NAM, Presurgical Orthodontia

Presurgical orthodontics known as nasal alveolar molding, or NAM, is a device that brings the lip segments of the cleft closer together and gives the nasal deformity increased projection, resulting in a significantly better surgical outcome. This small, hand-crafted, and personalized plastic appliance is fitted to the infant’s mouth, nose, and lip and is worn daily for 3-4 months beginning in the 1st week of life. The appliance is made in our office by our technician, Heather Early. Ms. Early also assists parents as they learn to apply the NAM on their child and supports them through the months-long procedure.

Another advantage of the appliance is that it can make feeding easier for most patients.

NAM therapy is integral to the success of the surgery. Take a look at the photo of this beautiful baby at her initial diagnosis:

Cleft before NAM therapy

While a surgeon could force the lip together, it would be under severe tension and the nose would remain flat and distorted. These are not things that can be overcome surgically.

Take a look now, after 8 weeks of NAM therapy:

Cleft after NAM therapy

Now the lip will come together under minimal tension, and we can shape a beautiful nose for this patient. This is the power of NAM.

Dr. Hobar on his experience with NAM:

“I saw the power of nasoalveolar molding or NAM when I completed my craniofacial training in 1990 under the direction of Dr. Joseph McCarthy at NYU. Under the leadership of Dr. McCarthy, Dr. Barry Grayson, craniofacial orthodontist, and Dr. Court Cutting, cleft surgeon extraordinaire, were working closely together to perfect the symphony of preoperative nasoalveolar molding and surgical reconstruction.

The first team to begin working in this area was Dr. Ralph Millard (known as the father of cleft surgery and the creator of the Rotation Advancement Lip Repair, widely known as the Millard procedure) out of Miami and Dr. Ralph Latham, an orthodontist, out of Canada in the 1980s. Together they developed what is frequently known as Presurgical Orthopedics, which is essentially correcting the bony platform that accompanies a cleft with forces applied through orthodontic devices. Dr. Grayson demonstrated that if treatment is begun very early (1st week of life), the gums, nose, and lip can all be positively affected with very gentle but steady force using soft acrylic and tape. Dr. Grayson is the person who coined the term nasoalveolar molding and championed the techniques behind it.

Seeing the power of nasoalvelar molding, I could not begin my practice of cleft care without incorporating this powerful and revolutionary technique. I literally woke up in the middle of the night in cold sweats when I had my first cleft patient, and no one to help me with the presurgical appliance. I started taking my own impressions and sending them to Dr. Latham’s lab in Canada. I was fortunate enough to meet Dr. Cheryl Anderson-Cermin, who was completing her orthodontic fellowship while I was beginning my practice at the University of Texas Southwestern (UTSW). She went to New York to train with Dr. Grayson then returned to join our faculty. As far as I know, we were the third team in the world using this powerful technique, and Dr. Anderson-Cermin has become one of the best, most experienced orthodontists in the world with NAM. Dr. Anderson-Cermin also became one of the founding board members of LEAP (www.leap-foundation.org), and even though she has relocated her practice to St. Croix Falls, Wisconsin, she still travels to Dallas for our LEAP board meetings and accompanies us on our annual LEAP mission trips to Central India.

Currently, we are blessed to have Heather Early working with us at Wellspring, in a capacity that is specifically dedicated to making presurgical appliances, NAM, and acting as a parent-to-physician liaison for our cleft families. Dr. Anderson-Cermin, Ms. Early, and Ms. Nora Hooks worked together with our team at Children’s Medical Center and UTSW in Dallas for about 10 years caring for our cleft and craniofacial patients.”