Cleft Lip and Palate Treatment with Nasoalveolar Molding, Orthodontics and Periodontally Assisted Osteogenic Orthodontics

What is cleft lip and cleft palate?

Cleft lip and cleft palate is a facial malformations in which with sides of the face and skull that form the upper lip and mouth remain separated, instead of ‘stitching’ together in very early gestational development. These splits can also occur in the roof of the mouth, which is called the bony or hard palate.

Though the defect occurs in early fetal development, in the majority of cases, the cause is associated to genetic and environmental influence that exposures during pregnancy.

Aside from aesthetics, this defect can affect people in even more serious ways:

Difficulty eating:

When there is a separation or opening in the hard and/or soft palate, food and liquids can pass from the mouth back out through the nose. While waiting for surgery, patients are often prescribed a custom prosthetic to keep fluids flowing downward toward the stomach, and ensure they receive adequate nutrition.

Speech difficulties:

Because of the malformed upper lip and palate, it can be difficult for children to speak clearly. When they do, it may produce a nasal sound. For these reasons a speech pathologist may be called upon to help resolve these issues.

Ear infections:

Having a cleft lip and palate can lead to a buildup of fluid in a child’s middle ear, leaving them at a higher risk for ear infections, and, if not properly treated, even deafness. To help prevent infections stents may be placed in the eustachian tubes to facilitate fluid drainage.

Dental problems:

Children with cleft lip and palate also often have missing, malformed, or displaced teeth, which can lead to a higher number of cavities and other dental and orthodontic issues.

How is CLP treated?

Infancy: Presurgical orthopedics

Presurgical infant orthopedics is sometimes used to relocate the segments of the cleft in maxilla prior to lip repair. A custom-fitted orthodontic appliance is applied to bring the parts of the lips, upper jaw, and nose closer together. This is called Nasoalveolar Molding (NAM). These appliances can make lip closure easier.

Nasoalveolar Molding (NAM)

Nasoalveolar Molding is a pre-surgical method of reshaping the gums, lips, and nose before cleft lip and palate surgery, to lessen the severity of the cleft. NAM is used mainly for children with large clefts and the technique has revolutionized cleft repair. It is part of a field of sub-specialty referred to as Craniofacial Orthodontics, which is part of a larger specialty of Craniofacial Orthopedics, which is in turn part of the overall treatment for CLP.

The goals of repair of cleft lip and palate are to:

help patients to develop normal speech;
restore dentition and oral functions;
improve hearing;
minimize facial difference;
attain social acceptability of cleft individuals
increase assimilation into society (psychological support); and
restore/reconstruct facial and oral anatomy.

There are some medical specialists who disagree with using NAM or other pre-surgical orthopedic methods, stating the cost and overall burden on the parents, as well as limited positive long-term outcome. They do agree that infants who undergo NAM or other PSO treatment do look better than those who do not. Of course, that can significantly impact how people respond to and interact with the child, and, therefore, the shaping the child’s perception of themselves.

Since the CLP patient will be under lifelong multi-disciplinary care, it is the opinion of this practice that any advantage gained for the patient is worthwhile. But, parents of the CLP infant should be well-informed and allowed to make the best decision for them and their child.

What exactly does NAM do?

[Excerpt from “Presurgical cleft lip and palate orthopedics: an overview” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5459959/ ]

‘NAM is a technique utilizing a nasal stent attached to the intra-oral mouth plate, and is designed to improve nasolabial anatomy. It is reported that columella (the portion of septum that extends beyond the edge of the nostril) lengthening, reduction in alar asymmetry (the nostril roundness), and recovery of nasal tip projection can be achieved. The use of nasal stents in bilateral CLP in combination with lip tapes and elastics can lengthen the deficient columella. It has been proven that NAM improved surgical outcome for cleft patient, as it is effective in reducing hard and soft tissue deformity.’

Naso alveolar molding appliance.

[ Excerpt from “Cleft Lip and Palate Patients: Diagnosis and Treatment” https://www.intechopen.com/books/designing-strategies-for-cleft-lip-and-palate-care/cleft-lip-and-palate-patients-diagnosis-and-treatment ]

During primary dentition

Midfacial deficiency (gaps) is a common feature of cleft lip and palate patients due to scar tissue of the lip and palate closure. During deciduous (‘baby teeth’) dentition, frequently, no orthodontic and orthopedic treatments are given because it has limited advantage for many patients. Orthodontic and orthopedic intervention typically starts in the mixed dentition stage of a patient’s life.

During mixed dentition

Early orthopedic treatment in cleft palate children is essential because the maxillary bones and their component parts may be moved and altered in young children with relative ease and thereby creating a more functional dental arch.

It is during this stage of a CLP patient’s life that the most effective and long-lasting results will be achieved using advanced orthodontic techniques and periodontally assisted osteogenic orthodontics.

Permanent dentition

Comprehensive fixed appliance therapy usually occurs in the permanent dentition stage with the aim of preparing for alveolar bone graft that can be done by an oral surgeon. This phase usually involves the alignment of malposed maxillary incisors. Reverse pull headgear or face mask therapy, expansion of maxillary arch may be continued during this time period. Final alignment of teeth is carried over with or without extraction. Orthodontic management is limited after eruption of permanent dentition. The established malocclusion and discrepancy between the upper and lower arch often require orthognathic surgery.

Cleft is the most common craniofacial malformation that an orthodontist may encounter, and involves a complex treatment plan spanning the patient’s life from infancy into adulthood.

The orthodontist’s role in the cleft lip and palate team requires close relationship with the other team members all working to achieve the best outcome for the patient. The most common specialties involved in the care of a child with a cleft are: oromaxillofacial surgeon, plastic surgeon, psychologist, orthodontist, general dentist, otolaryngologist, speech therapist, pediatrician, and prosthodontist.

Thanks to NAM and other advances in surgical and orthodontic treatments, a child born with a cleft now has excellent chance of living a much more normal life, and enjoying a more normal childhood than before.

For further reading on the topic, please see the links below.

SOURCES