We have a special post today because it is something that is very interesting to me for 2 reasons: 

1. I never had the chance to experience a NAM appliance myself when I was a baby.
2. I’m fascinated by the appliance, and I did a research paper on it in dental school!

Nowadays, it is very typical for a cleft baby to either have a NAM appliance or the Latham appliance prior to closure of the lip. While it is not absolutely necessary to have these appliances, it does help tremendously with the surgical result. In this post, we will be focusing on just the NAM appliance.

I will also be interviewing my husband towards the end of this post because he is currently working on a cleft baby, and he made a NAM appliance for the little one!  He is a maxillofacial prosthodontist fellow at UCLA.

What NAM stands for…

Nasoalveolar Molding

• Naso= nose 
• Alveolar= bone 

So literally, it means it helps to shape the nose and the segments of the palate on either side of the cleft (bone).

What it does

A cleft lip + palate creates a large defect in the lip and palate, often causing the nose to be off-center, especially in a unilateral cleft lip + palate. The reason for this is because due to the location of the cleft, there is no bone in the area to support the structure of the nose. Therefore, the bridge of the nose is pushed to the side.  In a bilateral cleft lip + palate, the nose may be centered, but it is often wide and flat.

NAM does not involve surgery! It is a device that helps shape the gums, lips, and nose in both unilateral and bilateral clefts. It gradually creates pressure to shape the facial structures and reduce the size of the cleft.  After that, the lip is surgically repaired.

The NAM appliance needs to be cleaned daily.  It is taken out of the mouth by the parent or caregiver and rinsed with toothpaste, toothbrush, and warm water before replacing the tapes.

Why it is so great! 

It usually requires the child to have less surgeries to repair the cleft than in the past. Reducing the size of the cleft with the NAM appliance allows for a thinner scar and helps the surgeon achieve a better shape of the nose. Quite often, the NAM can help prevent future surgeries that were once required for a cleft child. 

What it looks like

It is clear acrylic, and it looks like a retainer that fits over the entirety of the baby’s upper jaw.

There is a button that comes out the front of the mouth where the cleft is through the lip.  Rubber bands are placed around the button on either side and pulled to create tension. Tape is then used to hold the appliance in place by taping the rubber bands to the cheeks. 

When the cleft in the gums is reduced to about 1/4″, the nasal portion is added to the appliance. This is a projection that extends up into the nostril coming out of the front of the appliance and helps to remodel the nose from a flat shape to a more rounded shape. 

How it works 

1. A dental impression is made of the newborn’s upper jaw by a dentist

   

2. The NAM appliance is made and inserted into the baby’s mouth
3. The rubber bands are applied, and tape is placed on the baby’s cheeks
   • This creates pressure upward and backward. It is perfectly NORMAL for the eyes to droop down and the skin to be irritated by the tape. The eyes will return to normal once NAM is finished, and the doctor actually uses the skin irritation as an indication that you are correctly using the appliance at all times!
   • Tape is replaced daily by the parent
   • If the appliance is not sturdy in the mouth, replace the tape and pull more tension on the rubber bands 

     

4. Adjustments are made to the NAM on a weekly basis by adding to the acrylic on the inside surface
   • Each time the baby comes in, more material is added to the area of the cleft to continue creating pressure. The pressure helps to redirect the growth of the face and palate as the child grows. Each adjustment is very small. 
5. When the cleft is reduced to about 1/4″, the nasal portion is added to shape the nose

   

   

6. By the time the baby is ready for surgery, the cleft has been reduced significantly, which makes for easier surgical repair 

Benefits 

• Helps to create suction by closing the cleft while appliance is in place (easier for feeding)
  

  

• Weekly checkups are always nice to have to make sure the baby is progressing well!
• Speech will be much better due to smaller cleft
• Minimal scarring
• More rounded nose
• Fewer future surgeries 

Interview with Dr. Paul Canallatos

At what age does the NAM appliance start?

It is ideal to start within the first 6 weeks of life.

Does the baby need to wear the appliance all the time?

The baby should wear the prosthesis at all times, including feeding. It can be removed temporarily for hygiene, but it is ideal to have it worn as much as possible to allow the molding to take place.

Does it hurt the baby?

It does not hurt the baby, but it is uncomfortable for a couple of days after an adjustment is made- much like a patient is sore after getting an adjustment at the orthodontist.

How does the baby eat with the appliance in?

The baby is able to be fed via a bottle the same way as without the prosthesis. The baby can sometimes even eat better with the prosthesis in after a while.

How long does the baby need to wear the appliance before surgery?

It is ideal to have the prosthesis worn up until the 3-month period before the first surgery, which is the lip surgery.

How do you make the impression of the baby’s mouth?

The impression is made with a putty material that is very viscous so the patient will not breathe in the material. While making an impression, we make sure there is plenty of room for the baby to breathe. The patient cries during the impression because it is something new, but it does not hurt. Crying is a good thing because we know we have a clean airway then!

Let us know if you have any other questions!

 *pictures provided by UCLA