Journal of Advanced Clinical & Research Insights (2014), 1, 108113

REVIEW ARTICLE

Nasoalveolar molding: Areview

S.M. Laxmikanth, Trupti Karagi, Anjana Shetty, Sushruth Shetty
Department of Orthodontics and Dentofacial Orthopaedics, AECS Maaruti College of Dental Sciences and Research Centre, Bengaluru, Karnataka, India

Keywords
Cleft lip and cleft palate, nasoalveolar
molding appliances, nasoalveolar
molding, nasal deformity, presurgical
infant orthopedics
Correspondence
Dr.S.M. Laxmikanth,
Department of Orthodontics and
Dentofacial Orthopaedics, AECS Maaruti
College of Dental Sciences and Research
Centre, #108, BTM 6thStage, I Phase,
Hulimavu Tank Bund Road, Opposite
Bannerghatta Road, Bengaluru-560076,
Karnataka, India. Phone: +91-9844093035,
Email: laxmikanthsm72@yahoo.co.in

Abstract
Cleft lip and palate (CLP) is the most common congenital defect of the oral cavity
which possesses a serious socioeconomic trouble. It varies in form and severity. In
these patients who have deficient hard and soft tissue structures presented a major
task to bring about a functional and cosmetic outcome. Recently, nasoalveolar
molding (NAM) has gained more attention as it improves facial appearance and
function. The objectives of presurgical NAM involves correcting lip segments, lower
lateral alar cartilages, and alveolar cleft segments. Results of NAM are promising for
CLP, hence are encouraged to be used promptly after the birth and continued till
further specific corrective surgeries are performed.

Received 10 July 2014;

Accepted 25 September 2014
doi: 10.15713/ins.jcri.28

Introduction
Cleft of the lip, alveolus and palate (CLAP) are the most common
congenital mal-formations of the head and neck. India being the
second most populated country in the world with a population
of 1.21 billion, it is estimated that out of 24.5 million births per
year - the birth prevalence of clefts is between 27,000 and 33,000
clefts.[1] The incidence of CLP in India is 1 in 781 live births.[2]
Unilateral clefts are nine times as common as bilateral clefts,
and occur twice as frequently on the left than the right. The ratio of
left:right:bilateral clefts are 6:3:1. Males are predominantly aected
by CLP (M: F - 2:1) whereas females are more commonly
aected by isolated CP.[3]
The management of cleft patients should be approached as
a multidisciplinary team. It has evolved dramatically in recent
years because of advanced surgical techniques, timing, and
integration of methods like presurgical orthopedics. The basic
treatment objective is to restore normal anatomy. In past decade,
it has been made known that improvement of nasal abnormality
by elongating of the nasal mucosal lining, and attainment of
nonsurgical columella lengthening can be united with shaping of
the alveolar process in these patients.[4,5]
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Presurgical nasoalveolar molding (PNAM) is a non-surgical

method of reshaping the gums, lips and nostrils previous to
CLP surgery, thus lessening the severity of the cleft. Before
the introduction of the concept of NAM, repair of a huge cleft
involved several surgeries between birth and 18 years of age,
setting the child at risk for emotional and social adjustment
problems. With the advent of PNAM multiple surgical procedure
is bypassed, and better results are obtained, with only one or two
surgeries.[6]
History
In 317 AD, Chinese general Wei Yang-Chi corrected his CL
by cutting and stitching the edges. Many methods have been
accepted over the centuries to recover the location of the cleft
alveolar segments [Table 1].[7-9]
Principle of NAM
PNAM works on the principle of Negative sculpturing and
Passive molding of the alveolus and adjacent soft tissues. In
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Laxmikanth, et al.

Nasoalveolar molding

passive molding, custom made molding plate of acrylic is used

gently to 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.[6]

In infants with bilateral CLAP, the goal consists of the

nonsurgical lengthening of the columella, retraction of
premaxilla gently to accomplish continuity with the posterior
alveolar cleft segments and centering of the premaxilla along
the mid-sagittal plane. The main point of nasal molding is to
move the alar domes anteriorly in a sagittal path for increasing
length of columella.[10,11]

Objectives

Steps for NAM therapy

Primary goal of PNAM is to decrease the severity of the

primary cleft deformity and provide symmetry to distorted
nasal cartilage.
Nonsurgical lengthening of the columella.
Approximation of lip segments to decrease tension in the
tissues after lip repair and thus reduce scarring.
To produce additional favorable bone formation by
decreasing the size of the cleft and improving nasal tip
projection, decreasing the width of nasal alar base and nasal
tip.
Reduce the need for secondary alveolar bone grafts.

Evaluation of the infant for PNAM is started soon after birth.

During the 1st week or early 2nd week after birth the clinical
procedures and fabrication of PNAM plate should be started.
Molding of tissues is easier because of raised level of hyaluronic
acid and maternal circulating estrogen in neonates. PNAM
should ideally be completed before 6 months of age.[6]
Impression technique

1556

Pierre Franco gave the first detailed description of the indications,

surgical technique, and post-operative care of the CL

1575

Amboise Pare pioneered a technique that bears his name

involving lip repair with cleft lip pins

1689

Hoffmann demonstrated the use of facial binding to narrow the

cleft and prevent postsurgical dehiscence

1790

Desault used similar technique to retract the maxilla before

surgical repair in patients with bilateral cleft repair

1844

Hullihen stressed the importance of presurgical preparation of

clefts using an adhesive tape binding

1927

Brophy demonstrated the passing of a silver wire through both

the ends of the cleft alveolus, and then progressively tightened the
wire to approximate the ends of the alveolus before lip repair

1946

Pritchard observed that the rate of bone healing was inversely

proportional to the size of the gap

1950

McNeil used a series of plates to actively mold the alveolar

segments into the desired position

1952

Tennison developed a technique preserving the accurate position

of Cupids bow

1958

Burston, further developed McNeils technique and made it

popular

The initial impression is made with a heavy-bodied silicone

impression material. It should be taken soon after birth as the
cartilage is plastic and is moldable. The presence of the surgeon
is important during the procedure to help in case of an airway
emergency. Grayson and Maull[8] held infant upside down
position to keep the tongue forward which permitted fluids to
draw o the oral cavity and impression tray is placed. The tray
should be placed until impression material just begins to extrude
from the posterior border. Yang et al.[7] took the impression
using a pre-trimmed customized pediatric tray with the baby
mainly in the erect position, being held by one of the parents.
Utility wax is utilized to circumvent any sharp edges on the tray
and to enhance adaption to the infants mouth. Prashanth et
al.;[12]Mishra et al.[4] obtained impression when the infant was
awake in a prone position on the dental chair. The child is held
on the lap of their parents with no anesthesia in an outpatient
clinic. Dubey et al.[6] made impression of the cleft region upper
arch using ice cream stick and impression compound.
The impression material is allowed to set, and then the tray
is taken out of infants mouth [Figure 1]. The mouth is checked
for remaining impression material. A cast or model is poured
with a dense plaster material (dental stone) [Figure 2]. The
plate is made-up on the stone model.[8] Using special tray, and
putty consistency polyvinyl elastomeric impression material
final impression is made, with the same technique as of primary
impression.[6]

1960

Millards rotation advancement closure technique brought the

Cupids bow and the philtrum into a symmetrical position

Appliance fabrication

1975

Georgiade and Latham introduced a pin-retained active

appliance to simultaneously retract the premaxilla and expand
the posterior segments

1987

Hotz described the use of a passive orthopedic plate to slowly

align the cleft segments

1993

Grayson etal. described a new technique to pre-surgically mold

the alveolus, lip and nose in infants born with CLP

Table1: History details

CLP: Cleft lip and palate, CL: Cleft lip

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Undercuts present on the cast are blocked out with utility wax.
Separating media is applied. The NAM plate described by Grayson
and Maull[8] is prepared up of hard, clear self-cure acrylic. It is lined
with a thin layer of a denture soft material. The retention arm is
located at about 40 degrees to get appropriate activation and to
avoid dislodgement of the NAM plate from palate. The retention
arms vertical position should be at the intersection of the upper
and lower lip while retention button with the aid of elastics and
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Laxmikanth, et al.

The molding plate is examined for rough areas and then is

inserted in the oral cavity. Appliance is checked for proper
fitting and retention. The primary retention of the appliance
is through extra-oral bilateral facial adhesive tapes applied to
cheeks [Figures 4 and 5] and to acrylic extension from oral plate
that is positioned between lips under the cleft and at one end
orthodontic elastics are attached.
The elastics used should have an inner diameter of 0.25 inch,
and it should be stretched about two times the diameter for

activation force of about 2 oz.[8] Depending on the clinical

purpose and mucosal tolerance the quantity of force used may
vary.[9]
One-retention arm is used in cases with the unilateral cleft
only, and it is positioned on the labial border of the plate. It is
determined by pulling, the CL segments together while centering
the philtrum and columella. Approximation of lip segments
with no lower lip obstruction is seen when vertical position
of the retention arm rests at the junction of upper and lower
lips.[8] After the initial insertion, the baby is observed for several
minutes to check the stability of the appliance in place against
the palate. Bottle feeding was done to ensure proper suckling
without gagging.[6] Some authors suggest a liquid adhesive such
as Mastisol painted with a cotton-tipped applicator horizontally
on the cheeks where the Steri Strips will be placed.[7]
The plate is kept in the mouth for full time, and parents are
instructed only to remove it for daily cleaning. Initial days parents
may find diculty or need time to adjust to feeding infant with
the NAM appliance.

Figure 1: Alginate impression

Figure 3: NAM Appliance

Figure 2: Dental stone cast

Figure 4: Appliance insertion

extra-oral tapes secures the molding plate in the oral cavity. This
is the most commonly used NAM appliance [Figure 3]. Various
materials have been substituted for an auto polymerizing resin
in fabrication of the appliance by various researchers. They are
heat-cure polymerizing material (Sharma et al.;[2] Soltan-Karimi
et al.[13]), light-cure polymerizing material (Yang et al.[7]) and
2 mm thermoplastic base plate (Upadhyay et al.[14]).
Appliance insertion

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Nasoalveolar molding

Figure 5: Extraoral bilateral adhesive tapes

Figure 6: NAM appliance with nasal stents

Maintaining the tight apposition of lip segments with

the tape results in the orthopedic benefits of the traditional
lip adhesion without the consequent scar. It also serves to
improve the position of the nasal base region by bringing the
columella toward the mid-sagittal plane and by progressing
the regularity of the nostril apertures. The lip adhesion alone
produces uncontrolled orthopedic benefits; whereas the lip tape
adhesion combined with the molding plates produce controlled
movement of alveolar segments.[15]

a little laxity, and with the nasal stent, this is elevated into a
proportioned and convex form.[8,9]
Major surgical closure of the lip and nose are performed
between 3 and 5 months of age.
As the alveolar segments are in approximation, a
gingivo-periosteoplasty (GPP)is simple to perform, which avoids
widespread dissection and not aecting growth of the mid-face.[8]

Appliance adjustment

The appliance is left for 24 h in mouth and parents are instructed

to remove it only for cleaning purposes. After 24 h patient is
recalled to evaluate and correct sore spots or other problems
with the appliance, if any. The recall appointments are scheduled
weekly to modify the molding plate by selective trimming and
addition of acrylic to direct the alveolar fragments into the
required location. As the alveolar gap come closure, the lip
segments come together, reducing the nasal base width, and
bring in laxity of the alar rim. Addition of Nasal stent should be
delayed till laxity of the alar rim is achieved because it may result
in the enlarged circumference of the nostril. The elastics should
be changed on regular bases which ensures the eciency of the
appliance by maintaining the tension.[6-10]
Nasal stent

The incorporation of nasal stent is recommended when the

alveolar gap width is decreased to 5mm. It is made up of 0.036
gauge round wire and resembles kidney shape [Figure 6]. It is
added to the vestibular shield of the appliance. Tip of nasal stent is
pointed in the direction of the medial wall of the defective nostril.
Wire is allowed to extend into the nostril, and then it is curved
back to create a small loop which helps in retaining the intranasal
portion. The upper lobe enters the nose and lightly elevates the
dome until a reasonable amount of tissue blanching is apparent.
The lower lobe elevates the nostril apex and delineates the top of
the columella. The alar rim, stretched at birth will demonstrate
Journal of Advanced Clinical & Research Insights Vol. 1:3 Nov-Dec 2014

Active and passive appliances

Appliances are classified into active or passive or semi-passive

depending on forces required.
Active appliances are fixed intra-orally and apply traction
through mechanical means such as elastic chains, screws, and
plates. Passive appliances maintain the distance between the
2 maxillary segments while external force is applied primarily to
reposition the segments posteriorly. External taping of the lip,
head cap with elastic straps across the prolabium, or a surgical
lip adhesion applies external forces. Active maxillary appliances
use controlled forces to move the alveolar cleft segments in a
predetermined manner, but passive appliances act only as a
hinge on which the forces produced by surgical lip closure, shape
and mold the alveolar segments in an expected manner.[16-18]

Modifications
They are modified muscle-activated maxillary orthopedic
appliance used by Suri and Tompson[19] in NAM therapy;
Retnakumari et al.[17] described alveolar molding appliance with
expansion screw; dynamic presurgical nasal remodeling intraoral
appliance designed by Bennun and Figueroa;[20] extra-oral nasal
molding appliance by Doruk and Kili[21] and self-retentive
appliance with orthodontic wire used by Singh et al.[22] and
Ijaz[23] in presurgical infant orthopedics.
Complications

The complications associated with NAM.

Irritation of the oral mucosal.
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Nasoalveolar molding

If there is more force application by the upper lobe of the

nasal stent, it may cause inflammation of intranasal lining of
the nasal tip.
If the lower lobe is not positioned correctly notching can
occur along the alar rim.
If the band is too tight, the region under the horizontal
prolabium band may become ulcerated.
Loss of valuable treatment time if parents compliance is
poor.
The risk of dislodgement of the molding plate which may
obstruct the airway.
Possibility that the posterior limit of the NAM plate may drop
down onto the tongue if the arms are taped too horizontally
or with inadequate activation.
Pressure from molding plate may cause premature emergence
of the labial surface of maxillary deciduous central incisors.
Benefits

The benefit of NAM is that it enables the surgeon to accomplish

a better outcome with a lesser scar tissue formation. It decreases
the cleft side alar curvatures, increases length of columella,
makes prolabium more visible. Studies show that the nasal shape
is stable[24]with better lip and nasal form. NAM decreases the
required number of surgical revisions for oronasal fistulas, excessive
scar tissue, and nasal, labial deformities. Adult teeth erupt in a good
position with sucient periodontal support.[25]
Studies show that patients who were treated with NAM and
GPP did not necessitate secondary bone grafting.[26] NAM has
proven to be cost eective for families due to the fewer number
of surgeries[27] and is a chance for the parents to take part keenly
in the habilitation of their child.[25]
Conclusion
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 a
simple yet eective adjunctive therapy for reducing hard and soft
tissue cleft deformity before surgery. However, 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. It
is reported in the literature that the presurgical molding used
to reduce the cleft deformity does not inhibit mid-face growth.
Despite the relative paucity of high-level evidence, NAM appears
to be a promising technique that deserves further study.
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How to cite this article: Laxmikanth SM, Karagi T, Shetty A,

Shetty S. Nasoalveolar molding: A review. J Adv Clin Res Insights
2014;3:108-113.

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