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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 : 2017  |  Volume : 35  |  Issue : 3  |  Page : 279-281
 

A novel approach for prosthodontic management of patient with cleft of palate


Department of Prosthodontics, SRCDSR, Faridabad, Haryana, India

Date of Web Publication31-Jul-2017

Correspondence Address:
Shalini Goyal
House No 96, Block C, Sec-49, Noida - 201 301, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_269_16

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   Abstract 

Nutrition is important in every stage of child development. A child born with cleft lip and palate may experience difficulties while feeding due to the lack of seal of the oral cavity due to incomplete facial and palatal structures. Difficulty in feeding leads to inadequate nutrition and affects the health. Children with cleft lip and palate need certain modifications to thrive and grow. Feeding difficulties should be assessed and intervened as early as possible, as they are an important aspect of multidisciplinary team approach in management and may have an impact on long-term outcome. This case report presents fabrication of feeding appliance in 6-month-old infant with cleft palate with ethylene vinyl acetate.


Keywords: Cleft palate, cleft lip, feeding appliance, ethyl vinyl acetate


How to cite this article:
Goyal S, Rani S, Pawah S, Sharma P. A novel approach for prosthodontic management of patient with cleft of palate. J Indian Soc Pedod Prev Dent 2017;35:279-81

How to cite this URL:
Goyal S, Rani S, Pawah S, Sharma P. A novel approach for prosthodontic management of patient with cleft of palate. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Jul 20];35:279-81. Available from: http://www.jisppd.com/text.asp?2017/35/3/279/211850



   Introduction Top


Cleft of lip and palate is one of the most common developmental birth defects of complex etiology.[1] It is a type of craniofacial malformation that occurs during the embryonic stage of life. It can present itself as an opening at the back of soft palate, to a nearly complete separation of the roof of the mouth.[2] The defect is either solitary or may be associated with congenital heart defects, skeletal anomalies, ocular lesions, and mental retardation.[3] The most common syndrome associated with cleft lip and palate is Van der Woude syndrome with or without lower lip pits or blind sinuses.[4]

Clefts of lip and palate are generally divided into two groups: (a) isolated cleft palate (b) cleft lip alone or with cleft palate. Incidence is of about 17/1000 live births, with ethnic and geographic variation.[5] The classification presented by Balakrishnan, in 1975 is a popular cleft classification system in India [Table 1].[6]
Table 1: Indian Classification as presented by Prof. Balakrishnan (1975)

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Cleft lip and palate is most common and together accounts for approximately 46% of all cases followed by isolated cleft palate (33%) and then cleft lip alone (21%). The occurrence of the unilateral cleft is 9 times more than bilateral cleft, and left side of the face is 2 times more affected than right. Males are more affected by cleft lip and palate, and isolated cleft palate is more common in females.[4] Although there has been marked progress in identifying genetic and environmental factors for syndromic clefts of lip and palate (associated with other malformations), more common nonsyndromic (isolated) forms remains poorly characterized.[1]

Cleft lip and palate can also lead to middle ear diseases, hearing deficiencies, deviation in speech and resonance, and dentofacial abnormalities.[7] Effects on speech, hearing, appearance, and psychology can cause long-lasting adverse effects on health and social integration, and a multidisciplinary approach is required for the management of these cases.[5] This case report presents a novel method of fabrication of feeding appliance in 6-month-old infant with cleft palate with ethylene vinyl acetate (EVA).


   Case Report Top


A 6-month-old infant reported to the Department of Prosthodontics and Crown and Bridge with the chief complaint of difficulty in feeding. On examination, it was found that the child was suffering from the cleft of the palate (Gp2). On taking history, it was found that the child was born with nonsyndromic cleft of palate [Figure 1] and therefore, the mother had difficulty in feeding the child. After discussion with the parents, a feeding appliance was planned for the child.
Figure 1: Preoperative intraoral view: Defect in soft and hard palate

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  • Patient's preliminary impression was made with rubber base impression material (Zeta plus, Zhermack, Italy) with the help of two fingers after packing the defect with gauze piece [Figure 2]a and [Figure 2]b
  • A preliminary cast was poured with dental stone (Kalstone, Kalabhai, India) on the preliminary impression obtained [Figure 3]a
  • Block out of undercuts was done with modeling wax (DPI, India) and a custom tray was then fabricated using transparent self-cure acrylic resin (DPI-RR Cold Cure, India). Numerous holes were made in custom tray [Figure 3]b
  • The custom tray was brushed with tray adhesive and a secondary impression was made using rubber base impression material [Figure 4]a
  • The definitive impression was poured in dental stone to obtain definitive cast [Figure 4]b
  • A feeding appliance was then made on the final cast using pressure molding technique in biostar machine. EVA (bioplast ® [thickness 1 mm]) was used for fabrication of the feeding appliance. Excess margins were trimmed with the help of scissor, and final finishing was done with bur
  • After finishing, holes were made in the canine region with round bur in feeding appliance for attachment of dental floss. Floss was attached to the feeding appliance because it prevents swallowing and allows easy retrieval of appliance [Figure 5]a
  • Then, the feeding appliance was inserted in the oral cavity of the infant [Figure 5]b and postinsertion instructions were given to the parents. Parents were instructed for regular follow-up. The patient was comfortable at follow-up visits, and the patient was easily fed with the appliance, and patient weight was increased due to proper feeding.
Figure 2: (a and b) Preliminary impression with rubber base impression material using two fingers

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Figure 3: (a) Preliminary cast with special tray. (b) Special tray with multiple holes

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Figure 4: (a) Secondary impression with rubber base impression material. (b) Definitive cast

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Figure 5: (a) Feeding appliance of ethylene vinyl acetate attached with floss. (b) Feeding appliance placed in the oral cavity of the infant

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   Discussion Top


Adequate nutrition is the main priority in patients with cleft of lip and palate, and technique should be found so that feeding is as close to normal breastfeeding as possible.[7] Patients with cleft of lip and palate have difficulty in compressing nipple between the tongue and hard palate, to squeeze out liquid due to oro-nasal communication which diminishes the ability to create negative pressure necessary for suckling.[8] Feeding process becomes complicated due to nasopharyngeal reflux, nasal regurgitation of food, choking, and prolonged feeding time.[9]

Nowadays, a variety of alternatives are available that can be very useful in successfully feeding an infant with a cleft lip and palate like soft nipple, plastic squeeze bottle, especially designed nipple with enlarged opening and wide based nipple (useful in sealing off the cleft lip). In this case, patient's parents insisted on breastfeeding the infant. Taking this into consideration, a feeding appliance was fabricated to aid the infant in breast feeding. It helps to compress the nipple easier which provides a contact point and helps the infant to express milk. It facilitates feeding by reducing the time and reduces nasal regurgitation.

In the presented case report, the preliminary impression was made with rubber base impression material as alginate material could flow to the posterior part and choke the oropharynx. Furthermore, the temperature of impression compound could cause burns or discomfort to the child. The impression was made with the help of fingers as stock tray could not be inserted in the patient's mouth. EVA was chosen for fabrication of feeding appliance due to its following advantages:[2]

  1. Softer than acrylic
  2. Smooth surface
  3. Lightweight
  4. Good fit intraorally
  5. Simple procedure
  6. Retentive wires are not needed.


Feeding appliance needs to be modified at regular intervals according to the eruption of deciduous dentition and size of the defect. For eruption of primary teeth feeding appliance needs to cut from the region of the tooth to be erupted.


   Conclusion Top


Adequate nutrition is very important for proper growth and development of a child. Inadequate nutrition acts as a stumbling block in the milestones of normal development. Several methods are available to manage feeding difficulties in patients with cleft of lip and palate, but simple feeding plate is easy to fabricate, and it also promotes natural breastfeeding.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Dixon MJ, Marazita ML, Beaty TH, Murray JC. Cleft lip and palate: Understanding genetic and environmental influences. Nat Rev Genet 2011;12:167-78.  Back to cited text no. 1
[PUBMED]    
2.
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.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Bansal R, Kumar Pathak A, Bhatia B, Gupta S, Kumar Gautam K. Rehabilitation of a one-day-old neonate with cleft lip and palate using palatal obturator: A case report. Int J Clin Pediatr Dent 2012;5:145-7.  Back to cited text no. 3
[PUBMED]    
4.
Hopper RA, Cutting C, Grayson B. Cleft lip and palate. In: Thorne C, Beasley RW, Aston SJ, Bartlett SP, Gurtner GC, Spear SL, editors. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. p. 202-4.  Back to cited text no. 4
    
5.
Mossey PA, Little J, Munger RG, Dixon MJ, Shaw WC. Cleft lip and palate. Lancet 2009;374:1773-85.  Back to cited text no. 5
[PUBMED]    
6.
Agrawal K. Classification of cleft lip and palate: An Indian perspective. J Cleft Lip Palate Craniofacial Anomalies 2014;1:78-84.  Back to cited text no. 6
    
7.
Padawe D, Takate V, Gunjikar T. Successful management of feeding difficulties in patient with severe bilateral cleft lip and palate. J Contemp Dent 2014;4:124-6.  Back to cited text no. 7
    
8.
Agarwal A, Rana V, Shafi S. A feeding appliance for a newborn baby with cleft lip and palate. Natl J Maxillofac Surg 2010;1:91-3.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Goswami M, Jangra B, Bhushan U. Management of feeding problem in a patient with cleft lip/palate. Int J Clin Pediatr Dent 2016;9:143-5.  Back to cited text no. 9
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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