Recent Articles: Early Management of Unilateral Cleft Lip, Alveolus, and Palate

1. Directly Matching Article

• Authors: Shakti P, Kumar S, Haider K, et al.
• Journal: International Journal of Clinical Pediatric Dentistry, 2026; 19(5):662-666
• PMID: 42291008 | PMC: PMC13262089
• DOI: 10.5005/jp-journals-10005-3508
• Summary: Five cases of unilateral CLAP (cleft lip, alveolus, and palate) treated with Grayson's PNAM technique before primary lip repair. Model analysis showed substantial reduction in cleft deformity in all cases, contributing to superior postoperative results with minimal tension and finer scar formation.

2. Presurgical Management - Reviews (2025)

• Authors: Hughes EB, Patel D, Randhawa KS, et al.
• Journal: Facial Plast Surg Clin North Am, 2025 Nov
• PMID: 41101802
• Summary: Compares upper lip taping, nostril elevation systems, and NAM, proposing a model for presurgical optimization. Covers key decisions before formal cleft lip and palate repair surgery.

• Authors: Ahmed MK, Kim JY, Jolly LR
• Journal: Facial Plast Surg Clin North Am, 2025 Nov
• PMID: 41101803
• Summary: Comprehensive review of NAM as presurgical infant orthopedic therapy. Discusses improvements to palatal, alveolar, and nasolabial parameters; reduced revision surgery rates; psychosocial benefits; and emerging digital/CAD-CAM workflows.

• Authors: Cecola C, Patel K, Jones LR, et al.
• Journal: Facial Plast Surg Clin North Am, 2025 Nov
• PMID: 41101804
• Summary: Reviews prenatal diagnosis via ultrasonography, postnatal feeding strategies, NAM, and primary surgical techniques (Millard, modified Millard/Mohler, Fisher). Emphasizes multidisciplinary care and functional/aesthetic outcomes.

3. Presurgical NAM - Narrative Review + Case Report (2025)

• Authors: Divakar S, Rathee M, Tomar SS, et al.
• Journal: Journal of Prosthodontics, 2025 May
• PMID: 40369702
• Summary: An 18-day-old female with unilateral CLP treated with Grayson's PNAM combined with conventional and 3D-printed nasal stent. After 4 months, alveolar cleft width reduced from 1.24 cm to 0.70 cm. Highlights the role of combined prosthodontic-surgical approaches.

4. Digital Technology in NAM - Scoping Review (2026)

• Authors: Nguyen BK, Caro C, Stevens K, et al.
• Journal: Cleft Palate Craniofac J, 2026 Aug
• PMID: 40934105 | PMC: PMC13334062
• Summary: PRISMA-based scoping review identifying 4 CAD/CAM methods for NAM: stepwise alveolar molding with manual plates (SM_MP), with 3D-printed plates (SM_3P), stepwise plate expansion + 3D printing (SPE_3P), and semi-automated expansion (SAPE_3P). SM_MP remains most common; 3D-printed variants show increasing sophistication.

5. Surgical Outcomes

• Authors: Xu Y, Yao M, Shi B, et al.
• Journal: Clinical Oral Investigations, 2024 Sep
• PMID: 39304571
• Summary: 115 patients followed from primary repair to 5.3 years postoperatively using 3D photogrammetry. Growth lag in cleft-side lateral lip and slower columellar growth cause progressive deviation toward the cleft side. Preoperative severity predicts postoperative outcomes; laterality does not significantly affect long-term results.

• Authors: Munns C, Reade J, Chong D, et al.
• Journal: J Craniofac Surg, 2026 Jul-Aug
• PMID: 41925527
• Summary: Scoping review of 19 articles showing full-face evaluation is equally reliable to nasolabial-cropped assessment and provides better insight into overall facial balance and growth over time.

6. 3D Printing in CLP - Broad Review (2025)

• Authors: Kelly SS, Suarez CA, Mirsky NA, et al.
• Journal: J Craniofac Surg, 2025
• PMID: 38738906
• Summary: Reviews 3D printing across presurgical planning, surgical training, implantable scaffolds, and postoperative care. Discusses future integration with AI, 4D printing, and in-situ bioprinting.

7. Updates in Cleft Care - General Review (2023)

• Authors: Parham MJ, Simpson AE, Moreno TA, Maricevich RS
• Journal: Seminars in Plastic Surgery, 2023 Nov
• PMID: 38098682 | PMC: PMC10718659
• Summary: Covers current standards from prenatal diagnosis through adulthood, including primary repair (lip, nose, palate) during infancy, alveolar bone grafting, orthognathic surgery, and multidisciplinary care frameworks per ACPA guidelines.

Key Themes Across Recent Literature

Article 3 - Detailed Profile

"Early Management of Cleft Lip and Palate Using Presurgical Nasoalveolar Molding and 3D-Printed Feeding Plate and Nasal Stent: A Narrative Review and Case Report"

Background & Rationale

The Case

• Patient: 18-day-old female infant referred from the Department of Plastic Surgery with a complete unilateral cleft lip and palate (UCLP)
• Treatment plan: Presurgical nasoalveolar molding (PNAM) using the Grayson technique combined with both conventional and 3D-printed nasal stent technology

What Was Done - Step by Step

1. PNAM initiation at 18 days of age using Grayson's technique (intraoral molding plate + extraoral nasal stent)
2. A 3D-printed nasal stent was fabricated alongside the conventional acrylic nasal stent - this hybrid approach used digital scanning and additive manufacturing to improve stent precision and fit
3. Treatment continued for 4 months
4. After PNAM therapy: alveolar cleft width reduced from 1.24 cm to 0.70 cm (a 43.5% reduction)
5. Following primary lip repair surgery, a feeding plate and nasal stent prosthesis were newly fabricated to prepare for the upcoming cleft alveolus and palate surgery

Key Outcomes

• Significant reduction in alveolar cleft width
• Improved nasal cartilage alignment and columellar position
• The combined prosthodontic-surgical approach resulted in "optimal therapeutic results"
• Reduced surgical tension at primary lip repair

Significance

Related Articles (PubMed-linked)

• PMID 37020760 - Rathee M et al. (2023): PNAM using innovative impression technique - from the same research group
• PMID 39372347 - Taori et al. (2024): PNAM with columella lengthening in unilateral CLAP

Article 4 - Detailed Profile

"Computer-Aided Design and Computer-Aided Manufacturing Technology for Conducting Nasoalveolar Molding for Infants With Cleft Lip and Palate: A Scoping Review"

Objective

Study Design

• Type: Scoping review following PRISMA-ScR (Preferred Reporting Items for Scoping Reviews) guidelines
• Databases searched: MEDLINE, Embase, Web of Science, Cochrane Library, Scopus
• Population: Infants with unrepaired, non-syndromic, complete UCLP or bilateral CLP (BCLP)
• Final inclusion: 13 articles

The 4 CAD/CAM Methods Characterized

Key Findings

• SM_MP was the most commonly used method - it has the longest track record but requires significant manual chairside work after virtual planning
• SM_3P advances further by using 3D printing for fabrication, reducing manual labor but retaining stepwise molding logic
• SPE_3P and SAPE_3P represent a conceptual shift - instead of simulating incremental tooth/alveolar movements, they design a series of progressively enlarged plates, with SAPE_3P using a semi-automated algorithm to minimize clinician input
• Only SM_MP and SM_3P had been applied to BCLP patients; SPE_3P and SAPE_3P were validated only for UCLP at the time of review

Clinical Workflow (General CAD/CAM NAM Process)

1. Digitize the maxilla (intraoral scan or photogrammetry)
2. Virtually model the desired alveolar movements or plate shapes
3. Manufacture plates - either manually (SM_MP) or via 3D printing (SM_3P, SPE_3P, SAPE_3P)
4. Fit, monitor, and adjust in clinic - though frequency of visits may be reduced vs. conventional NAM

Why This Matters

How Articles 3 and 4 Connect

• Article 3 demonstrates a hands-on clinical application: a single neonate treated with hybrid conventional + 3D-printed PNAM, showing measurable anatomical improvement before surgery
• Article 4 provides the systematic landscape: a structured review classifying every published CAD/CAM NAM protocol, showing where the field stands and where evidence is still weak

The Grayson Technique (Presurgical Nasoalveolar Molding - PNAM)

Origin and History

Core Concept and Objectives

For Unilateral CLAP, the objectives are:

1. Reduce the alveolar cleft width
2. Align the alveolar segments (greater and lesser segments into proper arch form)
3. Lengthen the columella on the cleft side
4. Reposition the alar dome and nasal tip
5. Reduce nasal asymmetry (nostril width ratio, alar base deviation)
6. Approximate the lip segments non-surgically via taping

For Bilateral CLAP, additional objectives include:

• Non-surgical columellar elongation (to avoid a formal columellar lengthening surgery)
• Centering and retracting the premaxilla along the midsagittal plane
• Reducing nasal tip width and improving projection

The Appliance - Components

1. Intraoral Molding Plate

• Custom-fabricated acrylic plate that covers the hard palate and alveolar ridges
• Fits passively (no screws, no active expansion)
• Modified incrementally at each visit by adding soft acrylic where bone movement is desired and removing hard acrylic where tissue needs to advance
• Prevents tongue from entering the cleft (which would worsen the deformity)
• Retained in the mouth by surgical tape + elastics from the plate's retention arm to the cheeks

2. Nasal Stent (added later in treatment)

• A bilobed projection of acrylic supported by a round stainless steel wire (0.036 gauge) bent in a "swan neck" shape
• Attached to the intraoral plate via the retention arm
• Positioned approximately 40° downward from the horizontal plane
• Covered with a thin veneer of soft acrylic to apply gentle upward pressure inside the nostril
• Lifts the collapsed alar dome, reshapes the nasal cartilage, and elongates the columella

Step-by-Step Procedure

Phase 1 - Alveolar Molding (Weeks 1-6 approximately)

Phase 2 - Addition of Nasal Stent (when alveolar gap < 0.5 cm)

Phase 3 - Completion and Surgery

Grayson vs. Other PNAM Techniques

Clinical Evidence (2025 Meta-Analysis)

• Improved nasolabial aesthetics vs. other presurgical orthopedics
• No harm to midfacial skeletal growth through age 12
• Possible reduction in labial and nasal revision surgeries
• High upfront cost but reduced long-term costs and reduced caregiver psychosocial burden

Limitations and Challenges

• Frequent clinic visits (every 2 weeks for 3-4 months) - a burden for families far from cleft centers
• Compliance-dependent - requires parents to maintain daily taping diligently
• Skin irritation from adhesive tape is the most common complication
• Skill-intensive - appliance fabrication and adjustment require specialized prosthodontic/orthodontic training
• Evidence quality remains low-to-moderate due to lack of standardized outcome measures across studies

Why It Matters in the Context of Articles 3 and 4

• Article 3 (Divakar et al.) used Grayson's technique as the foundation but added a 3D-printed nasal stent alongside the conventional acrylic one - modernizing the appliance fabrication without changing the underlying Grayson protocol
• Article 4 (Nguyen et al.) shows how Grayson's original manual workflow (SM_MP category) has now evolved into fully digital CAD/CAM variants, with the SM_3P method being essentially "Grayson digitized" - keeping the stepwise alveolar molding logic but replacing manual acrylic work with 3D printing