Orthopaedic traction with passive nasoalveolar moulding in a bilateral cleft lip and palate patient – Rediscovering the old

Introduction: A 22-day-old male infant presented with complete bilateral cleft lip and palate with prominent premaxillary segment, wide alar base, flat alar domes and no columellar tissue, thus leading to a severe facial deformity. A presurgical nasoalveolar moulding (PNAM) procedure was planned to facilitate an optimal surgical approximation of the cleft and surrounding tissues. Methods: PNAM was performed on the basis of the hypothesis that ‘The palatal shelves continue to grow unabated if adequate relief is provided by wax mock up while preparing the feeding plate’. An intraoral device, which consisted of an acrylic feeding plate, was constructed after adequate wax mock up in the cleft area for passive moulding, along with extraoral traction force through active lip taping. A nasal stent was subsequently attached to lift the nasal domes and lengthen the columella. The changes thus achieved with PNAM were assessed using innovative photographic and model analyses. Results: On completion of PNAM, the qualitative photographic changes showed significant premaxillary setback, columellar lengthening and fullness of alar domes. The quantitative model analysis revealed reduction in the anteroposterior cleft gap by 5 mm and 5.5 mm on right and left sides, respectively. Transverse distance between the two palatal segments reduced by 3.5 mm, 8 mm and 8.5 mm in anterior, middle and posterior regions, respectively. Conclusion: Orthodontic intervention performed for 11 weeks by PNAM helped to retract the premaxilla, reduce the cleft gap, improve the arch form, approximate lip segments and distinctly lengthen the columella. Hence, it improved the morphology of the nose by correcting the flattened nasal wings. This aided the surgeon to achieve an optimal surgical repair. Keywords: Pre-surgical nasoalveolar moulding, Lip taping, Nasal stent, Columellar lengthenin