PEDIATRIC DENTISTRY V 34 / NO 3 MAY / JUN 12

Clinical Article
Nasal Changes With Nasoalveolar Molding in Colombian Patients With Unilateral Cleft Lip
and Palate
Ana María López-Palacio, DDS, Cert Ped Dent1 • Ana María Cerón-Zapata, DDS, Cert Ped Dent2 • David F. Gómez, DDS, Cert Ortho, MS3 •
Ángela P. Dávila-Calle, DDS, Cert Ped Dent4 • María Adelaida Ojalvo-Arias, DDS, Cert Ped Dent5

Abstract: Purpose: Presurgical nasoalveolar molding (PNAM) is controversial in maxillofacial orthopedics. It supposedly improves the nasal esthetics and
function in unilateral cleft lip/palate (UCLP) patients. However, there is no research available in South America to support this claim. The purpose of
this study was to evaluate the efficacy of presurgical nasoalveolar molding therapy on morphological changes of the noses of unilateral cleft lip/palate
patients in a Colombian sample. Methods: Seventeen neonate UCLP patients using PNAM received facial impressions at the beginning of treatment; before
primary rhinocheiloplasty; and before palatoplasty. A submentovertex photograph of each cast was taken and analyzed by digital photogrammetry.
Wilcoxon and Friedman tests were used for within- and between-group comparisons. Results: A statistically significant reduction of cleft nostril width,
without significant changes in noncleft nostril width or total nasal width, was found after PNAM. A significant increase in cleft and noncleft nostril height,
plus a nonsignificant increase in nostril area in both sides and a nonsignificant uprighting of the columella were found. These changes were maintained or
further improved after rhinocheiloplasty. Conclusion: The presurgical nasoalveolar molding technique improved nasal tip projection and alar cartilage
depression and decreased partially columella deviation before rhinocheiloplasty in South American unilateral cleft lip/palate patients. (Pediatr Dent 2012;
34:) Received August 3, 2010 | Last Revision May 25, 2011 | Accepted June 5, 2011

KEYWORDS: UNILATERAL CLEFT LIP AND PALATE, PRESURGICAL NASOALVEOLAR MOLDING, PRIMARY RHINOCHEILOPLASTY, PRESURGICAL CLEFT APPLIANCE

Cleft lip and palate (CLP) is a congenital craniofacial anomaly
produced by embryological defects during formation of the
face. It is considered the most frequent developmental ano-
maly of the face.1 The prevalence of cleft lip and palate is 1 in
500 to 1 in 2,000, depending on the population affected
(1:1,000 in Caucasians, 2.1:1,000 in Japanese, and 0.5:1,000
in African Americans). Of these patients, 76% present unilateral
clefts and 24% present bilateral clefts.1,2 In Colombia, the prev-
alence of this anomaly is 1 in 500 to 1 in 1,000, depending
on the geographic zone and the socioeconomic standard of
the population.3
Unilateral cleft lip and palate (UCLP) patients have an es-
thetic and functional compromise of the middle third of the
face primarily involving nasal structures.4 The UCLP noses are
deformed in the 3 planes of space.5,6 This deformity is caused by
the distortion and displacement of the nasal structures.7 The
alar cartilage on the cleft side is depressed and concave, which
results in depression and displacement of the nasal tip toward
the side of the cleft. The columella and the nasal septum are
1 Dr. López-Palacio is an associate professor, Department of Basic Integrated Studies,
College of Dentistry, University of Antioquia; 2Dr. Cerón-Zapata is an associate pro-
fessor, Department of Basic Integrated Studies, College of Dentistry, University of Antio-
quia and Instructor, Graduate Program in Pediatric Dentistry, College of Dentistry, CES
University; 3Dr. Gomez is an assistant professor, Graduate Program in Orthodontics,
College of Dentistry, CES University, and the Department of Basic Integrated Studies,
College of Dentistry, University of Antioquia; 4Drs. Dávila-Calle and 5Ojalvo-Arias are
in private practice, all in Medellín, Colombia, South America.
Correspond with Dr. López-Palacio at anamarialopez@une.net.co
inclined, and the base is deviated toward the noncleft side
(Figure 1).5,8 These characteristics have a psychological influence
on the patients and their families, generating low self-esteem,
low value of their self-image, and difficulties in their social
development.9
The nasal cartilages, columella, philtrum, and alveolar seg-
ments should be aligned and adequately reconfigured to faci-
litate surgical repair of the cleft area. To obtain this objective,
Grayson et al. proposed the use of presurgical nasoalveolar
molding (PNAM), an orthopedic device that aligns alveolar
ridges intraorally and improves malposition of nasal cartilages
extraorally. In UCLP patients, PNAM repositions the philtrum
and columella via nasal extension.5,8,10,11 Several techniques of
labial adhesion with adhesive tape can be used additionally to
this procedure to approximate the labial cleft segments, thus
reducing tension in surrounding tissues and facilitating surgical
intervention. The tape helps to close the defect by diminishing
the nasal base width, moving the columella to the midsagittal
plane, improving the symmetry of both nostrils, and approxi-
mating the labial segments.5,8,12 Presurgical nasoalveolar mold-
ing appliances and labial adhesion with tape decrease the size
of the cleft in order to perform surgery of the nasolabial complex
in coordination with the alveolar deformity.8
The use of PNAM and labial tapping in patients with
UCLP is a controversial subject in developing countries regard-
ing the therapeutic benefits vs time and costs involved. A
modified PNAM technique has been used at the Fundación
Clínica Noel (FCN), Medellin, Colombia, over the last decade.
The soft tissue response to this type of therapy, however, has
not been evaluated systematically.

546 NASOALVEOLAR MOLDING NASAL CHANGES IN COLOMBIAN UCLP PATIENTS

 PEDIATRIC DENTISTRY V 34 / NO 3 MAY / JUN 12

irreversible hydrocolloid (Orthoprint, Zhermarc SpA,

1 Rome, Italy) were taken in all patients to obtain a plaster
working model. The nasoalveolar molding plate was fa-
bricated on this model with thermocured acrylic (Veracryl,
New Stetic SA, Guarne, Colombia). At the same time,
the nasal extension for the cleft nostril was added; this
extension was constructed with 0.036-inch round stain-
less steel wire (Masel, Carlsbad, Calif ) and covered at the
nasal extreme with hard acrylic (Veracryl). The intraoral
Figure 1. Patient with a unilateral cleft lip and palate: (a) frontal facial view; (b) maxillary oc-
side of the plate and the free nasal extension were covered
clusal view; (c) graphic representation of his nasal deformity. The alar cartilage of the side of with soft acrylic (Neoloy, Dentex Inc, Chicago, Ill) at the
the cleft appears depressed and concave and the columella deviated toward the side of the cleft. time of initial placement on the patient (Figure 2).
In conjunction with the molding plate, an adhesive
Table 1. DESCRIPTION OF THE UNILATERAL CLEFT LIP/PALATE tape (Micropore, 3M, St. Paul, Minn) was placed to join
PATIENT PRESURGICAL NASOALVEOLAR MOLDING the labial segments temporarily. Instructions and recommen-
SAMPLE dations on the use of the molding plate and the adhesive tape
Age (days) were given to the parents. The PNAM plate was removed twice
a day to permit oral hygiene. The PNAM appliance was ad-
n T1* T2** T3†
justed on a weekly basis to perform trimming of the intraoral
17 Median Range Median Range Median Range
and nasal portion of the appliance or to add acrylic as needed.
♂=10 ♀=7 26.0 4-103 107.0 65-137 140.5 109-188 During the time of treatment with the molding plate,
records of the facial middle third were taken with irreversible
* T1 = Before PNAM; **T2 = After PNAM; †T3= After primary rhinocheiloplasty. hydrocoloid (Orthoprint) at 3 specific times:
1. at the beginning of treatment (T1);
2. after using the nasoalveolar molding plate and the
The purpose of this study was to evaluate the efficacy of adhesive tape, before the primary rhinocheiloplasty
presurgical nasoalveolar molding therapy on morphological soft (T2); and
tissue changes of the nose in Colombian unilateral cleft lip/ 3. before the palatoplasty (T3).
palate patients. The impressions were poured with type III plaster. Each
model was photographed with a submentovertex technique at
Methods 45º with a Sony Cyber-Shot DSC-P73 digital camera rated at
Sample. This was a descriptive study carried out in patients with 4.1 megapixels (Sony Corp, Tokyo, Japan). The photographs
UCLP before and after treatment with PNAM and primary were standardized using a tripod to hold the camera. The mo-
rhinocheiloplasty at the FCN. The population consisted of dels were placed on a parallelometer to fix their position, and a
UCLP neonates who attended the pediatric dentistry service millimeter ruler was used as a parameter to verify magnification.
between January 2005 and February 2007 and who received this Before taking the photographs, the nasal contour and four
infant presurgical orthopedic protocol as part of the guidelines nasal reference points (Pronasal, Subnasal, and Alar Curvature
for treatment of the FCN cleft lip and palate team. [cleft and non-cleft]) were drawn on the cast (Table 2). The pic-
The sample was selected by convenience sampling (non- tures were stored in BMP format using a software for image
probability sampling from the population close to hand and management (Microsoft Photo Editor HP, Microsoft Corp,
readily available) and had to comply with the following inclu- Redmond, Wash). The remaining bilateral nasal reference
sion criteria: Zero- to 3-month-old UCLP patients, without points (Subnasal’, Subalare and C’) were digitally placed in the
associated syndromes, and with a health status that permitted pictures afterwards. The facial models were measured using 2D
the proposed procedures to be performed; patients living in digital photogrammetry. The program used for this purpose
the city of Medellin, Colombia, during the study period and was Scion β Image 4.0.3.2, developed in conjunction with the
whose families were willing to participate in the follow-up and
continuous control appointments; and patients who had not
been subjected to previous maxillary orthopedic treatment or to
previous nasolabial surgical procedures. Twenty-eight new pa-
tients were evaluated. Of them, 17 fulfilled the inclusion criteria
(10 females; 7 males). The median age at initial evaluation was
26.0 days, after PNAM treatment (before the primary rhino-
cheiloplasty) was 107.0 days, and before the palatoplasty was
140.5 days (Table 1). Before treatment, informed consent was
obtained from all parents or supervising adults for the inclusion
of the patients in the sample. The integrity and privacy of the
patients were protected at all times. This study was approved by
the Research Committee of the College of Dentistry of the 2
University of Antioquia, Medellín, Colombia, South America.
Clinical procedures. The procedures performed on the Figure 2. Presurgical nasoalveolar molding appliance with unilateral
patients were as follows. Initially, intraoral impressions with nasal extension used in the present study.

NASOALVEOLAR MOLDING NASAL CHANGES IN COLOMBIAN UCLP PATIENTS 547

PEDIATRIC DENTISTRY V 34 / NO 3 MAY / JUN 12

National Institutes of Health. The linear, angular, and Table 2. LANDMARKS AND LINEAR, ANGULAR, AND AREA MEASUREMENTS USED IN
area measurements were evaluated on the cleft side THIS STUDY*
and compared to the noncleft side. The measurements Landmarks
obtained with this methodology permitted the eval-
Pronasal (prn) Most protruded point of the nose
uation of the tissue response after each stage of the
Subnasal (sn) Midpoint formed where the lower
therapy of PNAM and after primary lip surgery border of the nasal septum and the
(Table 2). surface of the upper lip meet
A pilot study to calibrate intra- and interexaminer Subnasal’ (sn’) Columella base toward the inner
side of the nostril
error was conducted. The results showed that the intra- Subalare (sbal) Labial insertion of the alar base
examiner error was 0.39 mm maximum for the linear Alar curvature (ac) Facial insertion of the alar base
measurements, 1.12 mm 2 for the area measurements, Columella’ (c) Most superior point on the colu-
and 1.41º for the angular measurements. For the inter- mella crest
examiner error, the results were 0.34 mm for the linear Linear measurements
measurements, 1.15 mm 2 for the area measurements, 1. Width of the nasal Width between the facial insertion
and 3.31º for the angular measurements. base (Ac-Ac) points of the alar base
Statistical analysis. The Shapiro-Wilk test was 2. Height of the nostril Distance between c’ passing through
(HN)(C-NC) the subalar-subnasal’ plane
used for all variables to establish sample distribution.
3. Width of the nostril Distance between subnasal’ and
Test results showed that the sample did not fall into a (WN)(C-NC) subalar points.
normal distribution; therefore, nonparametric statistical
Angular measurements
tests were used. The Friedman test was used to compare
the differences among the T1, T2, and T3 medians, 4. Inclination of the Angular measurement between
columella (Cl) pronasal-subnasal plane and
and the Wilcoxon test were used to test for differences subalare-subalare plane.
between T1-T2, T1-T3, and T2-T3. The level of sta- Area measurement
tistical significance was .05. For the variables in which
5. Area of the nostril Area covering the open space inside
both nostrils were studied, the value corresponding to (AN) (C-NC) the nostril; in the cleft side, it refers
the difference between the cleft nostril vs the noncleft to the area existing over a plane
was used. To determine the percentage of improve- between the subalare and the inter-
section of the vestibule line, with
ment due to the use of PNAM combined with growth the center of the maxillary alveolar
from the overall nasal results (PNAM + surgery + process in the lateral view
growth), a ratio between PNAM + growth : overall re-
sult was obtained for all variables studied. *After Farkas et al., 1992; Farkas et al., 1993.

Table 3. NONPARAMETRIC STATISTICAL ANALYSIS OF NASAL MORPHOLOGY MEASUREMENTS USED IN THE PRESENT STUDY
Measurement Beginning of treatment Before primary Before palatoplasty Friedman Wilcoxon %
rhinocheiloplasty
Median Range Median Range Median Range T1**-T2 T2†-T3 T1-T3 § PNAM +
growth at T3

Width of nose Width of nasal 28, 76 25, 34-34, 70 28, 78 22, 49-33, 86 28, 72 25, 61-32, 89 NS* NS NS NS NS
(mm) base
Nostril width Width of nostril 14, 21 10, 13-18, 64 12, 61 10, 89-15, 28 9, 75 7, 26-11, 95 0.000 0.017 0.000 0.000 35.87
cleft (mm) (cleft)
Nostril width Width of nostril 5, 96 3, 57-8, 15 5, 61 2, 50-7, 39 7, 04 4, 76-8, 53 0.000 NS 0.000 0.000 -32.40
noncleft (mm) (cleft)
Nostril width Width of nostril 8, 89 1, 98-12, 78 7, 62 5, 31-9, 29 2, 81 0, 50-6, 53 0.000 NS 0.000 0.000 20, 88
difference cleft- difference
noncleft (mm)
Nostril height Height of nostril 1, 63 0, 71-2, 83 2, 20 0, 97-4, 13 2, 65 1, 15-4, 61 0.005 0.039 NS 0.003 55, 88
cleft (mm) (cleft)
Nostril height Height of nostril 2, 41 1, 33-3, 28 3, 12 1, 92-4, 22 3, 03 1, 37-5, 39 0.011 0.005 NS 0.028 114.5
noncleft (mm) (noncleft)
Nostril height Height of nostril (-)0, 69 (-)1, 80 - (-)0, (-)0, 69 (-)2, 09-0, 91 (-)0, 54 (-)1, 51-1, 40 NS NS NS NS NS
difference cleft- difference 03
noncleft (mm)
Columella Inclination of 73, 78 62, 67-87, 97 76, 34 64, 74-86, 88 88, 07 73, 26-94, 24 0.005 NS 0.002 0.004 17, 91
inclination columella
(degrees)
Nostril area Area of nostril 35, 7 18, 60-47, 26 34, 81 18, 73-63, 81 29, 59 13, 93-58, 90 NS NS NS NS 14.57
cleft (mm2) (cleft)
Nostril area Area of nostril 22, 19 10, 03-33, 15 22, 34 14, 92-41, 83 31, 28 22, 17-55, 48 0.000 NS 0.013 0.001 1.65
noncleft (mm2) (noncleft)
Nostril area Area of nostril 11, 05 (-)2, 15-26, 76 7, 8 (-)6, 28-28, 79 (-)1, 31 (-)21, 99-25, 38 0, 001 NS 0, 001 0, 007 26, 29
difference cleft- difference
noncleft (mm2)

*NS=nonsignificant. * * T1 = Before PNAM; †T2 = After PNAM; §T3= After primary rhinocheiloplasty.

548 NASOALVEOLAR MOLDING NASAL CHANGES IN COLOMBIAN UCLP PATIENTS


Results
The age at the beginning of treatment (median) was 26 days.
The average time of use of the appliance was 3½ months
before the primary rhinocheiloplasty. All data regarding the
ages when T1, T2, and T3 facial impressions where taken
appears in Table 1. No nasal changes obtained after palato-
plasty were assessed in the present study.
The nose’s width median did not show statistically signifi-
cant differences in the 3 time points of evaluation (Table 3,
Figure 3a). The median values for nostril width on the cleft
side significantly decreased 4.4 mm. A significant decrease
(median: 1.6 mm; 36% of total change) corresponded to the
PNAM protocol used, which was followed by an even higher
significant decrease after surgery (median: 2.8 mm; 64% of
total change). The same measurement in the noncleft side dem-
onstrated a decrease after PNAM (median: -0.35 mm; ~32%
decrease from total change) that was followed by a recovery
of normal growth afterward (median: +1.43 mm; ~132%
increase to reach total change). This effect of the behavior
of the 2 measurements explains why the difference in the
width of the nostril (subalar to subnasal) of the cleft vs
the noncleft sides showed a progressive reduction along the
evaluation periods, which was only statistically significant
between T2 and T3 (Table 3, Figure 3b).
The median values for nostril height on the cleft side in-
creased 1.02 mm, with a 0.57 mm (~56%) increase corre-
sponding to PNAM treatment. The same median values on
the noncleft side demonstrated a 0.71 mm (~115%) increase
after PNAM, followed by a slight decrease after rhinochei-
loplasty (-0.09 mm; a ~15% decrease). As the 2 measure-
ments increased with PNAM, the Friedman test performed to
assess the nostril height differences between cleft vs non cleft
sides failed to show significant differences (Table 3, Figure 3c).
The inclination of the columella had a statistically significant
increase when the 3 times were compared, but only the T2-T3
increase was statistically significant (~18% increase after PNAM;
~82% increase after rhinocheiloplasty; Table 3, Figure 3d).
A slight decrease in the median area values of the cleft
nostril after PNAM (-0.89 mm2; a ~15% decrease) was followed
by a major decrease after primary lip and nose surgery (median:
Figure 3. Distribution box plots of the anthropometric nasal measurements: (a) width
of the nose; (b) difference in the width of the nostrils; (c) difference in the height of
the nostrils; (d) inclination of the columella; (e) difference in the area of the nostrils.
PEDIATRIC DENTISTRY V 34 / NO 3 MAY / JUN 12
-5.22 mm2; a ~85% decrease), while the noncleft nostril area
remained essentially unchanged after PNAM (median: 0.15
mm2; a ~2% increase) and increased by a median of 8.94 mm2
(a ~98% increase) after primary nasal and lip repair. A statis-
tically significant decrease was found when analyzing the dif-
ferences between cleft and noncleft side’s medians for this
measurement at the 3 time points. Only T2-T3 and T1-T3
differences, however, demonstrated a statistically significant
decrease (~26% decrease after PNAM; ~74% decrease after
rhinocheiloplasty; Table 3, Figure 3e).
Discussion
The technique of presurgical nasoalveolar molding is used to
correct nasal deformity, approximate alveolar segments, and im-
prove labial position in patients with UCLP. This procedure
permits the anatomical correction of the nasoalveolar structures
and facilitates surgical repair of the lip and the nose with mini-
mum tension. At the same time, the use of adhesive tape over
the lip improves the conditions of healing after primary lip and
nose repair (rhinocheiloplasty) by limiting the stretching of
tissues, further favoring tissue recovery. This, in turn, benefits
the esthetic results after rhinocheiloplasty and prior palato-
plasty.8 PNAM creates a nasal floor by the intraoral acrylic plate,
and the repeated adjustments made in the alveolar and nasal
portions throughout the time the appliance is used help to
obtain the desired nasal and alveolar molding results (Figure 4).
In the present study, no significant statistical results were
found in the evaluation of the PNAM intervention at the
width of the nasal base. Farkas et al., compared the changes in
the nasal cavity in children with unilateral and bilateral cleft
lip and palate and reported a wider nasal base in UCLPs who
were not operated on13 compared with a normal nasal growth
from a previous report from the same group.14 Similar changes
were found by Ezzat et al. in their study, where stability in the
width of the nasal base was evidenced. 15 In our data, the fact
that the width of the nose did not change after PNAM and
lip-tape adhesion or even after rhinocheiloplasty demonstrated
that this combined approach served to stabilize this measure-
ment while nasal growth was occurring elsewhere.
The changes in the cleft nostril width were significant,
being higher between T2 and T3. This decrease in the mea-
surement indicated that the initially stretched cartilage had a
favorable, but nonsignificant change with the use of PNAM
Figure 4. Latin American unilateral cleft lip/palate patients treated by presurgical
nasoalveolar molding (PNAM) (patient 1—a, b, and c; patient 2—c, d, and e): (a
and d) initial facial casts; (b and e) post-PNAM facial casts. Notice the beneficial
effects of PNAM to correct the alar cartilage depression, the better appearance in
the projection of the nasal tip, and the partial improvement in columella deviation.
(c and f ) Postprimary rhinocheiloplasty facial casts. Acceptable outcomes regarding
nose esthetics were achieved. Although perfect symmetry of the nose was not ob-
tained, future nose revisions will be reduced with the use of this treatment approach.
NASOALVEOLAR MOLDING NASAL CHANGES IN COLOMBIAN UCLP PATIENTS 549
PEDIATRIC DENTISTRY V 34 / NO 3 MAY / JUN 12
that was followed by a significant reduction after rhinocheilo-
plasty. These findings were similar to those reported by
Grayson et al., Maull et al., Pai et al., and Ezzat et al.5,8,15,16 The
nonsignificant decrease in nostril width measurement after
PNAM and lip-tape treatment could be an additional, positive
change toward the improved nasal results after surgery. The
difference between the cleft transversal nostril width minus the
non-cleft one showed a reduction among the 3 timeframes of
the study. This difference, however, was only significantly higher
between T2 and T3 (Table 3). Similar effects were found by
Pai et al., in 2005, when they compared the affected side with
the non-affected one and found higher transversal symmetry
after the use of PNAM.16
Regarding nostril height, the increase in the measure-
ment indicated a favorable change in the cleft alar cartilage that
was depressed at the beginning of treatment. These findings
were similar to those reported by Grayson et al., Maull et al.,
Pai et al., and Ezzat et al.5,8,15,16 The measurements between T2
and T3 increased, although at a lesser proportion, showing that
the height of the alar cartilage insertion obtained by PNAM
remained stable after rhinocheiloplasty. As the cleft nostril
width and height PNAM results could have been affected by
the healing effect and tension in nasal tissue after rhinocheilo-
plasty, it is our recommendation that a postsurgical nasal con-
former be used to keep the results obtained with PNAM, as
was suggested by Pai et al.16
The results when assessing the columella inclination indi-
cate a significant increase from T1 to T3 in the measurement of
this angle in time. A nonsignificant improvement in the colu-
mella final position before rhinocheiloplasty was observed,
however, between T1 to T2. This indicates that PNAM ther-
apy could play a role in the straightening of the columella,
taking the nasal tip to a more vertical position. Additional and
more significant surgical modifications of nasal cartilage form
must be done, however, to totally fulfill this purpose. Addi-
tional testing of the same measurement on a larger sample
would be helpful to answer this question.
Similar results were found by Singh et al., who found that
the columella was placed medially after the use of PNAM, im-
proving the projection of the nasal tip. 17 Grayson et al., re-
ported that the use of PNAM repositions the columella, taking
it from an oblique position to a straighter one and oriented
toward the midline, producing symmetry in the alar cartilage
and an optimal projection of the nasal tip.8 Ezzat et al., reported
an improvement in the vertical deficiency of the nasal struc-
ture due to tension of the columella in the affected side after
PNAM.15 Likewise, Pai concluded that, after this therapy, the
angle of the columella changed, reaching values closer to the
ideal 90° and redirecting itself toward the midline.16
When an assessment of the cleft nostril area was per-
formed, a nonsignificant and gradual decrease from T1 to T3
was found. On the other hand, the noncleft side demonstrated
a significant increase among the endpoints of the study, being
highly significant between T2 and T3 (Table 4). The same trend
was found when an evaluation of the nostril area difference be-
tween cleft and noncleft sides among all endpoints was done.
Symmetric nostrils are a composite of nostril area and form.
As the present study failed to identify differences between the
nostril areas, a subjective evaluation of the form of the affected
nasal cartilages should be done next to answer this question.
550 NASOALVEOLAR MOLDING NASAL CHANGES IN COLOMBIAN UCLP PATIENTS
The purpose of the adhesive tape was to approximate the
soft tissues around the cleft. There are no references about the
precise technique of the use of the tape regarding direction
and amount of force. When using the tape, the indication given
to the parents consisted of applying pressure between the 2
segments to approximate and close the gap between them. The
main effect of this pressure was in sagittal and transversal direc-
tion. In our study, however, the width of the nasal base re-
mained unchanged with the use of this approach. Although it
has been claimed that the use of adhesive tapes applied on the
lips could reduce the width of nasal base and help to maintain
the plate into proper position,8,15,16 in the present study it was
not the purpose of the adhesive tape to reduce this measure-
ment or even keep the appliance in place.
It is well known that maxillofacial orthopedics have signifi-
cant effects on the arch shape, especially regarding the widen-
ing effect in anterior arch width. After its usage, the maxillary
arch appears more rounded and with more room for additional
alveolar and palatal growth.17,18 Additional to these effects,
PNAM therapy has the benefit of changing nasal cartilage form
before surgery to improve surgical results, as was shown by the
present study. The question regarding potential outcome dif-
ferences for intraoral characteristics between the 2 approaches
(conventional vs PNAM appliances), however, remains unsolved.
Additional research should be undertaken to solve this issue.
Also, our sample size limits the results to the specific popula-
tion attending our clinic, and they cannot be used as a rule for
all populations. This study demonstrated results obtained with
the PNAM therapy, an increasingly common procedure.
In summary, an improvement was found between initial
and final nasal form at the end of PNAM and surgery. It also
can be sustained that a percentage of the results is due to
PNAM and normal growth changes (56% improvement in
nostril height, 21% increase in columella length, and 18% im-
provement in columella deviation). The change in form of the
cleft nasal cartilage with PNAM was identified, but further ana-
lysis of the available data is required to support its significance.
Conclusions
Based on this study’s results, the following conclusions can be
made:
1. The presurgical nasal alveolar molding technique im-
proves the alar cartilage depression, projection of the
nose tip, and partially the columella deviation before
primary lip and nose surgery in unilateral cleft lip/
palate patients in a South American population.
2. Future studies should be done next to:
a. evaluate the effect of the nasal surgical repair of
unilateral presurgical nasoalveolar molding vs a
maxillofacial obturator-treated sample of unilateral
cleft lip/palate patients; and
b. address the long-term effect of presurgical nasal
alveolar molding in nasal soft tissue esthetics
in unilateral cleft lip/palate patients from this
population.
Acknowledgment
We wish to acknowledge the Fundacion Clinica Noel and its
Interdisciplinary CLP group, which allow us to collect all data
used in the present research.

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