What is nasoalveolar molding (NAM)?
Nasoalveolar molding (NAM) is a nonsurgical method of reshaping the gums, lip and nostrils before cleft lip and palate surgery, lessening the severity of the cleft. Surgery is performed after the molding is complete, approximately three to six months after birth.
NAM is used mainly for children with large clefts, and has revolutionized cleft repair.
In the past, fixing a large cleft required multiple surgeries between birth and age 18, putting the child at risk for psychological and social adjustment problems.
The first procedure pulled the lip together, a second improved the position of the lip, another two would be for the nose, then another — often including a bone graft — would close the palate, and so on.
With nasoalveolar molding, the orthodontist and surgeon can improve a large cleft in the months before surgery. This helps the surgeon get a better shape of the nose and a thinner scar in only one surgery.
A better result in the first surgery means fewer surgeries later in childhood.
How does NAM work?
To start NAM, parents work with an orthodontist. Within the first couple of weeks after birth, babies are fitted with a custom-made molding plate that looks like an orthodontic retainer. The device is attached with a small orthodontic rubberband that is taped to the baby's face.
The molding plate causes no pain and after the first few days the plate usually doesn't bother babies at all; it's an accepted part of their face.
Unlike some older techniques, the molding plate does not push or stretch the delicate tissues; it only helps gently direct the growth of the gums.
The baby wears the molding plate 24 hours day, seven days a week, including when they are feeding. The parents change the tape and clean the molding plate daily as needed.
After the baby has worn the molding plate for a week, the orthodontist slowly adjusts the shape by sculpting the plastic. Each adjustment is very small, but it starts to guide the baby's gums as they are growing.
Adjustment of the molding plate is done by the orthodontist weekly or every other week depending on progress. Each appointment takes 40 to 60 minutes.
Once the cleft gap in the gums is small enough (around a quarter inch), a post is attached to the molding plate and is inserted in the nostril. This post is then slowly adjusted to lift up the nose and open the nostril.
By the time of the surgery, the nose has been lifted and narrowed, the gap in the gums is smaller and the lips are closer together.
A smaller gap means less tension when the surgeon closes the cleft. In our experience this results in a better final result than if NAM had not been done.
What is your experience with NAM?
Drs. Barry Grayson and Court Cutting at New York University Medical Center developed NAM and have established it as a safe and effective technique.
Although NAM is a more recent advance in cleft care, it is an improvement of techniques that have been used in the U.S. and in Europe for decades. It is therefore not a "new fad," but is here to stay.
One of our plastic surgeons and orthodontists trained with Drs. Grayson and Cutting in New York, and we have been performing nasoalveolar molding at Seattle Children's since 2001. Our plastic surgeons use the specific surgical techniques designed for patients after molding.
An average of six children are undergoing NAM at Children's at any time.
What type of NAM is done at Children's?
We use the negative sculpturing passive molding technique described by Drs. Grayson and Cutting. Our surgical technique takes advantage of nasoalveolar molding by decreasing the size of the incisions and scars and the amount of surgery.
In select cases, a gingivoperiosteoplasty (GPP) can be performed to completely close the cleft in the gum at the time of the surgery.
Doing a GPP at the time of the lip surgery can prevent the need for a future alveolar bone graft (gum surgery) in approximately half of the children. Not all children undergoing NAM are good candidates for a GPP.
We will provide more information on NAM and discuss if it is appropriate for your child.
An orthodontist, a plastic surgeon and a nurse practitioner specially trained in NAM are available for questions between visits.
Although your child will come to the orthodontist for adjustments to the molding plate about once a week, they will still be followed as closely as necessary by the rest of the multidisciplinary team at the Craniofacial Center during regular clinic visits.