the hard
acrylic for comfort. The upper lobe enters the nose and gently
lifts forward the dome until a moderate amount of tissue
blanching is evident. The lower lobe of the stent lifts the
nostril apex and defines the top of the columella. The nasal
stent component of the NAM appliance is incorporated when
the width of the alveolar gap is reduced to about 5 mm. The
rationale for delaying the addition of the nasal stent is that
as the alveolar gap is reduced, the base of the nose and the
lip segment alignment is also improved. The alar rim, which
at birth was stretched over a wide alveolar cleft deformity,
will show some laxity; and with the nasal stent, this can be
elevated into a symmetrical and convex form.
In Figueroa’s technique, alveolar and nasal molding are
performed simultaneously using an acrylic plate with rigid
acrylic nasal extension. Rubber bands are connected to
the acrylic plate for gentle retraction of the premaxilla
backward. A soft resin ball attaching to the acrylic plate
across the prolabium is sometimes used to maintain the
nasolabial angle.
The nasal components are made up of 0.028 inch stainless
steel wire projecting forward and upward bilaterally from
the anterior part of the dental plate in Liou’s method.
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The top portion contains a soft resin molding bulb that
fits underneath the nasal cartilages for nasal molding. In
this method also, nasal and alveolar molding was done
simultaneously.[19]
Liao et al., conducted a blinded, retrospective study
[26]
of 58 patients with complete bilateral CLP, 27 patients
received Grayson NAM and 31 patients received Figueroa
NAM. Outcomes were compared by analyzing pre- and
posttreatment facial photographs and clinical charts for
efficacy (columella length ratio, alar width ratio, alar base
width ratio, nostril shape, nasal tip angle, nasolabial angle,
and nasal base angle), efficiency (molding frequency),
and incidence of complications (facial irritation and oral
mucosal ulceration). The results showed that Grayson and
Figueroa NAM similarly improve nasal deformities and
reduce alveolar gaps; however, the Figueroa technique is
associated with less oral mucosal complication and more
efficiency.
In bilateral cases, there is a need for two retention arms
as well as two nasal stents [Figure 6] which are similar
in shape to the unilateral stent. After adding the nasal
stents in the bilateral cleft, the attention is focused on
nonsurgical lengthening of the columella. To achieve this
objective, a horizontal band of the denture material is
added to join the left and right lower lobes of the nasal
stent, spanning the base of the columella. This band sits at
the nasolabial junction and defines this angle as the nasal
tip continues to be lifted and projected forward. The tape
is adhered to the prolabium underneath the horizontal
lip tape and stretches downward to engage the retention
arm with elastics. This vertical pull provides a counter
stretch to the upward force applied to the nasal tip of the
nasal stent. Taping downwards on the prolabium helps to
Figure 6: Nasoalveolar molding (NAM) appliance with two retention
stops and two nasal stents for bilateral cleft lip and palate cases
Archives of Medicine and Health Sciences / Jan-Jun 2014 / Vol 2 | Issue 1
lengthen the columella and vertically lengthens the often
small prolabium. The horizontal lip tape is added after the
prolabium tape is in place.[4]
Splengler et al., in 2006[14] gave the flow chart which shows
the protocol followed by them [Figure 7].
Shetty et al., used the following protocol for presurgical
NAM therapy:[13]
First visit:
Parent education and counseling:
• Use of audiovisual aids and live demonstrations
• Interaction with parents of older NAM patients
• Diet counseling
Detailed documentation:
• Photographs — standard 1:1 ratio frontal and basilar
view
• Dentofacial impressions
• Medical evaluation of patients
Fabrication of NAM appliance:
• >8-10 mm intersegment distance — alveolar molding
• <8-10 mm intersegment distance — NAM
Demonstration of home care instructions:
• Daily appliance care
• Awareness about possible complications and their
management
Telephonic correspondence after 2 days to ascertain parent
and patient compliance
Second visit (1 week subsequent to first visit):
Evaluation of patient and parent compliance.
Figure 7: Protocol used for presurgical NAM therapy[13]
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Retnakumari, et al.: Nasolveolar molding in presurgical infant orthopedics
Detailed documentation:
• Photographs — standard 1:1 ratio frontal and basilar
view
• Dentofacial impressions
Treatment outcome and assessment:
• Compatibility of appliance and required modifications
• <8-10 mm intersegment distance — initiate NAM
• >8-10 mm intersegment distance — aggressive alveolar
molding
Recall visits every 3 weeks:
Evaluation of patient and parent compliance.
Detailed documentation:
• Photographs — standard 1:1 ratio frontal and basilar
view
• Alveolar surface impressions
• Dentofacial impressions recorded prior to primary lip
repair
Treatment outcome and assessment:
• Compatibility of appliance and required modifications
• Nasal molding started at the earliest and continued till
completion
• Active alveolar molding continued till completion
• Passive alveolar molding started once complete
approximation of alveolar segment achieved
• Fabrication of new appliance every 2 months
• Parents participation in periodic NAM workshops.
Active and passive appliances
In literature there is no clear definition of active and
passive appliances used in NAM therapy. The NAM
appliances are classified as into pre- or postsurgical,
active or passive, and intraoral or extraoral. Active
maxillary appliances move alveolar cleft segments in a
predetermined manner with controlled forces; whereas
passive appliances deliver no force, but act as a fulcrum
upon which the forces created by surgical lip closure
contour and mold the alveolar segments in a predictable
fashion.[22]
Donalb[9] states that active appliances are fixed intraorally
and apply traction through mechanical means such as
elastic chains, screws, and plates. Passive appliances
maintain the distance between the two maxillary segments,
while external force is applied to the primarily to reposition
it posteriorly.
Neligan and Buck[27] mentioned that there are two dentofacial
orthopedics passive and active. According to them, passive
42 Archives of Medicine and Health Sciences / Jan-Jun 2014 / Vol 2 | Issue 1
strategies include presurgical NAM and active strategies
include latham appliance which is an intraoral active
appliance custom-made on the infant’s plaster cast of
the palate. It is fixed on the palate by four 0.70 mm
stainless steel pins on each side; a screw activated by the
parent pulls the cleft segments into alignment over 3-6
weeks. Latham appliance facilitates only alveolar molding
without nasal molding. In this article certain appliances
described have an active component. They are modified
muscle-activated maxillary orthopedic appliance used
by Suri and Tompson[22] in NAM therapy; alveolar molding
appliance with expansion screw described by Retnakumari
et al.,[21] in their research report; dynamic presurgical nasal
remodeling intraoral appliance designed by Bennun and
Figueroa;[28] and self-retentive appliance with orthodontic
wire used by Kamlesh Singh et al.,[29] in presurgical infant
orthopedics.
Modified muscle-activated maxillary orthopedic
appliance
Suri and Tompson[22] used a plate held in with outriggers,
which prevents the cleft-widening effect of the tongue,
helps with tongue tip placement, and utilizes the functional
movements of the facial musculature to guide and relocate
the major segment medially to its normal position in unilateral
CLP cases. Nasal molding is undertaken after most of the
lateromedial correction of the alveolar position. Stainless
steel wire outriggers are bent in situ, which emerge from
the cleft between the lip margins, and are gently contoured
at an angle upward to end in oblong terminal loops lying
beyond the modiolus region. The loops are bent in such a
fashion that their long axes are roughly at right angles to an
imaginary line extending from the lateral lip commissures
to the superior surface of the helix of the external ear. This
modified technique, which amalgamates nasal molding with
a muscle-activated alveolar molding infant orthopedic plate,
helps to improve alveolar position, nasal septum alignment,
nasal symmetry, and nasal tip projection prior to the primary
lip and nasal surgical repair.
Dynamic presurgical nasal remodeling
The newly designed intraoral appliance by Bennun and
Figueroa[28] consists of two elements: A perfectly adapted
conventional acrylic intraoral plate, which is left loose in
the mouth of the neonate, and a dynamic nasal bumper
attached to the vestibular flange of the intraoral plate.
It is placed lateral to the plate midline, in line with the
lip and alveolar cleft. In bilateral cases, two stents are
used. The nasal stent has a directional component which
is made of a U-shaped wire that can easily be bent. The
two free ends are secured to the plate, and the base of
the ‘U’ of the directional wire holds a soldered, vertical
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Retnakumari, et al.: Nasolveolar molding in presurgical infant orthopedics
stainless steel bar or stent 2 mm in diameter. A dynamic
component, a stainless steel open coil spring (2.2 mm
diameter), is inserted over the stent. It is used to regulate
the impact force and to reduce rebound of the nasal
extension or bumper. The coil exerts a force of 70 g/m for
each millimeter of compression. The coil is approximately
3 mm longer than the stent. Full compression of the
stent can generate a force up to 210 g/m. A remodeling
silicone component (bumper) is mechanically attached to
the cranial aspect of the open coil spring. It is in direct
contact with the intranasal soft tissues. It was designed
to avoid soft tissue lesions in the delicate nasal mucosa
and to obtain a superior remodeling effect of the nasal
structures.
Active alveolar molding appliance [Figure 8]
A new approach in presurgical infant orthopedics using
an alveolar molding plate with an expansion screw (Jack
screw) fully opened, incorporated into the appliance.
This formed the active component of the appliance for
retraction of the protruded premaxilla. The anterior
component of the appliance was fabricated with two
retention stops. These retention stops facilitated the
attachment of elastic traps on both sides. The appliance
was activated by closing the expansion screw and by
selective grinding and relining with denture base material.
The premaxilla was retracted and the cleft gap was
reduced with the use of this active alveolar molding
appliance within 3 months. This enabled better esthetic
results after surgery by reducing tissue tension and scar
formation.[21]
NAM with self retentive plate
Ijaz[12] in his study on unilateral CLP cases used a custom-
made orthopedic plate incorporating nasal stent, made
from self-cure acrylic on the labial vestibular flange of the
orthopedic plate. The nasoalveolar orthopedic plate was
Figure 8: Active alveolar molding appliance with expansion screw
Archives of Medicine and Health Sciences / Jan-Jun 2014 / Vol 2 | Issue 1
made self-retentive by adding soft acrylic on its palatal
surface in the defect part. There was no need of any extra
oral attachment As suggested by Grayson and Shetye[7]
for retention of the appliance. The palatal surface of this
orthopedic plate was adjusted fortnightly by adding over 1
mm of hard acrylic along the entire palatal surface, around
the soft acrylic, followed by insertion and adaptation of
the palate. Adhesive Steri strip 1/4´ 4 inches was applied
extraorally to facilitate approximation of the CL and
alveolar segments.
Karimi et al.,[9] used a prosthesis made with a heat-cure
acryl with a 3-4 mm extension into the nasal chamber. Most
retention was assumed to be provided form palatal shelves
of maxilla and nose chamber. Pronounced extension into
the nasal chamber was avoided to reduce the risk of airway
obstruction. As the details of inner nasal alar anatomy
would not be recorded satisfactory; this part of prosthesis
was molded again using tissue conditioner to ensure the
maximal fitness. Five adjustment sessions were performed
in every other day. A week after the prosthesis was delivered
to the parents, two crossed straps which were secured to a
head cap at the sides were added to augment the posterior
protraction of the displaced premaxillary segment and
corresponding soft tissue.
Ijaz [30] designed a custom made orthopedic plate
incorporating a self-cure acrylic ring around the protruding
premaxilla. The plate was made self-retentive by addition
of soft acrylic on its palatal surface, filling the cleft area.
This innovative self retentive plate was made up of acrylic
which comprised of two parts; the palatal plate covered
the palatal defect and served as a passive obturator and
the anterior part of the plate extended as a ring around the
protruded and deviated premaxilla. This ring acted as an
active part to align and retract the malposed premaxillary
segment.
The modified appliance used by Kamlesh Singh et al.,[29] is
nearly the same as described by Grayson and Cutting except
that they used an orthodontic wire covered the nasal tip
cartilage, proximity of the lip segments, and convexity in
the alar base with an acrylic bulb to give pressure for active
molding. This appliance does not need any further addition
of acrylic every week, only wire angle is increased a bit to
increase the pressure exerted.
Discussion
NAM is used effectively to reshape the nasal cartilage and
mold the maxillary arch before CL repair and primary
rhinoplasty. Nasal deformity in infants with nasolabial clefts
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Retnakumari, et al.: Nasolveolar molding in presurgical infant orthopedics
persists if it is not actively corrected. The principle objective
of presurgical NAM is to reduce initial cleft deformity. This
enables the surgeon and the patient to enjoy the benefits
associated with repair of a cleft deformity. The goals of
PNAM are to align the intraoral alveolar segments and
correct the nasal tip, the alar base, the philtrum, and the
columella.
Advantages of NAM technique
NAM device approximates the alveolar segments as close
as possible before surgery and brings the premaxilla
back into the position of the alveolar arch in bilateral
clef t patients. [14,30] When combined with primar y
gingivoperiosteoplasty (GPP), this potentially results
in a reduced need for alveolar bone grafting during the
mixed dentition period. In addition, there are several
other advantages to using a prosthetic device to place a
premaxilla in a more anatomically correct position before
surgical closure of the lip. First, soft tissue will be carried
with the segment, leading to a decrease in the width of
the defect.[13,15] Second, a centrally positioned premaxillary
segment provides a more ideal base for lip closure.[12,16] It
decreases tissue tension during the surgical procedure,
and finally, it allows healed soft tissues to rest against
a more normal bony anatomy. If the premaxilla is not
repositioned in these extreme cases, excessive tension
may develop at the surgical site, which compromises the
surgical result. By using orthopedic therapy, a second
operative session may be eliminated, thereby decreasing
total hospitalization time and cost. Besides the intraoral
advantages of NAM, there are also significant benefits
in helping to correct the external nasolabial deformities.
In unilateral cleft patients, the nasal stent is positioned
so that the columella and septum are molded to a more
vertical and upright position.[13] This will help correct the
deviation of the columella base to the noncleft side. With
careful adjustments, the alar cartilage can be molded
into a more normal convexity and bilateral symmetry
can be achieved without additional soft tissue surgery
or scarring.[4]
Disadvantages of NAM
The disadvantages mentioned by various researchers are
locked out segment, nostril overexpansion, irritation to skin
and mucosa, exposure of primary tooth bud, obstruction of
airway due to dislodgement of NAM appliance, and relapse
of the molded cartilages though not entirely to some extent
back to the original position.
Locked out segment
The most common hard tissue complication associated
with the presurgical NAM device is misdirected molding
44 Archives of Medicine and Health Sciences / Jan-Jun 2014 / Vol 2 | Issue 1
of the alveolar segments. This only results if there is poor
management of the molding process. It may be remedied
through corrective molding if recognized early. If the
greater segment is directed posteriorly more quickly
than the lesser segment advances outward, the cleft may
close with the lesser segment locked behind the greater
segment.[5,7,31]
Meganostril/nostril overexpansion
A potential soft tissue complication would be overexpansion
of the alar rim as a result of premature stenting before
sufficient closure of the cleft gap (5 mm). Again, direction
of tissue expansion and progress must be monitored on a
weekly basis to avoid this occurrence.[4,5,31]
Soft tissue irritation
The most common problems observed during NAM therapy
are irritation to the oral mucosa, gingival tissue or nasal
mucosa. Intraoral tissues may ulcerate from excessive
pressure applied by the appliance. These are commonly
found in the oral vestibule and on the labial side of the
premaxilla. The oral and the nasal cavities of the infant
should be carefully examined on each visit for ulceration
and appropriate adjustments should be made to the
molding plate to relieve sore spots. The intranasal lining
of the nasal tip can become inflamed if too much force is
applied by the upper lobe of the nasal stent. The area under
the horizontal prolabium band can become ulcerated if the
band is too tight.[20,21]
Another area of tissue irritation is the cheeks. Extreme care
should be taken while removing the cheek tape to avoid any
irritation to the skin. Skin barrier tapes like TegadermTM
are recommended. Slight relocation of the position of the
tape during treatment is also recommended to provide
rest to the tissues in case they become irritated. It is also
recommended that an aloe vera gel be applied to the cheeks
when changing tapes.
Exposure of primary tooth bud
Sometimes exposure of primary tooth bud may occur due
to the pressure applied during active molding.[31]
Obstruction of airway
If there is no proper retention, the appliance may dislodge
posteriorly and obstruct airway, for this always a hole should
be incorporated in the appliance in center of palatal region
of the molding plate.[4]
Relapse
Pai et al.,[32] has reported that patients who have received
NAM therapy has relapse of nostril shape in width (10%),
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Retnakumari, et al.: Nasolveolar molding in presurgical infant orthopedics

Table 1: Studies in relation to nasoalveolar molding (NAM) in unilateral cleft lip and palate
Author Objective
Maull et al.,[33] (1999) To evaluate the long-term
effectiveness of presurgical NAM
(PNAM)
Pai et al.,[32] (2005) To assess nostril symmetry and
alveolar cleft width in infants
with unilateral cleft lip and palate
following PNAM
Ezzat et al.,[6] (2007) To evaluate the outcome of PNAM
Aboul Hassan et al.,[15] To evaluate the outcome of PNAM
(2010) therapy
Ijaz[12] (2011) To introduce an effective, simple,
and cost-effective NAM appliance
Clark et al.,[16] (2011) To evaluate the long-term
effectiveness of presurgical NAM
Shetty et al.,[13] (2012) Comparison of results using NAM in
cleft infants treated within 1 month
of life versus those treated after
this period
Sample size Results Unique aspects
10 patients who had undergone Mean asymmetry index for NAM group was 0.74; Effectiveness of NAM compared with alveolar
NAM, 10 patients who had whereas, control group was 1.21 molding
undergone alveolar molding alone
57 patients treated with NAM Infants with PNAM improved symmetry of the nose Assessed the relapse of the corrections achieved
in width, height, and columella angle, as compared to with NAM at 1 year of age
their presurgical status. There was some relapse of
nostril shape in width (10%), height (20%), and angle of
columella (4.7%) at 1 year of age
Twelve patients with UCLP There was a statistically significant decrease in both PNAM therapy decreases intersegment alveolar cleft
treated from 1997 to 2003 intersegment alveolar cleft distance and columella distance while permitting an increase in posterior
deviation (P<0.05). There was also a statistically maxillary arch width. The improvement of the height
significant increase in cleft nostril height, maxillary width, of the cleft nostril was correlated with the time the
and columella width (P< 0.05). Moreover, although appliance was applied
there was no statistically significant reduction of the
affected nostril width, it demonstrated on average
1.7-mm reduction after PNAM therapy. The length of the
time the patient utilized the appliance and post molding
nostril height were found to have a statistically significant
positive correlation (P<0.05).
Fifteen patients, with average Narrowing of the interalveolar distance by more than Very short period of activation - 55 days
age 2 weeks 3.3 mm after PNAM. The nasal deviation angle improved
by >25 degrees in all cases. Pre-NAM alveolar distance
average is 7.333+1.291 post NAM alveolar distance
average is 4.067+0.961
32 neonates (18 males and Anterior cleft gap was reduced to 11.065 mm showing The appliance being self-retentive is comfortable to
14 females), age ranging from a post moulding reduction of 2.215 mm. The intercanine wear. Extraoral attachments are not needed
3 days to 12 days width however, showed a reduction of 1.718 mm after
moulding. Intermolar width, more or less remained the
same (0.156 mm) after NAM. Angular measurement was
made to record derotation or alignment of major cleft
alveolar segment. With this appliance, the major segment
showed 7.359 degree rotation after alveolar moulding
20 patients PNAM and Clinically, the improvement in the PNAM group was most Long-term follow-up
5 patients non-PNAM therapy evident in nasal and lip anatomy. However, there were
no statistically significant differences between the two
groups on each of the measurements on three-dimensional
facial images and dental models
Group I (n=15) treated with Group I patients demonstrated 81, 198, 69, and 145% Although the results in group II patients were inferior
NAM within 1 month of age; improvement in intersegment distance, nasal height, nasal to those of group I patients the relative improvement
group II (n=15) treated with dome height and columella height respectively; whilst in nasal dome height (69%), intersegment distance
NAM between 1 and 5 months group II patients demonstrated 51, 33, 21, and 38% (51%), columella height (38%), and nostril height
of age. Control: Group III improvement for the same. At 18 months, group I patients (21%) deserves a mention. This improvement
(n=15) comprised of noncleft closely resembled group III patients validates the use of NAM in infants that present for
18-month-old children treatment as late as 5 months of age

height (20%), and angle of columella (4.7%) at 1 year Conclusion

of age.
It is imperative that parents become active members of the
treatment team. If the appliance is lost or not worn, a cleft
gap that had been closed early during molding therapy may
widen again as the infant places his or her tongue into the
cleft. Compliance is an essential factor with this method of
treatment.
Many studies [Tables 1 and 2] have been performed to assess
the outcome of NAM. Universally authors have agreed the
positive outcome of NAM for better esthetics after CLP are
repaired. But the long-term effects of this therapy are yet
to be substantiated.
The NAM technique has been significantly shown to improve
the surgical outcome of CLP patients compared with other
techniques of presurgical orthopedics. NAM has proved
to be an effective adjunctive therapy for reducing hard
and soft tissue cleft deformity before surgery. However,
it is important that parents or caregivers become active
members of the treatment team. Similarly, it is crucial
that members of the cleft team provide the parents and
caregivers adequate training, education, active support, and
encouragement during NAM treatment. Lack of parent or
caregivers’ compliance and commitment results in less than
ideal clinical outcomes. Despite a relative paucity of high-
level evidence, NAM appears to be a promising technique
that deserves further study. The long-term effectiveness of

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Retnakumari, et al.: Nasolveolar molding in presurgical infant orthopedics

Table 2: Studies in relation to nasoalveolar molding (NAM) in bilateral cleft lip and palate
Author Objective Sample size Results Unique aspects
Splengler et al.,[14] To evaluate the outcome of presurgical NAM 8 patients with average age Intraoral measurements demonstrated that there was Very long treatment time of
(2006) (PNAM) therapy of 34 days a statistically significant reduction of the premaxillary 212 days
protrusion and deviation. There was also a significant
reduction in the width of the larger cleft. Extraoral
measurements revealed that there was a significant
increase in the bi-alar width and in the columella
length and width. Moreover, there was a significant
improvement in columella deviation. Finally, the nostril
heights of both sides were increased
Mishra et al.,[34] (2010) To evaluate the role of PNAM in correction of cleft 23 cases having either Nostril height was more in patients of experimental group Unilateral cleft lip had more
lip nasal deformity for patients with unilateral and unilateral or bilateral cleft lip (P=0.18), while nostril width and alar perimeter were not reduction in alveolar gap than
bilateral clefts of the lip and palate changed significantly. Children with NAM had significant bilateral group
lengthening of columella (P=0.02). Patients of unilateral
cleft lip had more reduction in alveolar gap (P=0.08) than
bilateral group (P=0.15)
Ijaz[30] (2010) To introduce a simple, self-retentive, and cost- 35 subjects (27 males, Retraction of premaxillary segment to be 3.80±1.3 mm. Self-retentive plate, cost-effective,
effective presurgical infant orthopedic plate with 8 females) with a median age Derotation of the premaxilla was recorded as 5.41±7.4 avoids traumatic, and cumbersome
anterior ring of 7 days (1-13 days) degrees; whereas, septum deviation was 1.67±1.48 use of appliance
degree. The increase in columella as well as prolabium
length recorded was 2.24 and 1.85 mm, respectively.
Intercanine width was increased by 0.78 mm after
moulding. The intermolar width however showed an
increase of 1.02 mm. The downward movement of
premaxilla measured from the cast was 2.92±2.3 mm
Liao et al.,[26] (2013) To compare outcomes of two NAM techniques 27 received Grayson NAM, Grayson and Figueroa NAM did not differ in treatment Both Grayson and Figueroa NAM
(Grayson and Figueroa techniques) 31 received Figueroa NAM efficacy for columella length ratio, alar width ratio, alar similarly improve nasal deformities
base width ratio, nostril shape, nasal tip angle, nasolabial and reduce alveolar gaps;
angle, and nasal base angle. Grayson NAM was less however, the Figueroa technique is
efficient, that is, required more adjustments (10.8±4.1 associated with less oral mucosal
vs 7.6±1.5, P=0.001), and had a higher incidence of oral complication and more efficiency
mucosal ulceration (26 vs 3%, P<0.05)

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How to cite this article: Retnakumari N, Divya S, Meenakumari S, Ajith PS.
Nasoalveolar molding treatment in presurgical infant orthopedics in cleft lip
and cleft palate patients. Arch Med Health Sci 2014;2:36-47.
Source of Support: Nil, Conflict of Interest: None declared.
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