Korean J Orthod.  2021 Nov;51(6):428-434. 10.4041/kjod.2021.51.6.428.

A modified presurgical alveolar molding technique for treatment of cleft in Down syndrome

• Gonca M
• Ozel MB

• KMID: 2522505
• DOI: http://doi.org/10.4041/kjod.2021.51.6.428

Abstract

Craniofacial clefts are extremely rare deformities. Tessier’s classification is a widely accepted system that is based on clinical, radiographical, and surgical observations. The Tessier No. 0 cleft most commonly affects the upper lip, nose, and palate. This case presentation aims to report the outcome of a modified presurgical alveolar molding (PAM) appliance used in the treatment of an infant with Tessier No. 0 cleft as an alternate approach to mold such defects before surgery. The modified PAM appliance consisted of reciprocal parts connected by a helix. The segments were approximated by stripping the appliance at the midline in a V-shaped manner and the force was exerted by the extraoral elastics. The procedure gave results in 8 weeks, which may be regarded as a reasonable duration. The anterior cleft gap, which was 13 mm before the treatment, was reduced to 3 mm after the treatment by using modified PAM appliance. On a 21-month follow-up period, oral reshaping was regarded successful due to stability of the improved oral mold.

Keyword

Appliances; Cleft lip and palate; Craniofacial anomalies; Functional

Figure

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  Figure 1 Pretreatment photograph.

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  Figure 2 A, Polyvinyl siloxane impression of the infant’s maxilla. B, Stone cast. C, Modified presurgical alveolar molding appliance.

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  Figure 3 Procedure of the modified presurgical alveolar molding (PAM) appliance. A, The purple line demonstrates that PAM appliance consists of two reciprocal parts. B, The red line demonstrates the boundaries of the acrylic area to be stripped. C, The red area demonstrates the acrylic region that has been removed. D, The green area demonstrates the acrylic region where additions were made.

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  Figure 4 Demonstration of the activation of the modified presurgical alveolar molding (PAM) appliance. A, Passive state of the modified PAM appliance after placement. B, Application of the force provided by right extraoral orthodontic elastic to the left surface of the button of modified PAM appliance. C, Application of the force provided by left extraoral orthodontic elastic to the right surface of the button of modified PAM appliance. D, Approximation of the two separate parts of the modified PAM appliance with the forces provided by orthodontic elastics.

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  Figure 5 Two months after modified presurgical alveolar molding appliance therapy.

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  Figure 6 After lip surgery.

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  Figure 7 Twenty-one months after modified presurgical alveolar molding appliance therapy.

Reference

1. Kawamoto HH. McCarthy JG, editor. 1990. Rare craniofacial clefts. Plastic surgery. W.B. Saunders;Philadelphia: p. 2952–5.

2. Ozaki W, Kawamoto HK Jr. Lin K, Ogle R, Jane J, editors. 2002. Craniofacial clefting. Craniofacial surgery: science and surgical technique. W.B. Saunders;Philadelphia: p. 309–31.

3. Rintala AE. 1986; Epidemiology of orofacial clefts in Finland: a review. Ann Plast Surg. 17:456–9. DOI: 10.1097/00000637-198612000-00004. PMID: 3827116.

4. Starck WJ, Epker BN. 1994; Surgical repair of a median cleft of the upper lip. J Oral Maxillofac Surg. 52:1217–9. DOI: 10.1016/0278-2391(94)90551-7. PMID: 7965322.

5. Kawamoto HK, Patel PK. Bentz M, editor. 1998. Atypical facial clefts. Pediatric plastic surgery. Appleton & Lange, cop.;Stamford: p. 175–225.

6. Tessier P. 1976; Anatomical classification facial, cranio-facial and latero-facial clefts. J Maxillofac Surg. 4:69–92. DOI: 10.1016/S0301-0503(76)80013-6. PMID: 820824.

7. Grayson BH, Santiago PE, Brecht LE, Cutting CB. 1999; Presurgical nasoalveolar molding in infants with cleft lip and palate. Cleft Palate Craniofac J. 36:486–98. DOI: 10.1597/1545-1569_1999_036_0486_pnmiiw_2.3.co_2. PMID: 10574667.

8. Grayson BH, Cutting CB. 2001; Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip, and alveolus of infants born with unilateral and bilateral clefts. Cleft Palate Craniofac J. 38:193–8. DOI: 10.1597/1545-1569_2001_038_0193_pnomip_2.0.co_2. PMID: 11386426.

9. Grayson BH, Maull D. 2005; Nasoalveolar molding for infants born with clefts of the lip, alveolus, and palate. Semin Plast Surg. 19:294–301. DOI: 10.1055/s-2005-925902. PMCID: PMC2884748. PMID: 15145660.

10. Grayson BH, Garfinkle JS. Losee JE, Kirschner RE, editors. 2009. Nasoalveolar molding and columella elongation in preparation for the primary repair of unilateral and bilateral cleft lip and palate. Comprehensive cleft care. McGraw-Hill Medical;New York: p. 701–20.

11. Grayson BH, Garfinkle JS. 2014; Early cleft management: the case for nasoalveolar molding. Am J Orthod Dentofacial Orthop. 145:134–42. DOI: 10.1016/j.ajodo.2013.11.011. PMID: 24485726.

12. Matsuo K, Hirose T, Tomono T, Iwasawa M, Katohda S, Takahashi N, et al. 1984; Nonsurgical correction of congenital auricular deformities in the early neonate: a preliminary report. Plast Reconstr Surg. 73:38–51. DOI: 10.1097/00006534-198401000-00009. PMID: 6691074.

13. McNeil CK. 1950; Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec (London). 70:126–32. PMID: 24537837.

14. Georgiade NG, Latham RA. 1975; Maxillary arch alignment in the bilateral cleft lip and palate infant, using pinned coaxial screw appliance. Plast Reconstr Surg. 56:52–60. DOI: 10.1097/00006534-197507000-00011. PMID: 1096192.

15. Hotz M, Gnoinski W. 1976; Comprehensive care of cleft lip and palate children at Zürich university: a preliminary report. Am J Orthod. 70:481–504. DOI: 10.1016/0002-9416(76)90274-8. PMID: 1068633.

16. Gong X, Yu Q. 2012; Correction of maxillary deformity in infants with bilateral cleft lip and palate using computer-assisted design. Oral Surg Oral Med Oral Pathol Oral Radiol. 114(5 Suppl):S74–8. DOI: 10.1016/j.tripleo.2011.08.031. PMID: 23083960.

17. Doruk C, Kiliç B. 2005; Extraoral nasal molding in a newborn with unilateral cleft lip and palate: a case report. Cleft Palate Craniofac J. 42:699–702. DOI: 10.1597/04-134r.1. PMID: 16241184.

18. Monasterio L, Ford A, Gutiérrez C, Tastets ME, García J. 2013; Comparative study of nasoalveolar molding methods: nasal elevator plus DynaCleft® versus NAM-Grayson in patients with complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 50:548–54. DOI: 10.1597/11-245. PMID: 22906392.

19. Bongaarts CA, van't Hof MA, Prahl-Andersen B, Dirks IV, Kuijpers-Jagtman AM. 2006; Infant orthopedics has no effect on maxillary arch dimensions in the deciduous dentition of children with complete unilateral cleft lip and palate (Dutchcleft). Cleft Palate Craniofac J. 43:665–72. DOI: 10.1597/05-129. PMID: 17105327.