Introduction
The facial cleft deformity or cleft lip, alveolus and palate cannot be treated successfully by only one discipline or specialty. The interaction and opinion between various disciplines enhances the understanding and limitations to devise a comprehensive treatment strategy (Grayson et al., 1999). Described pre-surgical naso-alveolar moulding (PNAM) which involved active moulding and repositioning of the deformed nasal cartilages and alveolar processes as well as the lengthening of the deficient columella. A basic treatment objective for the cleft lip, alveolus and palate patients is to restore normal anatomy. This includes the nasal components as well. Because of the major hard and soft tissue abnormalities observed in these patients, it is highly desirable to restore the correct skeletal, cartilaginous and soft tissue relationships pre-surgically. In case of bilateral deformity, it is particularly advantageous to lengthen the deficient columella prior to the primary surgical repair of the lip and nose (Taylor, 2000).

Case history
A 2-day old infant having mid-facial cleft was brought to the Department with the primary need of a feeder plate. On examination, a bilateral cleft lip and palate extending onto the soft palate was seen (Figure 1). The treatment goals, the procedure and the role of the parents, were explained to the patient’s parents. An impression in low fusing impression compound (Green Tracing sticks, MAARC, Mumbai, MH, India) was made when the patient was a week old. The size of the cleft was measured on the cast using a Vernier Calliper (Digital Vernier Calliper 200 mm, Sealy Power Products, Bury St. Edmunds, Suffolk, UK). The distance from the base of the alveolus on one side to the other was found to be approximately 9 mm. The cleft region of the palate and alveolus was blocked-out and normal anatomic contours were built with base plate wax (Figure 2). The cast was then duplicated in irreversible hydrocolloid (Neocolloid, Zhermach, Rovigo, Italy) to obtain a working cast on which 2 layers of base plate wax (Y-dents No. 2 Modelling wax, MDM Corp, Delhi, India) was adapted and acrylized in clear heat cure acrylic (Trevalon Clear denture material, Dentsply India, Gurgaon, India). After the plate was tried in the patient’s mouth, a retentive button of self-cured clear acrylic (Rapid Repair, Dentsply India, Gurgaon, India) was attached to the labial flange, at an angle of 45° to the occlusal plane (Figure 3). The intaglio surface of the plate was, then, modified to allow selective pressure on the three segments of the arch so as to correctly align them. One to 1.5 mm thick layer of permanent soft liner [Permasoft, Dentsply Austenal, New York PA] was applied onto the outer surface in the region of the greater segments and the inner surfaces were relieved to the same extent. One to 1.5 mm of the soft liner was then applied on the inner surface in the region of the middle segment and the outer region was relieved by 1.5 mm. This caused a force that was directed inward on the greater segment and outward on the lesser segment. Two thicknesses of adhesive tapes were required for retentive taping. The thicker adhesive tapes (0.5 x 2 inches) were secured onto the cheeks of the patients, superior and lateral to the commisures. The thinner tape was looped around a red orthodontic elastic (Tru-Force Latex Elastic System, TP Orthodontics Inc, La Porte, Indiana, USA).The loops were secured onto the larger base tapes with additional adhesive tapes. The direction of the force exerted by the loops was ensured to be in the lateral and superior directions (Figure 4). The patient was, then, recalled after a week. The parents were taught the procedure for retentive taping and were advised to change the tapes every day or whenever the tapes peeled-off. When the size of the cleft was reduced to <6 mm on both sides, the stage of active nasal moulding was begun. A nasal stent was constructed of 19 gauge round stainless steel wire (Smith SS wire, KC Smith, Monmouth NPS, UK) and was attached to the retentive button. (Figure 5). The superior loop was adjusted to fit passively in the nostril. The nasal part of the wire was covered with self-cured clear acrylic and then by a layer of the soft liner to support the nostril to the desired extent (Figure 6). At the age of 14 weeks, the desired nasal cartilage and alveolar shape was achieved. This can be seen from patient’s pre- (Figure 7) and post-operative (Figure 8) casts and pre- (Figure 9) and post-operative (Figure 10) clinical profile photographs.
 

Discussion
A high degree of plasticity is seen in the cartilages of infants in the first few months after birth. Matuso and Hirose (1991) postulated that a high amount of maternal estrogen caused an increased amount of hyaluronic acid in the fetal cartilage rendering it plastic. Hence, active soft tissue and cartilage moulding is most successful during the first 3-4 months after birth. While PNAM has proved to be a beneficial approach, especially when used with columella elongation, for bilateral cleft deformities, its success depends upon a modified surgical procedure for repair. The surgical procedure advised is the modified gingivo-periosteo-plasty (GPP) described by Millard and Latham (Millard and Lanthum, 1990). It is usually performed within 12-16 weeks of age but can be post-poned if additional weeks of PNAM therapy are deemed necessary. The procedure involves a first stage primary lip nose repair with GPP to close the alveolar defect. This should be followed by a one stage palatal repair at 11-13 months of age when phoneme speech development in evident.

Conclusion
PNAM allows an overall improvement in the esthetics of the naso-labial complex in both the unilateral and bilateral cleft conditions while minimizing the extent of the surgery and the overall number of surgical procedures.

References
Grayson B.H., Cutting C.B., Santiago P.E., and Brecht L.E., 1999, Pre-surgical naso-alveolar moulding in infants with cleft lip and palate, Cleft Palate Craniofac J, 36: 486-498
http://dx.doi.org/10.1597/1545-1569(1999)036<0486:PNMIIW>2.3.CO;2

Grayson B.H., Wood R.J., and Cutting C.B., 1997, Gingivo-perosto-plasy and mid-facial growth, Cleft Palate Craniofac J., 34: 17-20
http://dx.doi.org/10.1597/1545-1569(1997)034<0017:GAMG>2.3.CO;2

Matuso K., and Hirose T., 1991, Pre-operative non-surgical over-correction of cleft lip nasal deformity, B J Plast Surg., 44: 5-11
http://dx.doi.org/10.1016/0007-1226(91)90168-J

Millard D.R., and Lanthum R.A., 1990, Improved primary surgical and dental treatment of clefts, Plast Reconstr. Surg., 86: 856-871
http://dx.doi.org/10.1097/00006534-199011000-00006

Taylor T.D. (Ed.), 2000, Clinical Maxillofacial Prosthetics. 1st edition, Quintessence Pub., Illinois, pp.68-83