PNAM- Pre naso alveolar molding

Presented By:
Dr. Saili Chandavarkar
Prosthodontics M.D.S. III
1

DEFINITION
 Cleft palate – A congenital fissure or elongated
opening in the soft and/or hard palate .
OR
An opening in the hard and/or soft palate due to
improper union of the maxillary process and the
median nasal process during the second month of
intra uterine development. GPT 8
2

ROLE OF
PROSTHODONTIST
 Feeding plate
 Presurgical nasoalveolar molding
 Replacement of teeth
 Stabilization of teeth
 Stabilization and or achieving ideal arch
configuration before surgery
 Camouflage for the inadequacy in surgical or
orthopedic treatment
 Fabrication of speech prosthesis
3

 1689: Hoffman demonstrated use of facial binding to
narrow the cleft and prevent post surgical dehiscence.
 1790: Desault used a similar technique to retract the
maxilla before surgical repair in bilateral clefts.
 1844: Hullihen stressed the importance of presurgical
preparation of clefts using adhesive tapes binding.
 Esmarch and Kowalzig used a bonnet and strapping to
stabilize the premaxilla after surgical retraction
5
Grayson BH, Shetye PR, Cutting CB. Presurgical nasoalveolar molding treatment in cleft lip
and palate patients. Clin. Journal, 2005; vol (1):4-7.

 1927: Brophy demonstrated passing of a silver wire
through both ends of the alveolus and tightening to
narrow the cleft.
 1950: McNeil started the modern school of presurgical
orthopedic treatment in CLCP. He used a series of plates
to actively mold the segments into desired position.
 Burston popularized this technique
 1975: Georgiad and Latham introduced a pin retained
active appliance to simultaneously retract the premaxilla
and expand the posterior segments.
6

 1993: Grayson et al described a new technique to
presurgically mold the alveolus, lip and nose in
infants with CLCP.
 1998: Cutting et al described PNAM in detail
7

 1999:Grayson in his article listed four benefits of PNAM:
1. PNAM enables surgeon to perform a gingivoperiosteoplasty;
2. Presurgical alignment and correction of deformity in nasal
cartilage minimize the extent of primary nasal surgery
required;
3. In bilateral cleft deformity, nonsurgical columella elongation
4. PNAM used in conjugation with a modified surgical
approach, allows for a single initial surgical procedure to
address lip-nose alveolar complex and its deformity.
8

 Deidre J. Maull et al (1999) conducted a study to
determine the effect of presurgical nasoalveolar
molding(PNAM) on long term nasal shape in complete
unilateral cleft lip and palate. They concluded that PNAM
increases the symmetry of the nose.
9
Deirdre J. Maull, Barry H. Grayson, Court B. Cutting, Larry L. Brecht, Fred L. Bookstein,
Deljou Khorrambadi, Jon A. Webb, Dennis J. Hurwitz. Long-term effects of Nasoalveolar
Molding on three-dimensional shape in unilateral clefts. Cleft Palate Craniofac J,
September 1999;36(5):391-7.

 Nita Viwattanatipa et al (2001) in the presurgical
orthopaedic phase used an obturator and active lip strapping
followed by a naso-alveolar molding appliance. The first
surgical procedure involved the gingivoperiosteoplasty, lip
and nasal reconstruction, all in one operation. They
concluded that this coordinated treatment brought about
better early esthetics of the soft tissue lip and nose.
10
Nita Viwattanatipa, Palakom Surakulprapa, Bowornsilp Chowchuen.
Bilateral cleft lip and cleft palate. Srinagarind Med J 2001;16(1):54-60.

 Tracy M. Pfeifer et al (2002) conducted a study to compare
the financial impact of two treatment approaches to the
unilateral cleft alveolus, the recently advocated NAM and
gingivoperiosteoplasty at time of lip repair were compared
with traditional approach of secondary alveolar bone graft.
They concluded that the treatment of unilateral cleft
alveolus by NAM and gingivoperiosteoplasty results in
substantial cost savings compared with treatment by
secondary alveolar bone graft.
11
Tracy M. Pfeifer, Barry H. Grayson, Court B. Cutting. Nasoalveolar molding and
gingivoperiosteoplasty versus alveolar bone graft: An outcome analysis of costs in the treatment
of unilateral cleft alveolus. Cleft Palate Craniofac J, January 2002;39(1):26-9.

 Sue Yang et al (2003) brought to light that as a result of
the PNAM appliance, the primary surgical repair of the
nose and lip heals under minimal tension, thereby
reducing scar formation and improving the esthetic result.
12
 Eric Jein-Wein Liou (2004) Their study revealed that the
nasal asymmetry was significantly improved after
nasoalveolar molding and was further corrected to
symmetry after primary cheiloplasty. To compensate for
relapse and differential growth, the authors recommend
(1) narrowing down the alveolar cleft as well as possible by
nasoalveolar molding, (2) overcorrecting the nasal vertical
dimension surgically, and (3) maintaining the surgical
results using a nasal conformer.
Sue Yang, Eric J. Stelnicki, Misook N. Lee. Use of nasoalveolar molding appliance to direct growth in newborn patient with complete unilateral
cleft lip and palate. Pediatric Dentistry 2003;25(3):253-6.
Eric Jein-Wein Liou, Murukesan Subramanian, Phil K. T. Chen, C. Shing Huang. The progressive changes of nasal symmetry and growth after
nasoalveolar molding: A three-year follow-Up study. Plast Reconstr Surg, September 15, 2004;114:858-64.

 Iino Mitsuyoshi et al (2004) reported a new preoperative
nasoalveolar molding for infants with unilateral cleft lip
and palate. The nasal stent of PNAM is made of cobalt
chrome wire with a 3mm diameter loop in the middle of
the stent which enables precise manual control of the force
and direction of the stent with considerable ease. In
addition, this wire is easy to make, prepare and keep clean.
13
Iino Mitsuyoshia, Wako Masahikob, Fukuda Masayukia. Simple modified preoperative
nasoalveolar moulding in infants with unilateral cleft lip and palate. British Journal of Oral
Maxillofacial Surgery 2004;42:578-80.

 Sanjay Suri and Bryan D Tompson (2004)23 conducted a
study to describe a treatment approach for PNAM in unilateral
CLCP. This approach uses 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. Nasal molding
is undertaken after most of the lateromedial correction of the
alveolar position. They concluded that this technique helps to
improve alveolar position, nasal septum alignment, nasal
symmetry, and nasal tip projection prior to lip repair.
14
Sanjay Suri, Bryan D. Tompson. A modified muscle-activated maxillary orthopedic appliance for
presurgical nasoalveolar molding in infants with unilateral cleft lip and palate. Cleft Palate
Craniofac J, May 2004;41(3):225-9.

 Betty Chen – Jung Pai et al (2005)25 conducted a study
that concluded that infants with presurgical nasoalveolar
molding had improved symmetry of the nose in width,
height, and columella angle, as compared to their
presurgical status. There was some relapse of nostril shape
in width, height, and angle of columella at 1 year of age.
 Ziai MN et al (2005)27 conducted a study which
concluded that, in patients with cleft lip and palate with
natal/neonatal teeth who require NAM, the tooth must be
removed to facilitate the fabrication and placement of the
device.
15
Ziai MN, Bock DJ, Da Silveira A, Daw JL. Natal teeth: A potential impediment to naso alveolar molding
in infants with cleft lip and palate. J Craniofac Surj, Mar 2005; 16(2):262-6.
Betty Chen-Jung Pai, Ellen Wen-Ching Ko, Chung-Shing Huang, Eric Jen-Wen Liou. Symmetry of the
nose after presurgical nasoalveolar molding in infants with unilateral cleft lip and palate: A preliminary
study. Cleft Palate Craniofac J, November 2005;42(6):658-63.

 Marcos Jaeger et al (2007)30 developed a within-subjects
study in which 11 infants with unilateral lip deformity and
varying degrees of alveolar gaps were treated by NAM. All
patients obtained significant reduction of the alveolar gap.
The appliance also facilitated primary nasal positioning,
significantly improving nasal symmetry and nostril shape.
 Barry H. Grayson and Pradip R. Shetye (2009)33
discussed the appliance design, clinical management and
biomechanical principles of NAM therapy. Long term
studies on NAM therapy indicate better lip and nasal form,
reduced oronasal fistula and labial deformities, 60%
reduction in need for alveolar bone grafting.
16
Marcos Jaeger, Jefferson Braga-Silva, Daniel Gehlen, Yuki Sato, Ronald Zuker, David Fisher.
Correction of the alveolar gap and nostril deformity by presurgical passive orthodontia in the
unilateral cleft lip. Ann Plast Surg 2007;59:489–94.
Barry H. Grayson, Pradip R. Shetye. Presurgical nasoalveolar moulding treatment in cleft
lip and palate patients. Indian J Plast Surg 2009;42(Suppl.S1):56-61.

 Abida Ijaz, Arsalah Raffat, Junaid Israr (2010)37 conducted
a study to introduce a simple, self-retentive and cost effective
presurgical infant orthopaedic plate with anterior ring to
retract and align the grossly protruded and deviated pre-
maxilla and to perform the nasoalveolar moulding in order to
facilitate initial lip repair.
35 subjects with bilateral CLCP were treated with custom made
orthopaedic plate with an acrylic ring around the protruded
premaxilla for around 3 months.
They concluded that the orthopaedic plate causes significant
retraction of premaxillary segment without applying extraoral
forces. It produces columellar elongation and increase in
prolabium length facilitating the primary cheiloplasty and
rhinoplasty without scarring.
17
Abida Ijaz, Arsalah Raffat, Junaid Israr. Nasoalveolar molding of bilateral cleft of the lip and
palate infants with orthopaedic ring plate. J Pak Med Assoc July 2010; 60(7):527-31.

 Judah S. Garfinkle et al (2011)39 conducted a study to
compare the nasal morphology of patients treated with
presurgical nasoalveolar molding. They concluded that
patients with bilateral cleft lip–cleft palate treated at their
institution with nasoalveolar molding and primary nasal
reconstruction, performed at the time of their lip repair
attained normal nasal morphology through 12.5 years of
age.
18
Judah S. Garfinkle, Timothy W. King, Barry H. Grayson, Lawrence E. Brecht, Court B. Cutting.
A 12-Year anthropometric evaluation of the nose in bilateral cleft lip–cleft palate patients
following nasoalveolar molding and cutting bilateral cleft lip and nose reconstruction. Plast

 V.Shetty et al (2012)42 conducted a study to evaluate
the effects of nasoalveolar moulding (NAM) in
complete unilateral cleft lip and palate infants
presenting for treatment at different ages; propose a
new NAM protocol in these patients; improve the
predictability of NAM. This study validates the use
of NAM in infants presenting late for treatment (at
18 months).
19
V. Shetty, H. J. Vyas, S. M. Sharma, H. F. Sailer: A comparison of results using nasoalveolar
moulding in cleft infants treated within 1 month of life versus those treated after this
period: development of a new protocol. Int. J. Oral Maxillofac. Surg. 2012;41: 28–36.

 Perry van der Heijden et al (2013)47 performed a systematic
review of the literature with the intention of performing a
meta-analysis. They concluded that results of studies of
nasoalveolar molding are inconsistent regarding changes in
nasal symmetry; however, there is a trend towards a positive
effect.
20
Perry van der Heijden, Pieter U. Dijkstra, Cees Stellingsma, Bernard F. van der Laan, Astrid
G.W.Korsten-Meijer, Sieneke M. Goorhuis-Brouwer. Limited evidence for the effect of
presurgical nasoalveolar molding in unilateral cleft on nasal symmetry: A call for unified
research. Plast Reconstr Surg January 2013;131(1):62e-71e.

What is PNAM?
 PNAM is a non surgical method of reshaping the gums, lips
and nostrils before cleft lip and palate surgery, thus
lessening the severity of the cleft.
 Before introduction of concept of nasoalveolar molding,
repair of a large cleft required multiple surgeries between
birth and 18 years of age, putting the child at risk for
psychological and social adjustment problems.
 With advent of PNAM, the dentist can reduce the size of the
cleft and mould the alveolar and nasal tissues in the correct
anatomic position.
21
Habel A, Sell D. Management of cleft lip and palate, Archives of diseases in childhood
1996;74:360-4.

 Principle of 'Negative sculpturing' and 'Passive molding' of
the alveolus and adjacent soft tissues.
 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.
 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.
22
Habel A, Sell D. Management of cleft lip and palate, Archives of diseases in childhood
1996;74:360-4.

Some of the problems that traditional infant orthopedics
failed to address include deformity of nasal cartilages in
unilateral as well as bilateral clefts of lip and palate and
deficiency of columella tissue in infants with bilateral
clefts.
23
Matsuo K. Repair of cleft lip with nonsurgical correction of nasal deformity in the early neonatal
period. Plast Reconst Surg 1989;83:25-31.

 PNAM takes advantage of the flexibility of the
cartilaginous septum in the first few weeks after
birth(caused by high levels of hyaluronic acid found
circulating in infants).
 At this time, it is relatively easy to apply external
traction and by means of controlled forces rotate the
lower part of the premaxilla to a more surgically
advantageous position.
24
Matsuo K. Repair of cleft lip with nonsurgical correction of nasal deformity in the early neonatal
period. Plast Reconst Surg 1989;83:25-31.
Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of lip, alveolus and
palate. Clin Plast Surg 2004;31:149-58.

 The purpose of the traction is not to produce a normal
dental arch form but to facilitate approximation of the
alveolar cleft segments while at the same time achieving
correction of the nasal cartilage and soft tissue deformity.
PNAM improves nasal asymmetry and deficient nasal tip
projection associated with bilateral cleft lip and palate.
25
Adam L. Spengler, Carmen Chavarria, John F. Teichgraeber, Jaime Gateno, James J. Xia.
Presurgical nasoalveolar molding therapy for the treatment of bilateral cleft lip and palate:
A preliminary study. Cleft Palate Craniofac J, May 2006;43(3):321-8.

Objectives and Rationale
 Retraction of premaxilla.
 Alignment of cleft alveolar segments.
 Presurgical elongation of collumella
 Up-righting of collumella
 Correction of nasal cartilage deformity
 Increase in surface area of mucosal
lining.
26
Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of lip, alveolus and
palate. Clin Plast Surg 2004;31:149-58.

Clinical approach
 Evaluation by the interdisciplinary cleft palate team.
 Examination
 Explanation of treatment goals and procedure to
parents
 Impression
 Fabrication of plate
 Pnam activation
 Retentive taping
 Follow up
 Nasal stent addition
 Follow up
 Difference between unilateral and bilateral treatment
29

Impression of intraoral cleft
Material:
 Impression compound/Elastomeric impression material
 Consistent results have ben obtained fastest setting time
polysiloxane material with the Base: catalyst ratio being 2:1.
 Light body wash not used : registration of minute details is
not necessary and it may cause gagging.
 Irreversible hydrocolloid never used: poor tear strength
creates possibility of having small pieces break free occlude
nasal passage or respiratory tree. It also does not provide two
reliable cast from same impression.
30

Technique:
 The infant is fully awake without any anesthesia.
Infant is held face down to prevent aspiration of
regurgitated stomach contents.
 One person cradles the infant securely around the
chest and torso supporting the head and neck,
while another obtains the impression.
 High volume evacuation should be ready.
 Head is gently held in a slightly upright position.
31

 The material should reach the border maxilla,
premaxilla and cleft region. Two much
pressure not required as it would harm the
nasal tissue.
 Excess material in the posterior area should not
block the airway as infants are obligate nasal
breathers.
 Infant should cry while making the impression
which means the airway is patent.
 It should be done in hospital set up and surgeon
should be present.
32

Impression of the nasal region:
 It is not necessary but may be helpful in comparing the pre
and post orthopedic molding results.
 Obtained in clear polyvinylsiloxane.
 Cotton plugs with floss used to prevent material lodging into
deep nostrils.
 Not used for fabricating the nasal stent.
33

Fabrication of the device
 Pour two casts
 Fabrication of prosthesis
 Patients permanent record
 Cleft region of palate and alveolus is filled with wax.
 Cast is lubricated with thin layer of petroleum jelly.
34

 Soft ,resilient, slowly polymerising acrylic
resin is added to the undercut areas of the
cast.
 Remainder of the oral molding plate is
fabricated from clear methyl
methacrylate.
35

Methods of fabrication of the plate
 Heat processed method: waxed in 2 layers of baseplate
wax then packed and lab processed.
 Sprinkle on: porosity, cloudy.
 Preferred method: thick consistency loaded in syringe,
expressed onto the cast in lines. Ensure uniform
coverage. Before the material begins to set place it in
pressure pot at approx. 32 psi,198 F, 10 mins. Reduces
bubbles and residual free monomer.
36

Molding plate
 Borders trimmed
 Oral portion-Highly polished.
 Should be fairly retentive.
 No projection into cleft area.
37

Post insertion
considerations
 Observation: retention, extent posterior,
not too tight fitting, no acrylic in cleft
area.
 Suckling verification, no gagging.
 Molding of the alveolar segments
38

Molding of alveolar
segments
 Desired movement-direct greater segment
inward and lesser segment outward
 Selective removal-1 to 1.5 mm
 Changes made weekly
 Ultimate goal: reduce the gap
39

Method to achieve Pnam:
 Acrylic removal-where one desires
alveolar bone to move
 Permasoft addition-where one desires
bone to be reduced
40

Retentive taping
 Broader base tape-0.5*1.5 inch
 Thin suture strips-0.25*4 inch
42

 Small red orthodontic elastics-0.25 inch diameter.
 Elastics- Stretched to twice the original length
 Force vector: posterior and superior.
 Timings for changing taping
 Adhesive and Adhesive relieving agents
43

Use of retentive taping
 Retention of appliance
 Controlled orthopedic effects
 Alignment of nasal base region
44

Follow up
 Weekly basis
 Progress of molding appliance monitored
 Retention evaluated
 Examination for possible sores
 Monitoring Change in size of defect
 Modification of appliance
45

Nasal stent
•When the size of the cleft is less than 6 mm.
•Causes active nasal cartilage molding.
•Should project passively in nostril.
46

 Base of nasal stent: above the retentive button
 Orientation: nasal tip and the dome on the cleft side
are projecting toward the cleft side and not upward. It
will also serve to bring the columella into more midline
position.
 Outer Permasoft veneering. Blanching occurs at the
nasal tip as infant suckles and activates the appliance.
It also exerts a reciprocal intraoral molding force
against the alveolar segments.
47

Bilateral CLCP
PNAM consists of following phases-
1. Alignment of posterior lateral segments
while retracting and derotating premaxilla
2. Molding the nasal cartilages by
repositioning apices of alar cartilages
towards nasal tip
3. Elongation of columella
4. Addition of nasal stents
5. Horizontal prolabial band or saddle is attached
across the two acrylic nasal stents.
52

Force vector
 Downward force-Surgical tape placed on
prolabium
 Posterior force-from horizontal band
 Upward and anterior force-from nasal
stents.
53

Considerations before
surgery
 Alignment of alveolar segments, nasal
cartilages, columella and philtrum.
 GPP- To close alveolar defect
 Timing for surgery: 2-3 months.
 Evaluation of infant: Rule of 10.
55

Gingivoperiosteoplasty- gpp
 Millard and Latham 1990
 Between 12-16 weeks of age.
 Prior oronasal orthopedics is required.
56
Tracy M. Pfeifer, Barry H. Grayson, Court B. Cutting. Nasoalveolar molding and
gingivoperiosteoplasty versus alveolar bone graft: An outcome analysis of costs in the treatment
of unilateral cleft alveolus. Cleft Palate Craniofac J, January 2002;39(1):26-9.

Post surgical considerations
 Lip is taped for several weeks even after
surgery
 No nasal stent or supporting device is
employed.
57

Surgical nasoalveolar molding
and columellar elongation
58

Complications
 Locked-out Segment: most common
• Hard tissue complication-misdirected
molding
• Successful alveolar molding but lack of
soft tissue support.
• Resulting misshapen corrected
orthodontically.
59
Thomas Tyalor, Complications associated with presurgical nasoalveolar moiding and
columellar elongation. Clinical Maxillofacial Prosthodontics.

 Nostril Over-expansion: most serious
• Soft tissue complication-MEGA-NOSTRIL
• Etiology: gap > 6 mm,
• Force vector
• Precautions
• Treatment: wedge
procedure at initial
surgical repair
60

 Tissue Ulceration
• Etiology
• Precautions
• Treatment: smooth appliance, no sharp
areas, aloe vera cream, tissue lubricant.
61

 Failure to Retain/ wear Appliance During
Oronasal Molding
62

 Failure to Tape Lip Segments
• Consequences: non retentive appliance
and very slow progress in closure.
Minimize the potential of soft tissue
expansion
63

 Exposure of a Primary Tooth
• Retained or Removed-
• Location, Prognosis, Surgical plan
64

Benefits
 Allows controlled, predictable
repositioning without Lip adhesion
surgery or Surgical insertion of pin
retained dynamic molding plate
 Reduction in size of cleft gap-
 One surgical procedure
65

 Allows surgeon to perform a GPP without
need for extensive tissue dissection.
 PNAM used in conjunction with GPP –
 Avoids additional surgery to bone graft
the alveolus
 Reduces need for early nasal revision
surgery.
 EXTREMELY COST-EFFECTIVE
66

 Additional force from nasal stent provides
final push that allows alveolar segments
to meet.
 Intra-oral molding plate provides
foundation that enhances function of
nasal stent.
67

 In Bilateral cleft patient, PNAM
combined with columellar elongation –
 Eliminates need of columellar elongation
surgery.
 No scar at lip-nose-columella.
 Improves the infants ability to feed
68

Limitations
 AGE
 CO-OPERATVE PARENTS
 LABOUR INTENSIVE
 REGULAR VISITS
69

Recent Advances: CAD
NAM
70
Correction of maxillary deformity in infants with bilateral cleft lip and palate using
computer-assisted design. Xin Gong, DDS, MDS, and Quan Yu, DDS, MDS Oral Surg Oral
Med Oral Pathol Oral Radiol 2012;114(suppl 5):S74-S78

The treatment planning and appliance design were accomplished with a
CAD technique, which enabled accurate analysis of the movement
amount in multiple planes.
The digital 3D model of the upper denture was constructed using laser
scanning to make the diagnosis and measurement of the BCLP alveolar
morphology.
The NAM treatment objective could be simulated on Rapidform 2006
software. The guiding principle is the application of constant low-grade
pressure to reshape and reposition anatomic structures.
This method of treatment requires attention with CAD to detail that is at
times 1 mm in dimension. The alveolar segments should be directed to
their final and optimal positions. Force and direction could properly be
controlled.
71

72

73

74
Quan Yu, Xin Gong, Gang Shen evaluated the effectiveness of
computer-aided designed nasoalveolar molding (CAD-NAM) on
maxillary alveolar morphology in infants with unilateral cleft lip and
palate (UCLP). 15 infants with UCLP treated by CAD-NAM therapy
composed the treatment group, and the control group consisted of
15 infants with non-presurgically treated UCLP. The maxillary
morphology was analyzed by Rapidform XOR3 software.
CAD presurgical nasoalveolar molding effects on the maxillary morphology in infants with
UCLP. Quan Yu, Xin Gong, Gang Shen. Oral Surg Oral Med Oral Pathol Oral Radiol
2013;116:418-426

This study suggests a trend toward morphological
improvement in maxillary alveoli of infants with UCLP
treated with CAD-NAM. The CAD-NAM effectively reduced
the cleft gap, corrected the maxilla midline, and improved
the sagittal length of the maxilla. The alveolar height
decreased significantly after the treatment, which indicated
that the traction force of the appliance may have obstructive
effects on the vertical growth of the alveolar bone.
75
CAD presurgical nasoalveolar molding effects on the maxillary morphology in infants with
UCLP. Quan Yu, Xin Gong, Gang Shen. Oral Surg Oral Med Oral Pathol Oral Radiol
2013;116:418-426

PNAM- Pre naso alveolar molding

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