|Year : 2011 | Volume
| Issue : 3 | Page : 239-243
Feeding plate for a neonate with Pierre Robin sequence
J Radhakrishnan, A Sharma
Department Of Pedodontics And Preventive Dentistry, College of Dental Surgery, Saveetha University, Chennai, India
|Date of Web Publication||10-Oct-2011|
Depatment of Pedodontics And Preventive Dentistry, No. 116/66, Perambur High Road Lane, Perambur Jamalia, Chennai - 600 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Pierre Robin Sequence is a congenital condition involving a combination of micrognathia and glossoptosis with or without a cleft palate. Feeding problems are often associated with cleft anamoly which make it difficult for the infant to maintain adequate nutrition. Here we present a case of 58-day-old neonate with Pierre Robin sequence, in whom we contructed a palatal obturtor for feeding.
Keywords: Cleft palate, feeding plate, Pierre Robin sequence, palatal obturator
|How to cite this article:|
Radhakrishnan J, Sharma A. Feeding plate for a neonate with Pierre Robin sequence. J Indian Soc Pedod Prev Dent 2011;29:239-43
| Introduction|| |
Pierre Robin sequence (PRS) is a well-recognized congenital condition involving a combination of micrognathia and glossoptosis, with or without a cleft palate. The prevalence of Pierre Robin sequences is 1:8500 live births. 
Neonates born with a cleft palate have difficulty eating, which may lead to failure to thrive.  The oronasal communication diminishes the ability to create negative pressure, which is necessary for suckling. ,,,
The feeding process is also complicated by nasal regurgitation of food  excessive air intake that requires frequent burping  and choking. ,
Here we are presenting the case of a 58-day-old neonate with PRS, in whom we constructed a palatal obturator for feeding required for the proper growth and development and also to prevent other associated complications.
| Case Report|| |
A 58-day-old male child with PRS was referred to the Department of Pedodontics and Preventive Dentistry, Saveetha University Chennai.
On extra-oral examination, the neonate showed receded chin, ocular lesion, and club feet [Figure 1].
On intra-oral examination, the palate was almost totally absent with only the alveolus present in right and left sides, with the cleft extending to the soft palate. The nasal septum and conchae were visible [Figure 2].
The child had been examined by ENT, oral surgeons, and plastic surgeons and surgical correction was planned at the age of 18 months for the cleft palate. For the purpose of feeding the child intra-orally, a palatal obturator was necessary to prevent nasal regurgitation or aspiration of milk into the trachea.
For the construction of an obturator, impression of the palate was taken with dental impression compound. First, the impression compound was softened and placed on the finger and allowed to lose a little heat. The child was made to cry and the finger was inserted into the oral cavity with the compound.
Once the child started sucking on the finger and the compound hardened preliminarily, the finger was removed from the mouth and the compound chilled with tap water. A primary model was prepared by pouring the impression [Figure 3].
The cleft defect in the primary model was blocked out by modeling wax and a special tray was fabricated using self cure acrylic resin [Figure 4].
An impression was taken on the special tray using addition cured silicone impression material [Figure 5]. A master cast was prepared using dye stone. An obturator was fabricated using cold cure acrylic material [Figure 6].
All the borders of the obturator were rounded and polished in order to avoid trauma. Two perforations were made on the peripherals of obturator for retention of floss thread [Figure 7].
Post-insertion adjustments were done by trimming excessive amounts of acrylic from the nasal surface inducing gagging until the obturator was comfortably accepted by the child and polishing on all the sides was completed. Proper instructions regarding the use were given to the mother. The patient was seen 24 h later for adjustment, then at 1 and 2 weeks. The patient was followed up annually. No major complications occurred.
| Discussion|| |
PRS (formerly known as a syndrome) is named after the French stomatologist who, in 1923 and 1934, described the problems associated with newborn micrognathia. The phenomenon is comprised by the triad of mandibular micrognathia, U-shaped cleft palate, and glossoptosis. 
The developmental anomaly was originally classified as a syndrome but was reclassified as a sequence in 1982  because the associated anomalies are due to a primary etiology, unlike a syndrome in which all anomalies have a single etiology.  In Pierre Robin, the primary anomaly is the mandibular micrognathia, which prevents the fusion of the palatal shelves.
It is hypothesized that abnormal embryologic development of the mandible in PRS occurs 7-11 weeks postconception, resulting in an unusually high tongue position within the nasopharynx. Concurrently, the lateral palatal shelves begin their medial growth towards the midline. However, the tongue is unable to descend due to the lack of mandibular growth. The palatal shelves are obstructed by the tongue from moving toward the midline and fusing, thus creating a U-shaped palatal cleft.
Additionally, the abnormally small mandible encourages the tongue to fall back into the pharynx and obstruct the airway. , The major risk for neonates with PRS is prolonged hypoxia due to airway obstruction, which can lead to brain damage and death. 
The infant with PRS has not only breathing problems, but feeding difficulties as well. According to Wolf and Glass (1992), respiratory obstruction leads to difficulties in the coordination of suction, swallowing, and respiratory functions, and glossoptosis impairs anteriorization of the tongue that is necessary in order to obtain adequate suction. Many professionals assume that feeding difficulties in patients with palatal clefts are related directly to the cleft, resulting in the inability of the infant to "suck." 
In addition, the authors pointed out that a cleft palate favors a deficit in the negative intraoral pressure necessary for efficient suction, as well as nasal reflux of food. The feeding difficulties of infants with PRSe often prevent oral feeding. The infant becomes undernourished and underweight and often is emaciated. The impediment in speech becomes more and more marked as time progresses, the patient having difficulty with guttural and labial sounds.
The feeding obturator is a prosthetic aid that is designed to obturate the cleft and restore the separation between the oral and nasal cavities. It creates a rigid platform toward which the baby can press the nipple and extract milk. , It facilitates feeding, ,,,, reduces nasal regurgitation, , reduces the incidence of choking,  and shortens the length of time required for feeding. 
The obturator also prevents the tongue from entering the defect,  and interfering with the spontaneous growth of the palatal shelves towards the midline.  It also helps to position the tongue in the correct position to perform its functional role in the development of the jaws,  and contributes to speech development. , The obturator reduces the passage of food into the nasopharynx, reducing the incidence of otitis media and nasopharyngeal infections. ,
The literature also shows the feeding obturator to be effective in reducing parents' frustration over the feeding problems , and in relieving anxiety related to the birth of a child with this pathology. The fabrication of an obturator demonstrates to parents that help is available and that the problem can be addressed. , During the impression procedure, the child is made to cry, so that it opens the mouth widely. The impression material is carried into the oral cavity with operator's fingers.
A variety of impression materials were advocated in the literature for the purpose of obtaining a definitive impression, including alginate  beeswax,  periphery wax,  Adaptol  (Jelenco Dental Products, Armonk, NY), Citricon  (Kerr USA, Romulus, Mich), polysulfide impression material,  and very-high-consistency vinyl polysiloxane.  The putty-type vinyl polysiloxane is the material of choice because its high viscosity reduces the danger of aspiration or swallowing, and its relatively good detail duplication is satisfactory for the purpose of fabricating a palatal prosthesis. The retention of the appliance is usually satisfactory, and no further means to enhance retention are needed.
The oral tissues should be monitored after 48 h to detect areas of ulceration or irritation due to excessive pressure. A new feeding obturator should be constructed after approximately 3 months to accommodate the facial growth of the baby.
The advantages of construction of palatal obturator is very important until the surgical correction of the defect is carried out because it provides a false palate against which infant can suck, reduces the incidence of feeding difficulties in newborns, helps maintain adequate nutrition., provides maxillary cross arch stability and prevents arch collapse after definitive chelioplasty (surgical closure of the lip) and also provides maxillary orthopedic molding of the cleft segments into approximation before primary alveolar cleft bone grafting.
| Conclusions|| |
This article describes a method for the fabrication of a feeding obturator for a preterm baby with Pierre Robin sequence. The feeding obturator can be effective in overcoming some of the feeding problems associated with a cleft palate defect. An obturator prosthesis may also reduce the stress that both parents and the baby experience with the feeding process and promote neonate weight gain, which is important in preparing the baby for corrective surgery.[Figure 8]
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]