Volume 2 Issue 1

February 2011

Cleft orthopedics

CLEFT ORTHOPEDICS USING LIOUS TECHNIQUE

- A Case Report
Dr.PRASHANTH C.S* , Dr.AMARNATH B.C* , Dr.DHARMA R.M*
Dr.DINESH M.R**
*

PROFESSOR, DEPT OF ORTHODONTICS,

**

PROFESSOR AND H.O.D. DEPT OF

ORTHODONTICS,D.A.P.M.R.V.D.C, BANGALORE

Abstract
The management of patients with cleft lip and palate requires a prolonged
orthodontic treatment and an interdisciplinary approach to achieve optimum
esthetics and function.The rationale of nasoalveolar moulding wherein
alveolar and nasal molding are done at the same time, is that the acquired
maternal estrogen decreases quickly six weeks after birth and there is an
increase in plasticity of cartilages.The device used in nasoalveolar moulding
consisted of an acrylic plate on The case of a newborn female patient with
unilateral cleft lip, alveolus and palate with a marked cleft nose deformity is
presented. This may lead to an unsatisfactory aesthetic result after primary
cheiloplasty and nasoplasty. Five months prior to surgery, the patient was
treated with Naso-alveolar molding of the maxillary arch to which was
attached a wire of 0.032 inch diameter which lifted the nasal dome. The
alignment of the alveolar segments creates the foundation upon which
excellent results of lip and primary nasal surgery are dependent in the repair
of the cleft lip and palate patient. The purpose of this article is to highlight
the effectiveness of naso alveolar molding appliance used to direct growth of
the alveolar ridge, lips, and nose in the pre surgical treatment of cleft lip and
palate. As a result of this appliance, the primary surgical repair of the nose
and lip heals under minimal tension, thereby reducing scar formation and
122 Journal of Dental Sciences and Research

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improving the esthetic result.

Keywords: Naso alveolar molding; pre surgical treatment; unilateral cleft lip
Palate
Journal of Dental Sciences & Research 2:1: Pages 122-131

orthopedics was started by Mc Neil

INTRODUCTION

in 1950.The NasoAlveolar Moulding

Cleft lip and palate are the
most

frequently

congenital

occurring
anomalies.The

technique has been significantly

shown

to

improve

the

surgical

outcome of cleft lip and palate

orthodontic treatment of patients

patients

compared

with clefts is extensive,initiating at

techniques

birth and continuing into adulthood

orthopedics.

of

with

other

presurgical

until the completion of craniofacial

growth.The role of orthodontist in
timing and sequence of treatment

CASE REPORT

is important in terms of overall

Here is a case of a newborn baby

team management.

girl with complete uni-lateral cleft

infant

lip and palate to our department

orthopedics has been widely used

for consultation. She had a nasal

for the treatment of cleft lip and

deformity and a displaced alveolar

palate.The

techniques

segment. The columella and nasal

focused on elastic retraction of

septum were inclined over the cleft

protruding

by

with base deviated towards the

surgical

non-cleft side. In addition, nasal tip

Presurgical

stabilization

early

maxilla
after

followed

repair.The modern school of cleft

appeared

123 Journal of Dental Sciences and Research

to

be

depressed

and

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Cleft orthopedics
displaced. The intraoral cleft gap

one week after birth the infant was

was 8 mm. (Fig 1A&B).

evaluated by the pediatrician and

other members of the cleft team.

The goals of pre-surgical nasoalveolar molding were to align and

Following the clinical examination,

approximate

the

alveolar

cleft

an impression of the intraoral cleft

segments,

to

correct

the

defect

was

made

using

an

malposition of the nasal cartilage

elastomeric material in an infant

and reduce soft tissue deformity by

acrylic

correcting the nasal tip, alar base

impression was taken when the

and the position of phitrum and

infant

columella.1,2,3,4,5,6,7,

position without anesthesia in the

impression

was

outpatient

awake

tray.

in

clinic. The

The

supine

newborns

It has been reported by Matsuo

preoperative orthopedic plate was

(1984)

constructed with auto polymerizing

plasticity

that
of

the
nasal

temporary
cartilage

is

acrylic resin.

believed to be caused by high

levels of hyaluronic acid, which is

The plate was inserted into the

found circulating in the infant for

newborns mouth when she was 16

several weeks after birth.4,8 Matsuo

days old. It covers the palate and

and Hirose (1991) were the first to

alveolar process. Before delivering

make the use of this elasticity in

the plate, the lip segments are

correcting the cleft nose deformity

approximated by applying micro

by inserting a nostril retainer or

pore

conformer

adhesion) (Fig-2A).With the tapes

to

lift

the

nasal

cartilage.8

in

tapes

place

the

(nonsurgical

molding

plate

lip

is

inserted into the mouth. The plate

So it was decided to do nasal

is held on the palate and alveolar

molding as early as possible. At

process through the use of denture

124 Journal of Dental Sciences and Research

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Cleft orthopedics
adhesive as well as using a tape-

This

elastics system applied externally

technique described by Grayson et

to the cheeks (Fig-2B).The nasal

al (1999).5 The intraoral cleft gap

stent and soft denture lining were

was reduced to 3 mm by gradual

added

activations. The soft denture lining

to

the

pre-operative

orthopedic

plate.

movement

of

Controlled

the

alveolar

segments was obtained by tight

of

procedure

the

appliance

is

similar

achieved

to

the

desirable movement of the cleft

region.

positioning of lip segments with a

tape combined with the plate. The

The correction of nasal cartilage

appliance is worn continuously and

and

removed only for daily cleaning.

achieved

Parents were instructed on how to

conformer to the intraoral molding

tape the lips together and maintain

plate.9,10,11 The nasal conformer is

the appliance in place.

composed of a 0.032 inch diameter

columella
by

deformity
adding

was
nasal

stainless steel wire with a hard

The molding plate was modified at

acrylic resin molding bulb on the

weekly intervals to gradually move

top (Fig-2). The wire is bent so

the

to

that the molding bulb is positioned

reduce the cleft gap. This was

inside the nose underneath the

achieved

apex

alveolar

segments

through

the

and

selective

of

the

lower

lateral

alar

grinding of the acrylic from the

cartilage. Parents and caregivers

region into which one desires the

are instructed on how to maintain

alveolar bone segments to move.

the appliance in place. Through bi-

At the same time soft denture liner

weekly adjustments to the wire

is added to the appliance in the

and additions of small amount of

region from where one desires the

hard acrylic resin on the bulb, the

alveolar bone to be reduced.

columella is gradually elongated. At

the same time, tapes-steri strip

125 Journal of Dental Sciences and Research

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Cleft orthopedics
should be applied to press back on

Complications:

the nasolabial side. When properly

Irritation of the cheeks was noticed

taped

some

after the first week due to lip

temporary blanching of the tissue

taping, this was overcome by using

overlying the tip of the molding

Comfeel as a base tape applied

bulb can be observed.

directly to the skin. The tapes used

and

adjusted,

to apply traction where adhered to

At the end of nasoalveolar molding,

these base tapes.

the columella is lengthened and

repositioned

from

an

oblique

CONCLUSION

position into an upright and more

Nasoalveolar molding has proved

midline orientation, which resulted

to

in improved nasal tip projection

therapy for reducing hard and soft

and alar cartilage symmetry. The

tissue

contour of the nostril on the cleft

surgery. However, it is important

side was fashioned to very nearly

that parents or caregivers become

resemble

the

active members of the treatment

unaffected side as the alar tissue

team. Similarly, it is crucial that

was molded into a normal convex

members of the cleft team provide

shape.

the

the

nostril

on

be

an

effective

cleft

deformity

parents

adequate

adjunctive

before

and

caregivers

training,

education,

At the conclusion of nasoalveolar

active support and encouragement

molding the convexity in the alar

during

base, elevation in the nasal tip

treatment.

cartilage and proximity of the lip

caregivers

segments at rest with significant

commitment results in less than

closure of the alveolar cleft gap

ideal clinical outcomes.

was noticed.(Fig-3)
.
126 Journal of Dental Sciences and Research

nasoalveolar
Lack

of

molding
parent

compliance

or
and

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Cleft orthopedics

Fig 1: Cleft nasal deformity; A& B

Prior to naso alveolar molding.Note
the nasal cartilage deformity,wide
alveolar and interlabial cleft
gaps.Short and obliquely deviated
columella C:During active naso
alveolar molding of the unilateral
cleft deformity

127 Journal of Dental Sciences and Research

Cleft orthopedics

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Fig2: Following nasoalveolar molding; A: Note

convexity of alar base,elevation of nasal tip
cartilage and proximity of the lip segments at
rest. B: Elongation of columella, proximity of
alveolar segments

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Cleft orthopedics

A
B

D
C

Fig3: A,B: Post surgical C,D: One year post treatment

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