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Treating the Tiniest of Patients by Dustin S. Burleson, DDS

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Treating the tiniest of patients.
by Dustin S. Burleson, DDS

Nasoalveolar molding (NAM) is a nonsurgical technique used by orthodontists to assist babies who are born with cleft lip and palate. Its objective is to restructure the gums, lip and nostrils, using a plastic plate, to reduce the cleft inside of the mouth and the opening in the upper lip. It also will lift and narrow the nose, making the cleft less severe, with the goal of decreasing the number of surgeries for cleft lip and palate the child will require in the future.

Once the molding is complete, initial surgery is performed, usually when the child is 3–6?months old.

NAM is used primarily for children who possess large or wide clefts, and has shown to significantly transform cleft repair. Formerly, children with such clefts required numerous surgeries from birth to the age of 18, which would often place them in jeopardy for psychological and social challenges. The initial surgery would pull the lip together; the next surgery improved the position of the upper lip; at least two more surgeries would follow to shape the nose. Another surgery, which frequently included a bone graft, would then be performed to close the palate, and so on and so forth for many years.

Using NAM in the months before the first surgery, orthodontists are able to reduce large clefts and improve the shape and position of the nose and upper lip. For babies with a smaller cleft, there will be less tension when the surgeon closes it. Hence, because the orthodontist molded the lip and nose beforehand, a reduced amount of reshaping will be required during surgery.

Orthodontists create a better result initially, which means children may need fewer surgeries.

Discover More About NAM
  • Dr. Barry H. Grayson, an associate professor of plastic surgery in craniofacial orthodontics, introduced NAM in the late 1980s and has been using the technique ever since. Grayson offers a workshop on NAM twice a year, and in 2017 will host the first International NAM Symposium. For information, visit nasoalveolarmolding.com.
  • Burleson Orthodontics and Pediatric Dentistry was the first practice in the Kansas City, Missouri, area to introduce NAM procedures for cleft lip and palate, exclusively at Children’s Mercy Hospital.
  • Burleson Orthodontics and Pediatric Dentistry is also committed to Smiles Change Lives (SCL), an international nonprofit that serves children ages 10–18 in need of orthodontic treatment, but whose families can’t meet the full cost of braces. SCL assists such families by linking them with orthodontic providers who are willing to donate their services to qualifying patients. If you’d like to help children in your community, visit smileschangelives.org.

In practice
NAM works by lightly guiding the growth of a baby’s gums and the shape of his nose throughout the initial 2–3 months after birth, when the body’s tissues are soft and easier to mold.

The orthodontist will fit the baby with a custom molding plate, which looks similar to the type of retainer one would get after braces The baby wears the plate 24/7—even while he’s being fed—as it’s held in place by small rubber bands that are taped to the baby’s cheeks. The parents will need to change the rubber bands and tape and also clean the molding plate at home as needed (typically every day). The orthodontist and her team will work with parents and teach them how this is all performed.

To help guide the baby’s gums as he grows, the orthodontist will make slight adjustments to the form of the acrylic plate at each visit—once a week, in most cases. When the orthodontist believes that adequate reduction in the cleft has been achieved, she will put in a nasal stent (or stents, for bilateral clefts), which is protected with both hard and soft acrylic added to the front of the plate. The plate will glide effortlessly into the baby’s nostril and will progressively lift up the nose and shape the nostril on the side of the cleft.

Treating the tiniest of patients. The goals of NAM therapy are to reduce the size of the cleft and improve nasal symmetry before the initial surgical repair. Stretching the nasal lining provides the surgeon with more tissue for the repair and helps to improve soft tissue nasal aesthetics. Note how collapsed the patient’s left nasal cartilage appears at birth. After NAM, the nose appears more symmetrical.

Treating the tiniest of patients. Nasoalveolar molding (NAM) treatment: Infant molding before primary surgical repair of cleft lip/palate

NAM FAQ

Trevor Lines, DDS How long will my baby wear a NAM device?
Babies who have unilateral clefts generally wear the NAM device for about three months. Babies who have bilateral clefts may require the device for up to six months. Once the plastic surgeon and orthodontist reach a consensus that the best possible results have been attained, the baby can then be scheduled for the initial corrective surgery.

Is my baby a candidate for the NAM procedure?
The deciding element as to whether a baby is eligible for NAM is the parents’ pledge to committing the necessary time and patience required for the method to succeed. The parents will need to vigilantly clean the device, tape it in place correctly, deal with possible skin and mouth irritations, and visit the orthodontist weekly. If the parents are able to dedicate the time and effort, NAM will deliver the greatest results.

Does NAM hurt the child?
Not at all. Although it is a different feeling for him, and may be slightly frustrating for the first few days, know that the plate used for molding and the nasal stent are not at all painful for the baby. It does not stretch the baby’s fragile tissues; its only purpose is to gently guide the growth of the gums (which is also called passive molding) and reduce the size of the cleft.
Once the baby gets used to the plate, usually a few days, he is generally happier wearing it than he was without it. We believe that this happens because the plate acts as the roof of the baby’s mouth and is more comfortable. An added benefit is that feeding becomes easier.

Trevor Lines, DDS

Dustin S. Burleson, DDS, is an assistant clinical professor in the Department of Orthodontics & Dentofacial Orthopedics at the University of Missouri—Kansas City School of Dentistry. He holds additional teaching affiliations with The Children’s Mercy Hospital and Saint Luke’s Hospital Cleft Palate and Craniofacial Teams. He maintains a private practice in Kansas City, Missouri, and is the director of the Leo H. Rheam Foundation for Cleft and Craniofacial Orthodontics.

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April 2024
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