The delivery of the appliance includes informing and instructing the caregiver of the proper way to place the appliance in the infant’s mouth. Base tapes are placed on the infant’s cheeks, and the appliance is secured to the face with Steri-Strips and small orth- odontic rubber bands. The rubber bands are attached to the appliance by a small button that protrudes from the appliance at the cleft opening and at a 45 degree angle.
A unilateral infant wears the NAM continu- ally for three to four months, with a bi-lateral infant wearing the NAM for approximately six months. During that time, the infant is seen in the office weekly to adjust the palatal shelves and add nasal stints to actively stretch and lengthen the columella. At each adjustment, the orthodontist removes hard acrylic and adds soft acrylic to the infant’s appliance to mold the alveolar segments and to stretch and lengthen the tissues. This lengthening is what provides the biggest ad- vantage in reducing the number of surgeries required for the lip repair.
Lengthening of the columella allows the plastic surgeon more tissue to work with when repairing the lip. The surgeon can ap-
proximate the lips for a better overall result and a more symmetrical nose and lip. After healing, the scar tissue is decreased, therefore reducing the chances for revision surgeries. However, the NAM’s success depends upon a team approach from the doctor and infant’s caregiver.
The infant’s caregiver has several responsi- bilities. In addition to weekly office visits, the NAM must be taped once a day. Generally infants accept the NAM as part of their face; however, it can be bumped or removed by the child’s uncontrolled movements. With this in mind, the caregiver must be diligent in caring for the NAM. This requires the caregiver to remove the NAM once a day, disinfect the appliance, check the infant’s mouth for any irritations and re-tape the appliance. With good teamwork, the NAM is a great success and results in an excellent lip repair outcome.
CONCLUSION
In the past, nasoalveolar molding has been controversial. However, there have been numerous articles written proving that with the NAM, the benefits of providing improved esthetics before surgery is beneficial to the
!
by ROBERT RETI, DDS; ALLISON WINKLER & MICHAEL NOBLE, DMD
BACKGROUND
emophilia is the most common bleeding disorder worldwide. Many patients with mild disease
may go unnoticed until a much later age. It is important for the dental practitioner to not only be competent in appropriate management of a diagnosed coagulopathy, but able to identify an abnormal bleed. Inappropriate treatment of this population can lead to major bleeds, and worse, pos- sible death if unrecognized.
Coagulopathies refers to the impairment of the blood’s ability to clot. Hemophilia (in Greek translates to “blood love”) is a type of coagulopathy and includes hemo- philia subtypes A, B and C. It is caused by insufficiency or defects in clotting factor VIII, factor IX and factor XI respectively. These clotting factors are sex-linked, reces- sive disorders that are transmitted on the X chromosome1,2,3
. Part of the intrinsic,
In this article we will review a case of a pa- tient with an undiagnosed hemophilia that presented to our emergency department. We also will review treatment guidelines for this unique group of patients.
coagulation pathway deficit of these factors result in inadequate formation of thrombin at sites of vascular injury. Prevalence is estimated at 1 in 5,000 to 1 in 30,000 male births, with a substantial proportion (30 percent) of hemophilia cases arising as new, spontaneous mutations2,3
.
patient. This procedure is providing patients and parents with a state-of-the-art method to improve the cleft condition through the least surgically invasive technique currently available. f
REFERENCES
Brecht L, Grayson B, Cutting C. “Columellar elongation in bilateral cleft lip and nose patient.” J Dent Res 1995; 74:257.
Cutting C, Grayson B, Brecht L, Santiago P, Wood R, Kwon S. “Presurgical columellar elongation and primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair.” Plast Reconstr Surg 1998; 101: 630.
Brecht L, Grayson B, Cutting C. “Nasoalveolar Molding in Early Management of Cleft Lip and Palate.” Clinical Method for Correction of the Unilateral Oronasal Cleft Deformity
DR. TARA CASH practices at Cash Family Orthodontics in Springfield and is one of only three trained Missouri orthodontists for nasoalveolar molding for cleft lip and palate in infants. She graduate of the UMKC School of Dentistry (DDS 2006; Orthodontic Residency Program 2008). Contact Dr. Cash at
taracashdds@yahoo.com.
GO ONLINE to
www.modental.org/focusce to access quiz questions that can be taken for CE credit. Follow the instructions provided, submit responses to the MDA after which you will be notified of credit. For questions contact Melissa Albertson.
Case of spontaneous gingival bleed H
Severe coagulopathies are characterized by spontaneous or traumatic bleeding and may result in life-threatening complica- tions. On the other hand, moderate and mild coagulopathies may remain clinically silent until detected on laboratory screen- ing tests or when these tests are ordered to evaluate the cause of abnormal bleeding or bruising. DNA analysis is available to detect carriers and establish prenatal diagnosis, but this is most often done for suspicion due to medical or familial history1
. Severe
hemophilia is typically suspected and diagnosed during infancy, in the absence of a family history. Among newborns, typically the first indication of a hemophilic disorder is spontaneous hemarthrosis occurring between 9 and 18 months of age when the
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