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• W2313941408 abstract "Sir: Loeffelbein et al. present excellent points that warrant discussion regarding our article presenting three-dimensional technology–assisted nasoalveolar molding: finding the proper trajectory for maxillary growth in cleft patients and achieving optimal results in greater segment molding.1 They bring up the importance of implementing a three-dimensional factor for growth when simulating alveolar segment movement in nasoalveolar molding. In our model, we compensated for transverse maxillary growth using a growth factor based on a small amount of historical data from our cleft patients. However, as the distance between T and T′ did not change significantly before and after nasoalveolar molding, it is possible that we did not compensate enough for transverse maxillary growth, and this warrants modifications to our growth factor. Anecdotally, we have seen that individual differences in alveolar segment growth are relatively large in the cleft population. The lack of large sample size data for three-dimensional pediatric facial growth in the cleft population makes it difficult to design factors for growth accurately. We eagerly anticipate the results from Dr. Loeffelbein’s group regarding the RapidNAM system that will take steps to provide these valuable data in cleft patient maxillary growth. Loeffelbein et al. also point out that in the patient example in Figure 2 (showing treatment progression in our three-dimensional computer-aided design–simulated nasoalveolar molding), the greater segment undergoes a “kink” to rotate into alignment with the lesser segment. In our experience, it can be difficult to prevent such a kink in cases where the greater segment is more deformed or less concave. Similarly, when there is significant asymmetry in the anteroposterior position of the greater and lesser segments, nasoalveolar molding providers often must choose between achieving a continuous arch versus a uniformly curved greater segment. In our series of images, the final rendering (yellow) displays a kink as the tradeoff for compensating for significant anteroposterior discrepancy. With or without three-dimensional computer-aided design assistance, preventing kinks such as these is technically difficult but not impossible. Lengthening the time course of nasoalveolar molding treatment and modifying the points of pressure and leverage of our intraoral devices can achieve improvements. We agree with Loeffelbein et al. that such technical modifications would improve the contour of the greater segment, and this is a challenge we will attempt to address in future versions of our program. There has been no evidence in the literature that a kink in the greater segment leads to long-term functional or aesthetic sequelae. Using orthodontics if necessary can compensate for this shortcoming. The primary goal of nasoalveolar molding is to correct skeletal deformities of the cleft maxilla in preparation for cleft lip surgery.2 Experts agree that a more anatomical bony framework, narrower cleft, and improved nasal symmetry facilitate better surgical outcomes.3,4 Although we agree that our current modeling algorithm has room for improving greater segment contour and accounting for maxillary growth, we believe that results from our pilot study are adequate to achieve the primary goals of nasoalveolar molding. We emphasize that the goals of our program were to create a nasoalveolar molding system that could serve a higher volume of patients, as each cleft practitioner at our institution sees over 50 patients each year who would benefit from nasoalveolar molding. One of the great shortcomings of nasoalveolar molding is its inaccessibility to patients in need, in terms of availability, time commitment, and cost.5 The ability to use three-dimensional technology–assisted nasoalveolar molding to overcome these barriers and better serve high volumes of patients could improve cleft outcomes with an advantageous value and risk-to-benefit profile. In the next steps, we look to use computer-aided design/computer-aided manufacturing and three-dimensional printing technology to not only fabricate impressions/molds, but also to fabricate nasoalveolar molding devices. As a significant amount of time and resources were devoted to creating nasoalveolar molding devices in our pilot study, this final hurdle may be tackled using existing three-dimensional technologies. Our long-term goals with future studies are to both improve modeling accuracy and expand the capacity of three-dimensional printing to fabricate complete sets of intraoral molding devices in advance of treatment. DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this communication or the article being discussed. Caroline A. Yao, M.D., M.S.William P. Magee III, M.D., D.D.S.Division of Plastic and Reconstructive SurgeryUniversity of Southern California Keck School of MedicineLos Angeles, Calif. Gang Chai, M.D., Ph.D.Department of Plastic and Reconstructive Surgery9th People’s Hospital of ShanghaiShanghai Jiao Tong University School of MedicineShanghai, People’s Republic of China" @default.
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• W2313941408 date "2016-05-01" @default.
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• W2313941408 title "Reply: Presurgical Nasoalveolar Molding for Cleft Lip and Palate: The Application of Digitally Designed Molds" @default.
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