Case Report: Enhancing Cleft Lip and Palate Outcomes with Presurgical Lip, Alveolus, and Nose Approximation (PLANA)

Article from USA

Jessica Canallatos, DDS, MS

Prosthodontist Craniofacial Center of Western New York

John R. Oishei

Children’s Hospital, Kaleida Health

Introduction

This case highlights the successful use of Presurgical Lip, Alveolus, and Nose Approximation (PLANA) in a male infant born at 39 weeks gestation with a right unilateral complete cleft lip and palate. The patient faced significant challenges, including a severe cleft deformity, feeding difficulties, and a cultural and language barrier with the parents. These factors made presurgical intervention essential to optimize outcomes for surgical repair.

PLANA is a simplified approach to presurgical infant orthopedics designed for babies with cleft lip and palate. It utilizes a series of progressively larger nasal stents, combined with lip taping, to mold the nasal cartilage, align the alveolar ridges, and bring the lips closer together. Unlike the Nasoalveolar Molding (NAM) prosthesis, PLANA does not have an intraoral component, making it a more suitable option for infants with feeding difficulties. Additionally, the method requires fewer clinic visits, providing a family-centered solution that accommodates individual needs and routines.

Clinical Presentation

The infant was delivered via cesarean section with Apgar scores of 9/9. Apart from the severe unilateral complete cleft lip and palate, the patient was otherwise healthy. Feeding challenges and parental overwhelm initially limited the consideration of traditional Nasoalveolar Molding. However, the PLANA appliance presented an alternative approach, offering a reduced visit frequency and non-intrusive integration into the family’s routine.

Birth Photos: Depicts the right unilateral complete cleft lip and palate.

Presurgical Treatment Protocol

Lip taping commenced at two days of age to encourage soft tissue movement and counteract forces that could exacerbate the cleft. At one week of age, the patient began treatment with PLANA:

1. Size 1 PLANA was worn for two weeks, alongside lip taping.

2. Size 2 PLANA followed for four weeks, with continued lip taping.

3. Size 3 PLANA was used for the final four weeks, with continued lip taping, before lip repair surgery.

PLANA in Place: Demonstrates initial placement, with the NoseAlign stent gradually seating fully. The elastics visibly center the septum and support nasal molding.

The stepwise increase in appliance size allowed for progressive alignment of the nasal cartilage and alveolar segments, while taking into account the growth of the baby. The treatment capitalized on the high moldability of infant cartilage, which diminishes after six weeks of age. The stepwise increase in lip taping size allowed for elongation of the philtrum. The family required only one to two visits per month, during which the parents were guided in lip taping techniques and PLANA insertion, fostering their confidence and engagement.

Outcomes

The results of PLANA treatment were outstanding:

• Nasal Symmetry: The nasal stents applied upward and lateral pressure to shape the cartilage, achieving excellent symmetry.

• Lip Approximation: The appliance and elastics aligned the lips on either side of the cleft, allowing the alveolar ridges to follow and move into close proximity.

• Improved Surgical Foundation: The elongation of the philtrum and nasal-lip junction provided an ideal foundation for surgical repair.

The parents reported a remarkable improvement and expressed immense relief and joy at the progress achieved within the 11-week treatment period.

Post-Treatment Photos: Shows nasal symmetry, cleft closure, and lips in proximity pre-surgery.

Discussion

PLANA treatment offers distinct advantages over traditional NAM:

• Simplified Follow-Up: Monthly visits reduce the burden on families compared to weekly NAM adjustments.

• Preserved Feeding Habits: PLANA does not interfere with feeding routines, accommodating the family’s established practices.

• Optimized Timing: Initiating treatment within the first week of life maximizes cartilage moldability, ensuring optimal results

  
  

This case underscores the importance of early intervention in presurgical infant orthopedics and highlights PLANA’s efficacy in reducing parental stress while achieving excellent clinical outcomes.

Conclusion

The use of PLANA for this patient achieved exceptional nasal symmetry, improved lip approximation, and enhanced readiness for surgical repair. This case exemplifies how innovative approaches like PLANA can deliver remarkable results while addressing the practical needs of families.