Pacific Coast Society of Orthodontists Bulletin Summer 2023 - 82

Special Section: Treatment of Patients with Craniofacial Anomalies
Angle Pearls
Making a Great First Impression
Dr. Kristen Lowe
Aurora, CO
NasoAlveolarMolding (NAM) is a presurgical infant
orthopedic technique for patients with cleft lip
and palate pioneered by Dr. Barry Grayson, a
craniofacial orthodontist, in the early 1990s. This
procedure approximates the clefted labial and
alveolar segments and reshapes the baby's nasal
cartilage in preparation for primary surgical repair.
NAM facilitates improved esthetic outcomes and
decreases the need for surgical revisions. As such, it
has changed the treatment protocol in many cleft
centers during the past three decades.
Dr. Paul Kasrovi
Berkeley, CA
PCSO Bulletin Contributor
Successful NAM begins with a great first impression
of the infant's palate. The molding plate traditionally
consists of a 2- to 3-mm acrylic base, and a
nasal stent is added when the alveolar cleft has
been reduced to approximately 5 mm (Figure 1).
An accurate impression is imperative to facilitate a
well-fitting appliance. Because obtaining an impression
on an infant is likely uncomfortable for most
orthodontists, I will share the modified technique
I have developed during the past decade following
my fellowship training with Dr. Grayson.
Patient Positioning
Patient positioning is a key consideration when
taking an impression on a patient in their first
few weeks of life. The ideal position protects the
patient's airway and allows the provider control
of the infant's head while the impression sets.
There have been several recommendations in the
literature ranging from having a parent hold the
patient upright to Dr. Grayson's method of having
his surgeon hold the infant in an inverted position
for the procedure.
My preferred patient position is demonstrated in
Figure 2. I sit knee to knee with one of my assistants,
and we have the infant supine on a pillow placed
on our laps. My assistant holds the infant securely,
and I have direct visualization of the infant's airway.
The infant is in the sniffing position, which is the
standard for optimizing the airway in pediatric
anesthesia. In this position, the glabella is aligned
horizontally with the patient's chin, the airway
space is open, and the external auditory meatus is
Figure 2. Infant in sniffing position for maxillary
impression. Printed with permission. © 2020 The
Regents of the University of Colorado. Created by
Berrien Chidsey.
Figure 1. Molding plate with and without nasal
stent
Figure 3. Modified DuraLock impression trays for use
with infants
82
PCSO Bulletin Summer 2023

Pacific Coast Society of Orthodontists Bulletin Summer 2023

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