What is nasoalveolar molding (NAM)?

Nasoalveolar (pronounced nay-zoh-al-VEE-uh-ler) molding (NAM) is a nonsurgical way to reshape the gums, lip and nostrils with a plastic plate before cleft lip and palate surgery. Pre-surgery molding may decrease the number of surgeries your child needs because it makes the cleft less severe.

  • It reduces the cleft inside the mouth.
  • It reduces the gap in the upper lip.
  • It lifts and narrows the nose.

Surgery is done after the molding is complete, when your child is around age 3 to 6 months.

NAM is used mainly for children with large or wide clefts, and has greatly changed cleft repair.

In the past, a child with a large cleft needed many surgeries between birth and age 18, putting the child at risk for psychological and social challenges.

The first surgery pulled the lip together, the second improved the position of the lip, 2 more would shape the nose, then another — often including a bone graft — would close the palate, and so on.

With NAM, a Seattle Children’s orthodontist can reduce a large cleft in the months before surgery. A smaller cleft means less tension when the surgeon closes the cleft. This helps the surgeon get a thinner lip scar and better nose shape in only 1 surgery.

A better result with the first surgery means fewer surgeries later in childhood.

How does NAM work?

NAM works by gently directing the growth of your baby’s gums and the shape of their nose during the first few months after birth, when these tissues are soft and easy to mold.

Parents work with a Seattle Children’s orthodontist during NAM therapy. The orthodontist fits your baby with a custom molding plate that looks like a retainer you would get after braces.

Your baby wears the molding plate 24 hours a day, 7 days a week, including when they are feeding. The plate is held in place using small rubber bands that are taped to your baby’s cheeks. You change the rubber bands and the tape and clean the molding plate at home as needed (usually each day). Your NAM team will teach you how.

Every 1 to 2 weeks, the orthodontist makes small changes to the shape of the molding plate to guide the baby’s gums as they grow. Each visit takes 40 to 60 minutes.

Once the gap in the gums is small enough (around a quarter inch), the orthodontist adds a post covered with smooth, rounded plastic to the front of the molding plate. This post (called a nasal stent) slides easily into the baby’s nostril. It slowly lifts up the nose and shapes the nostril on the side of the cleft.

How does NAM feel for my baby?

The molding plate and nasal stent are not painful. Unlike some older techniques, NAM does not push or stretch the delicate tissues; it only helps gently direct their growth (called passive molding).

After getting used to the plate for a few days, many babies seem happier wearing it than they did without it. This may happen because the plate acts as a palate (roof of the mouth). It keeps your baby’s tongue from pushing into the cleft, and it makes feeding easier for your baby.

What is Seattle Children’s experience with NAM?

We have been performing NAM at Seattle Children’s since 2001, and we treat more children with this technique than most other craniofacial centers. The team in our dedicated NAM clinic has special expertise to repair clefts with molding followed by surgery. Our plastic surgeons use the specific surgical techniques designed for patients after molding.

In our experience, NAM leads to a better final result in babies with large clefts than if NAM had not been done.

Our craniofacial team designed and patented a new device for treating cleft nose called the Seattle alar molding (SAM) device. It may decrease the number of visits your child needs to improve the symmetry of their nose before surgery.

If needed, the SAM device can be used at the same time as a standard NAM plate that molds your baby’s gums. The SAM device can also be used to improve nose symmetry in children who do not have NAM. We are making the device available to doctors at other centers around the country to improve cleft care for all children.

What type of surgery is done after NAM at Seattle Children’s?

After molding is complete, your child will have surgery to pull their lip together and to further shape their nose. We use surgical techniques designed to decrease the size of the incisions and the number of surgeries your child needs to get good results (thinner lip scar, better nose shape).

In some cases, surgeons can perform a gingivoperiosteoplasty (GPP) — surgery to completely close the cleft in the gum — at the time of the lip surgery.

Doing a GPP at the time of the lip surgery can prevent the need for a future alveolar bone graft in about half of the children. Not all children who have NAM are good candidates for a GPP.

Your Seattle Children’s orthodontist, plastic surgeon and nurse practitioner are specially trained in NAM and the surgery that comes after. They can answer any questions you have. During and after NAM therapy, your child will also see other members of the craniofacial team at regular clinic visits as often as they need.