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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2014  |  Volume : 32  |  Issue : 4  |  Page : 338-341
 

Simplified feeding appliance for an infant with cleft palate


Department of Paediatric and Preventive Dentistry, Christian Dental College, Ludhiana, Punjab, India

Date of Web Publication17-Sep-2014

Correspondence Address:
Reena Annie Chacko
Department of Paediatric and Preventive Dentistry, Christian Dental College, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.140970

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   Abstract 

A child born with cleft palate may experience difficulties while feeding. Early surgical treatment may need to be postponed until certain age and weight gain of the infant. The case presented here is of a 1-month-old neonate born with cleft palate, assisted with a new feeding appliance made with ethylene vinyl acetate using pressure molding technique to aid in proper feeding. The patient's weight and health significantly improved after the insertion of obturator. The advantages of this material included being lightweight, moldability, good palatal fit and decreased soft tissue injury.


Keywords: Dleft palate, ethylene vinyl acetate, obturator


How to cite this article:
Masih S, Chacko RA, Thomas AM, Singh N, Thomas R, Abraham D. Simplified feeding appliance for an infant with cleft palate . J Indian Soc Pedod Prev Dent 2014;32:338-41

How to cite this URL:
Masih S, Chacko RA, Thomas AM, Singh N, Thomas R, Abraham D. Simplified feeding appliance for an infant with cleft palate . J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2018 Nov 15];32:338-41. Available from: http://www.jisppd.com/text.asp?2014/32/4/338/140970



   Introduction Top


A cleft palate is a type of craniofacial malformation that occurs during the embryonic stage of life. This can range from just opening at the back of the soft palate, to a nearly complete separation of the roof of the mouth (soft- and hard-palate).

This type of opening in the palate can cause extensive feeding problems with nasopharyngeal reflux, nasal regurgitation, choking, prolonged feeding time, and slow or little weight gain. [1]

Male infants with a cleft lip ± palate are more likely to be affected than female infants. [1] According to a study, weight gain was the poorest in infants with a cleft palate only. [2]

The maxillary obturator resolves feeding problems, prevents nasal regurgitation, choking, allows better maxillary growth before surgery, and improves parent's psychosocial well-being. [3] This results in the appropriate growth for these infants.

Many authors suggest that a maxillary obturator should be applied as early as possible to avoid postsurgical problems. [4],[5],[6] Usually, the material used for traditional obturators is rigid and often injures the soft tissue [2],[4],[5],[6] In this clinical report, use of ethylene vinyl acetate (EVA) for the fabrication of an appliance that can passively adapt to the palate during function, is presented.


   Case Report Top


This clinical report describes a 1-month-old male infant who was born at Government Medical College, Kangra, Himachal Pradesh, India. The infant was born at full-term, with a hard and soft palate defect [Figure 1], weighing 2 kg, and had no family history of clefting or any other congenital defect. The parents gave a medical history of the child developing aspiration pneumonia a few days after birth. The pediatrician referred the patient at the age of 1 month to the Department of Pedodontics and Preventive Dentistry, Christian Dental College, Ludhiana, Punjab and requested a cleft palate feeding obturator to make it possible for the baby to be nursed. After discussion with the child's parents, it was found that the mother had difficulty in breastfeeding the newborn. Medical clearance was obtained before starting the treatment.
Figure 1: Cleft of soft- and hard-palate

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A nasogastric tube had been inserted for feeding, which was removed before taking the impression. A preliminary impression of the maxillary arch was made with polyvinyl siloxane putty material [Figure 2], [Figure 3], [Figure 4]. The impression was boxed and poured in Type V dental stone. After trimming, the cast [Figure 5] was used to fabricate the obturator. The obturator was fabricated in a vacuum former machine using a sheet of EVA (thickness-1 mm). Feeding appliance was made by using pressure molding technique in thermo forming machine [Figure 6]. Following adaptation of the polyethylene sheet to the cast, tight adaptation along the palate, and ridges was checked. The tray was then trimmed. An 8-inch floss was then attached on both sides of the feeding obturator to provide a safety mechanism in case of gagging or accidental swallowing [Figure 7]. The appliance was positioned in patient's mouth [Figure 8] and parents were instructed about placement, removal and cleaning of the feeding obturator. After the clinician made sure that the fit of the appliance was optimal, the response of the infant was observed in the hospital for a few hours. The parents were educated about appliance insertion and removal, feeding techniques, and cleaning of the appliance and the oral cavity. The infant was irritable in the first few hours after the application, but this was followed by excellent adaptation. The mother was able to bottle feed the infant comfortably with the new appliance in place [Figure 9] and [Figure 10]. The infant was followed-up weekly, and necessary adjustments were made. It was observed that the mother had gained satisfactory nursing experience. It was determined that use of the obturator supported high-volume nutrition intake, with less infant fatigue. Irritability decreased gradually, and weight gain was within normal limits. With these criteria taken into consideration, it was decided that the infant adapted well to the appliance.
Figure 2: Primary impression with heavy body putty

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Figure 3: Primary impression tray

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Figure 4: Secondary impression with heavy body putty

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Figure 5: Stone model of the cleft impression

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Figure 6: Ethylene vinyl acetate obturator outside the mouth

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Figure 7: Thermo forming machine

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Figure 8: Bottle feeding the child with the obturator inside the mouth

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Figure 9: Ethylene vinyl acetate obturator inside the mouth

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Figure 10: Patient with the obturator inside the mouth

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   Discussion Top


The high rate of morbidity and high occurrence of death in infants makes cleft lip ± palate an important category of congenital defects. [7] Feeding is an immediate concern due to the delay in growth of children born with clefts as compared to those without clefting. [8] This can be a major concern for infants who will be undergoing surgery to correct their cleft. These infants need to maintain a healthy weight to tolerate a major surgery.

A cleft palate defect site needs to be obstructed with a feeding obturator until corrective surgery can be performed. In such a procedure, usually the obturator is generally rigid and stable. This may cause irritation during swallowing, and adaptation may be difficult. [9] To eliminate this problem, EVA, which is a flexible and durable material that is used for fabrication of night guards, was used in the fabrication of the obturator.

In addition, the vacuum tray was chosen over an acrylic obturator because of its added advantages of being lightweight, moldability, and a good fit to palate and ridges and decreased the possibility of soft tissue injury because of soft texture.

The increased retention of the EVA tray is due to the extremely close fitting or conforming to certain portions of the maxilla. The upper anterior extent of the tray is matched with or generally level with the upper posterior extent. This anatomically matching relationship also serves to maximize retentive fit on the soft tissue.

In the 1 st week, on alternate days, the infant should be monitored for possible tissue irritation. The feeding obturator should be adjusted every 2-3 weeks and replaced every 2-3 months. To avoid interfering with the growth of the dental arch, the border of the obturator must be trimmed regularly until the retention becomes insufficient. Management of an infant with cleft palate involves a series of procedures, starting with obturator placement and followed by plastic surgery, orthodontic management. Within the limitations of this treatment, there is always a need for frequent assessments and modifications, especially in infancy during readjustments of the obturator. Resources available for this frequent follow-up should be determined and used accordingly. Materials used for the fabrication of this feeding obturator were EVA, which is inexpensive. The fabrication procedure is simpler, does not involve the use of tissue conditioners for enhancing retention, there is no need of a retentive wire has a smoother surface and is softer than standard acrylic obturator.


   Conclusion Top


This modified obturator fabrication does not encompass any additional cost, clinical time, or family burden when compared with traditional methods. Hence, it can be used as a suitable alternative to traditional acrylic obturators.

 
   References Top

1.Arvedson J, Brodsky L. Feeding with craniofacial anomalies. Craniofacial Anomalies: An Interdisciplinary Approach. Vol. 12. St. Louis Mosby; 1992. p. 527-59.  Back to cited text no. 1
    
2.Turner L, Jacobsen C, Humenczuk M, Singhal VK, Moore D, Bell H. The effects of lactation education and a prosthetic obturator appliance on feeding efficiency in infants with cleft lip and palate. Cleft Palate Craniofac J 2001;38:519-24.  Back to cited text no. 2
    
3.Prahl-Andersen B. Dental treatment of predental and infant patients with clefts and craniofacial anomalies. Cleft Palate Craniofac J 2000;37:528-32.  Back to cited text no. 3
[PUBMED]    
4.Redford-Badwal DA, Mabry K, Frassinelli JD. Impact of cleft lip and/or palate on nutritional health and oral-motor development. Dent Clin North Am 2003;47:305-17.  Back to cited text no. 4
    
5.Romero M, Latham R, Romance A, Salvan R. Treatment of an infant with a rare cleft resolved with use of an orthopedic appliance. Cleft Palate Craniofac J 2003;40:642-4.  Back to cited text no. 5
    
6.Suri S, Tompson BD. A modified muscle-activated maxillary orthopedic appliance for presurgical nasoalveolar molding in infants with unilateral cleft lip and palate. Cleft Palate Craniofac J 2004;41:225-9.  Back to cited text no. 6
    
7.Amstalden-Mendes LG, Magna LA, Gil-da-Silva-Lopes VL. Neonatal care of infants with cleft lip and/or palate: Feeding orientation and evolution of weight gain in a nonspecialized Brazilian hospital. Cleft Palate Craniofac J 2007;44:329-34.  Back to cited text no. 7
    
8.Glenny AM, Hooper L, Shaw BC, Reilly S, Kasem S, Reid J. Feeding interventions for growth and development in infants with cleft lip, cleft palate or cleft lip and palate. Cochrane Database Syst Rev. 2004;3:CD003315  Back to cited text no. 8
    
9.Kozelj V. The basis for presurgical orthopedic treatment of infants with unilateral complete cleft lip and palate. Cleft Palate Craniofac J 2000;37:26-32.  Back to cited text no. 9
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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    Abstract
   Introduction
   Case Report
   Discussion
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    References
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