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  Table of Contents    
CASE REPORT
Year : 2018  |  Volume : 36  |  Issue : 1  |  Page : 101-105
 

From birth till palatoplasty: Prosthetic procedural limitations and safeguarding infants with palatal cleft


1 Oral Health Sciences Centre, Unit of Prosthodontics, PGIMER, Chandigarh, India
2 Department of Neonatology, PGIMER, Chandigarh, India

Date of Web Publication28-Mar-2018

Correspondence Address:
Dr. Sudhir Bhandari
Oral Health Sciences Centre, Unit of Prosthodontics, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_208_17

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   Abstract 

The most imminent issue to be addressed in a child born with cleft lip and/or palate is restoration of normal feeding. Early surgical treatment for cleft repair is crucial but may need to be postponed until certain age and weight gain is attained in an infant. When other feeding interventions fail in these children, prosthetic obturation of the defect with feeding instructions in the interim period is indicated to ward off the prevailing concerns. However, the entire prosthetic management presents a significant challenge with respect to the child's age, scope of iatrogenic injury to the delicate oral tissues, and potential for life-threatening situation during the procedures. This article draws attention toward preemptive measures which should be undertaken in the clinical setting during the fabrication of obturator to ascertain a desirable outcome without experiencing a grave complication that may arise due to ignorance and/or lack of facilities.


Keywords: Clefts of lip and palate, feeding plate, obturator


How to cite this article:
Bhandari S, Soni BW, Saini SS. From birth till palatoplasty: Prosthetic procedural limitations and safeguarding infants with palatal cleft. J Indian Soc Pedod Prev Dent 2018;36:101-5

How to cite this URL:
Bhandari S, Soni BW, Saini SS. From birth till palatoplasty: Prosthetic procedural limitations and safeguarding infants with palatal cleft. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2019 Nov 15];36:101-5. Available from: http://www.jisppd.com/text.asp?2018/36/1/101/228742





   Introduction Top


Cleft of lip and palate (CLP) is one of the most common congenital orofacial defects. Its pathogenesis occurs early during embryonic development and is presumed to be the outcome from the failure of fusion of the various facial processes.[1] The incidence of CLP varies with the races and is estimated to be 1:700 in live human births and are believed to surface out of a complex interaction of genetic and environmental factors.[2],[3]

Nutritional sufficiency is the most pertinent aspect in the holistic growth and development of a newborn. Children born with CLP are unable to generate the normal level of suction and compression required for bottle and/or breastfeeding.[4] Level of this inability is affected by the extent, place, and width of the defect thereby, influencing the volume of milk intake, nasal regurgitation, air intake during feeding, and feeding time. The prevailing condition may result in a severe nutritional deficiency, delay in the surgical repair of palate, and even failure to thrive.[5],[6],[7],[8],[9] This is a major source of stress and anxiety in the family of the child.

While awaiting surgery, prosthetic obturator or feeding plate restores the separation between oral and nasal cavities, which is necessary to generate a negative pressure for sucking. Obturator aids in feeding by reducing nasal regurgitation, facilitating swallowing, reducing the length of time required for feeding thus, fulfilling normal dietary requirements of an infant, and shortening the time to surgery. Further, it prevents the tongue from entering the defect thereby; stimulating the normal growth of the maxillary segments toward each other.[10],[11],[12],[13],[14],[15],[16],[17]

Despite the procedure for the fabrication of feeding obturator is well documented, the inherent procedural limitations and their potential to cause a life-threatening situation in the dental clinics has not been emphasized more often. Literature is replete with the potential consequences of prosthetic procedures and safety measures to be followed to prevent any untoward incident in these patients. In light of the information deficit; this article through a case report addresses the preventive measures which should be undertaken during fabrication and delivery of the feeding plate obturator to ward off any emergency situation.


   Case Report Top


A 40 day-old male infant, who weighed 2790 g was referred for interim prosthodontic closure of the congenital palatal cleft. The main complaint of the parents was inability to feed the child due to excessive nasal regurgitation of milk. The baby had gained a meager 263 g since birth (as against normal weight gain of around 1200 g till 40 days), which was grossly inappropriate. Intraoral examination revealed cleft involving hard and soft palate in the midline (Veau Group II) [Figure 1]. The treating neonatologists tried long nipples, paladay, and postural modifications for feeding; however, these interventions were not successful. Baby had to be continued on nasogastric tube feeds until presentation to our institute, which signifies a severe feeding difficulty. Since the palatoplasty was not feasible at the presenting age and weight, a feeding obturator was planned to take care of the prevailing concerns. The complete procedure and its limitations were explained to the parents, and informed consent was obtained before starting the treatment.
Figure 1: Mid palatine cleft involving hard and soft palate (Veau Group II)

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It is prudent to carry out the impression and delivery of the prosthesis in a neonatal unit under the supervision of treating neonatologist. To safeguard the child against any iatrogenic injury, we adhered to the following steps during the procedure.

Preimpression considerations

  1. The baby was kept under radiant warmer to maintain euthermia (temperature range 36.5°C–37.5°C). It is essential to maintain temperature in young infants as they are very prone to hypothermia. Even a single degree fall in temperature increases adverse outcomes by as much as 28%.[18] Neonates should be kept on a servo controlled mode to maintain a target temperature of 36.5°C–37.5°C [19]
  2. During impression making, the vitals including heart rate and oxygen saturation were continuously monitored through pulse oximeter and periodically recorded by bedside nurse so as to prevent oxygen desaturation during the clinical procedure. Infants move a lot during procedures; hence, a pulse oximeter with signal extraction technology (e.g., MASIMO, NELCORE) is desirable as it can ignore motion artifacts. The goal is to keep arterial oxygen saturation (SpO2) value ≥90% in preterm neonates, ≥94% in later preterm and term neonates, and ≥95% in pediatric age group [19],[20]
  3. An 8 French size feeding tube placed through orogastric route was placed to decompress the stomach. Stomach decompression prevents the chances of aspiration
  4. No sedative was given to the child during the entire procedure. Strong sedatives such as midazolam/opioids should be avoided as it may develop desaturation during the procedure
  5. Crying of the child during the procedure should not be suppressed as cry cessation may be indicative of airway blockage. The procedure may be briefly stopped if the child cries incessantly and caregivers may be allowed to console the child
  6. Breathing efforts were continuously monitored to prevent the signs of the upper airway obstruction
  7. As the procedure of impression making is likely to lead the excessive salivary production; therefore, a suction apparatus during the procedure source was ready. For infants, suction pressure should not exceed 100 mmHg. An 8–10 French size suction catheter was used to clean the secretions
  8. Utmost care should be undertaken not to stimulate the pharyngeal mucosa as it might lead to apnea or vomiting secondary to vagal stimulation.


Impression making

Small oral aperture in infants would limit the utility of stock tray in making the primary impression. In addition, utilizing stock tray may exert an uneven pressure during impression making and create a scenario where the impression material may spread/mushroom inside the defect. An attempt to retrieve the set material can inflict severe injury to the delicate oral tissues and tearing of material inside the defect leading to an emergency situation in infants. Considering these limitations, the oral tissues were impressed with fingers using a putty form of polyvinyl siloxane as the material for the preliminary impression. The material is viscous, supports itself, and by virtue of being accurate gives a precise reproduction of the defect and the surrounding tissues. Further, the probability of the material getting stuck in the palatal defect is minimal as mild controlled finger pressure is required for its adaptation. Putty impression was then used as a tray for the final impression with light body polyvinyl siloxane (Imprint™ II Garant, 3M, ESPE, USA) [Figure 2]. After completion of impression making, the oral cavity was examined for residual impression material.
Figure 2: Hand impressed polyvinyl siloxane putty and light body impression of the maxillary arch

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Fabrication and delivery of the prosthesis

The conventional laboratory procedures were undertaken to fabricate the feeding plate in heat-cure acrylic resin (DPI, Mumbai, India). Any sharp edges and blebs were removed from the intaglio surface of the feeding plate. Finally, a permanent soft reliner was used to reline the feeding plate to provide intimate and resilient contact with the delicate oral tissues of the neonates [Figure 3]. Parents were taught the proper way of plate usage and proper feeding posture by the attending nurse. Delivery of the prosthesis seems to be a relatively safe procedure and presence of the treating neonatologist at this time is optional. Parents were informed that the appliance will have to be replaced to accommodate for the craniofacial growth of the child. The procedure for refabrication of the feeding plate is usually more simplified due to the feasibility of fabrication of custom trays on the previous gypsum casts.
Figure 3: Final prosthesis after relining with soft liner

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Follow-up schedule

  • First - Within first 24 h for any adjustments in the appliance if required and also to take feedback from parents. Although it was difficult for the child to use this feeding plate, parents were again motivated to try the prosthesis
  • Second - After about 3 days, the child started taking feed from the bottle. In 1 week, the child started developing sucking reflex with the feeding plate. Child positioning while feeding was reenforced
  • Third - After 1 month, fit of the prosthesis was rechecked
  • Fourth - After 3 months, weight of the child improved from 2790 g at presentation to 4735 g. At 5 and 8 months, the inadequately fitting plate was replaced by the newer ones [Figure 4]. At 10 months, successful surgical closure of the cleft palate was achieved [Figure 5].
Figure 4: Master models prepared at 40 days, 5 months, and 8 months

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Figure 5: Corrected palatal cleft at 12 months

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   Discussion Top


Despite cleft of lip and palate (CLP) being the most common orofacial defect, it is disappointing to notice weak evidence with respect to the effectiveness of feeding plate obturators in promoting feeding and warding off other concerns in infants born with CLP. Feeding methods and difficulties vary with the type and extent of the defect; however, when other feeding interventions fail to provide desirable results, treatment with feeding appliances may be initiated.

The feeding plate assists in alleviating the immediate distress in parents of the child due to apparently intractable feeding problems. The advantage in terms of reduction in feeding time, increased volume of milk consumed weight gain, reduced choking, decreased nasal discharge, improved parental confidence, and fulfilling the unmet need of surgery have been reported in infants treated with a prosthetic obturator in combination with early lactation advice to parents.[10],[11],[12],[13],[14],[15],[16],[17],[21] Careful lactation advice on specific feeding technique promises to aid in weight gain, which is critical to the child born with the defect.[22]

Parents' motivation and education are considered a strong predictor of the treatment outcome and have led to encouraging outcomes when lactation instruction was combined with the early insertion of feeding aid prostheses.[11] In the reported infant, consistent weight gain was achieved throughout the treatment time, and three feeding plate obturators were made to accommodate the growth of the child. This indicates the child's adaptability to the prosthesis and also emphasizes the impact of parent's motivation in the overall success of the treatment. The surgical procedure for the closure of the cleft palate was achieved at the age of 10 months; thus it is reasonable to believe that the purpose of feeding plate was well served.

As the physiology of neonates is unique, the dental chairside procedures may add an element of uncertainty while managing patients of this age group. In addition to inflicting injury to the delicate soft tissues, the impression material if lodged in the defect may cause life-threatening airway obstruction while the child is still in the dental chair. A constant vigil on the clinical signs which give clues of the upper airway obstruction (increased respiratory rate, suprasternal or subcostsal retractions, and baby showing irritability during such episodes) needs to be maintained. It is prudent to undertake all possible preventive measures to safeguard infants from such grave complication and ward off any untoward clinical emergency during the prosthetic procedures. It is advisable to undertake the entire management in proper clinical setting where the child is under the supervision of a treating neonatologist to take care of any emergency if arises.


   Conclusion Top


Despite being not supported by rigors of literature evidence, treatment with feeding plate obturator is worth utilizing as a prosthetic intervention in combination with other feeding alternatives. The clinical setting during the fabrication of obturator in infants should be given utmost importance to ward off any emergency situation that may arise due to ignorance and/or lack of facilities. Feeding plate obturator serves well to aid in adequate nourishment in children born with palatal defects and is an inexpensive presurgical means to prepare the child for the definitive palatal surgery. To achieve optimal results, parents' education and motivation by the treating doctor plays a pivotal role.

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.
Mossey PA, Little J, Munger RG, Dixon MJ, Shaw WC. Cleft lip and palate. Lancet 2009;374:1773-85.  Back to cited text no. 1
    
2.
Jia ZL, Shi B, Chen CH, Shi JY, Wu J, Xu X,et al. Maternal malnutrition, environmental exposure during pregnancy and the risk of non-syndromic orofacial clefts. Oral Dis 2011;17:584-9.  Back to cited text no. 2
    
3.
Carinci F, Scapoli L, Palmieri A, Zollino I, Pezzetti F. Human genetic factors in nonsyndromic cleft lip and palate: An update. Int J Pediatr Otorhinolaryngol 2007;71:1509-19.  Back to cited text no. 3
    
4.
Reid J, Reilly S, Kilpatrick N. Sucking performance of babies with cleft conditions. Cleft Palate Craniofac J 2007;44:312-20.  Back to cited text no. 4
    
5.
Choi BH, Kleinheinz J, Joos U, Komposch G. Sucking efficiency of early orthopaedic plate and teats in infants with cleft lip and palate. Int J Oral Maxillofac Surg 1991;20:167-9.  Back to cited text no. 5
    
6.
Trenouth MJ, Campbell AN. Questionnaire evaluation of feeding methods for cleft lip and palate neonates. Int J Paediatr Dent 1996;6:241-4.  Back to cited text no. 6
    
7.
Oliver RG, Jones G. Neonatal feeding of infants born with cleft lip and/or palate: Parental perceptions of their experience in South Wales. Cleft Palate Craniofac J 1997;34:526-32.  Back to cited text no. 7
    
8.
Carlisle D. Feeding babies with cleft lip and palate. Nurs Times 1998;94:59-60.  Back to cited text no. 8
    
9.
Pandya AN, Boorman JG. Failure to thrive in babies with cleft lip and palate. Br J Plast Surg 2001;54:471-5.  Back to cited text no. 9
    
10.
Glass RP, Wolf LS. Feeding management of infants with cleft lip and palate and micrognathia. Infants Young Child 1999;12:70-81.  Back to cited text no. 10
    
11.
Turner L, Jacobsen C, Humenczuk M, Singhal VK, Moore D, Bell H,et al. 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. 11
    
12.
Balluff MA, Udin RD. Using a feeding appliance to aid the infant with a cleft palate. Ear Nose Throat J 1986;65:316-20.  Back to cited text no. 12
    
13.
Samant A. A one-visit obturator technique for infants with cleft palate. J Oral Maxillofac Surg 1989;47:539-40.  Back to cited text no. 13
    
14.
Jones JE, Henderson L, Avery DR. Use of a feeding obturator for infants with severe cleft lip and palate. Spec Care Dentist 1982;2:116-20.  Back to cited text no. 14
    
15.
Goldberg WB, Ferguson FS, Miles RJ. Successful use of a feeding obturator for an infant with a cleft palate. Spec Care Dentist 1988;8:86-9.  Back to cited text no. 15
    
16.
Saunders ID, Geary L, Fleming P, Gregg TA. A simplified feeding appliance for the infant with a cleft lip and palate. Quintessence Int 1989;20:907-10.  Back to cited text no. 16
    
17.
Osuji OO. Preparation of feeding obturators for infants with cleft lip and palate. J Clin Pediatr Dent 1995;19:211-4.  Back to cited text no. 17
    
18.
Laptook AR, Salhab W, Bhaskar B, Neonatal Research Network. Admission temperature of low birth weight infants: Predictors and associated morbidities. Pediatrics 2007;119:e643-9.  Back to cited text no. 18
    
19.
Carlo WA. The high risk infant. In: Kliegman RM, Stanton BF, St Geme III JW, Schor NF, Behrman RE, editors. Nelson Textbook of Pediatrics. 20th ed. Pheladelphia: Elsvier; 2016. p. 818-31.  Back to cited text no. 19
    
20.
Sarnik AP, Clark JA, Sarnaik AA. Respiratory distress and failure. In: Kliegman RM, Stanton BF, St Geme III JW, Schor NF, Behrman RE, editors. Nelson Textbook of Pediatrics. 20th ed. Pheladelphia: Elsvier; 2016. p. 528-36.  Back to cited text no. 20
    
21.
Fleming P, Pielou WD, Saunders ID. A modified feeding plate for use in cleft palate infants. J Pediatr Dent 1985;1:61-4.  Back to cited text no. 21
    
22.
Richard ME. Weight comparisons of infants with complete cleft lip and palate. Pediatr Nurs 1994;20:191-6.  Back to cited text no. 22
    


    Figures

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



 

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