Abstract
Levy-Bercowski D, Abreu A, DeLeon E, Looney S, Stockstill J, Weiler M, Santiago PE. Complications and solutions in presurgical nasoalveolar molding therapy. Cleft Palate Craniofac J. 2009;46:521–528.
We read with interest the research article by Dr. Bercowski and coworkers (2009). It provides a comprehensive discussion on the potential problems one might encounter during nasoalveolar molding (NAM) and their probable solutions. Nasoalveolar molding is a relatively new treatment modality, and there is not much literature discussing its complications.
In our clinical experience with NAM since 2005, we have observed one complication that warrants mention: vomiting. Vomiting following initiation of NAM in infants with nongastroesophageal reflux disease is a rare complication and must be differentiated from possetting (regurgitation of milk), a common condition among infants in the early months of life. During NAM therapy, vomiting can occur as a possible sequel to an acute or chronic episode of gagging and may lead to aspiration pneumonia, which can manifest as a serious medical situation. It has been observed even when the appliance is well short of the hard palate-soft palate junction, possibly due to a hyperactive gag reflex.
Its occurrence is most common during early days of NAM initiation (while recording an alveolar surface impression or inserting the appliance in the mouth) because the infant is not yet desensitized to the foreign body placed in his/her mouth. In view of its serious implications, a brief description of some preventive measures that avoid potentiating a gag reflex during NAM therapy is provided below:
Keep the infant fasting for at least one half hour prior to recording an impression or initially inserting the NAM appliance.
While recording an alveolar surface impression, take care to select an appropriately sized noncustom tray so that it does not extend far behind posteriorly, and use as little impression material as possible to record the impression.
While fabricating the appliance, limit the posterior extent of the occlusal tray, preferably 2 to 3 mm short of the postgingivae (described as the posterior limit of the fleshy palate; Ashley-Montagu, 1934) in the periphery, the posterior border gently curving anteriorly (approximately 5 mm) in the central portion. An appliance with a shorter posterior extent may easily be dislodged by the tongue.
If the infant repeatedly dislodges the appliance, consider fabricating a new appliance after obturating the cleft palate gap in the working cast to a level slightly deeper than the adjacent palatal shelves, especially toward the central portion of the posterior border, using modeling wax. The palatal vault formed by the appliance can now be raised by a few millimeters. Take care to avoid contact with the nasal mucosa at all times. This modification is preferred over posterior extension of the occlusal tray.
Maintain a uniform occlusal plate thickness of 2 to 3 mm. Bulky plates may cause gagging by contact with the posterior portion of the tongue and soft palate, besides tending to displace the appliance by the actions of the buccinator (buccal aspect), the orbicularis oris (labial aspect), and the tongue (palatal aspect).
Observe the infant for at least one half hour after delivery and insertion of appliance (preferably until the baby goes to sleep) for the first few days of treatment. If the infant appears to gag, the appliance must be suitably modified. Parents must be advised to gradually begin oral feeds after this period.