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FEEDING PLATE FOR A NEWBORN WITH
CLEFT PALATE
DR. SATVIKA PRASAD
MDS (1ST YEAR)
MM COLLEGE OF DENTAL SCIENCES & RESEARCH, MULLANA
JOURNAL CLUB
PRESENTATION
CONTENTS
 Introduction
 Timing and sequence of orthodontic care
 Feeding
 Different approaches to feed
 Advantages of using feeding appliance
 Case reports
 Caring for cleft lip and palate infants: Impression
procedures and appliances in use
 Complications and its management
 References
INTRODUCTION SURGERY
DENTISTRY
SPEECH
THERAPIST
AUDIOLOGIST
ENT
PEDIATRICS
PSYCHOLOGIST
PROSTHODONTIST
ORTHODONTIST
PEDODONTIST
MAXILLOFACIAL
SURGERONS
PARAENTAL
GUIDANCE
CLEFT PALATE –
a congenital split of the palate that may extend through
the uvula, soft palate, and onto the hard palate ; the lip
may or may not be involved in the cleft palate
-GPT 9
 In India,
1. Cleft lip alone- 15%
2. Cleft lip and palate- 45%
3. Cleft palate alone- 40%
 The ideal treatment of cleft palate is closure by
bone graft and orthodontics , when this is not
feasible, many cases are solved by prosthodontic
rehabilitation.
 In 1764, Le Monnier, 1st operated a cleft of the
palate surgically, mainy to facilitate eating and
drinking
Acc. to MAZAHERI, 60% of individuals with clefts will require
some type of denture, and this % tends to increase if clefts
affects the alveolar ridge.
CAUSES
 The exact reason why this happens to
some babies is often unclear.
 In a few cases, cleft lip and palate is
associated with:
1. the genes a child inherits from their
parents (although most cases are a one-
off)
2. smoking during pregnancy or drinking
alcohol during pregnancy
3. obesity during pregnancy
4. a lack of folic acid during pregnancy
5. taking certain medicines in early
pregnancy, such as some anti-seizure
medications and steroid tablets
PROBLEMS RELATED TO CLEFT LIP AND PALATE
 A cleft lip and cleft palate can cause a number of issues,
particularly in the first few months after birth, before
surgery is done.
 difficulty feeding – a baby with a cleft lip and palate
may be unable to breastfeed or feed from a normal
bottle because they cannot form a good seal with their
mouth
 hearing problems – some babies with a cleft palate are
more vulnerable to ear infections and a build-up of
fluid in their ears (glue ear), which may affect
their hearing
 dental problems – a cleft lip and palate can mean a
child's teeth do not develop correctly and they may be at
a higher risk of tooth decay
 speech problems – if a cleft palate is not repaired,
it can lead to speech problems such as unclear or nasal-
sounding speech when a child is older
 Most of these problems will improve after surgery and
with treatments such as speech and language therapy.
CLASSIFICATION
 Davis and Ritchie classification (1922)
 Veau’s classificaation (1931)
 Fogh Andersen (1942)
 G Sanvenero and Rosseli (1967)
 American Cleft Palate Association Classification
(1962)
 Schuchardt and Pfeifer’s symbolic classification
 Kernahan’s striped “Y” classification (1971)
 Millard’s classification (1977)
 Lashal classification
 Nagpur classification
VEAU’S CLASSIFICATION
Classified into 4 groups –
 Group 1 – cleft of soft palate
only
 Group 2 - cleft of hard + soft
palate, extending NO further
than the incisive foramen,
thus involving the secondary
palate alone
 Group 3 – complete unilateral
cleft of soft + hard palate +lip
+ alveolar ridge
 Group 4 – complete bilateral
cleft of soft + hard palate +lip
+ alveolar ridge on both sides
LASHAL CLASSIFICATION
[L] [A] [H] [S] [H] [A] [L]
RIGHT LEFT
L – lip
A –alveolus
H – hard palate
S – soft palate
TIMING AND SEQUENCING OF ORTHODONTIC
CARE -
 It is divided into 4 distinct developmental periods
 These periods are defined by age and dental developmental, and,
should be considered as time frames in which to accomplish specific
objectives.
1. Stage I : Neonate and Infant [ birth to 18 months]
2. Stage II : Primary dentition [ 18 months to 6 yrs ]
3. Stage III : Late primary or early mixed dentition[6-12 yrs ]
4. Stage IV : Late mixed or permanent dentition [ 12-18 yrs ]
Feeding plate for a newborn with Cleft Palate.pptx
• Achieved by the time the infant is 2-6 months old
Lip repair
• Delayed until 12 months – 2yrs of age
• Early repair of the palate may have a negative
effect on growth and development of the maxilla
due to the resulting scar tissue may be seen
Palate repair
until, the surgical intervention, maintenance of adequate
nutrition is essential to allow normal growth of the newborn
and to prepare the infant for the corrective surgery
The advantage of dealing with the child in these separate stages,
with distinct targets in mind, within set time scales, is to avoid the
parent and the child making frequent visits throughout the child’s
developing years.
All clinicians involve in the treatment should recognize that above
all the child should be allowed and encouraged to live life as
normally as possible
FEEDING - Difficulty in
feeding can
result in
Delayed
development of
newborn
Parental anxiety
If complicated
feeding can
result in
Nasal
regurgitation of
oral fluids
Frequent burping
due to excessive
air intake during
deglutition
Oro-nasal communication
diminishes the ability to
create negative pressure,
which is a necessary part of
sucking but it can lead to
Choking
DIFFERENT APPROACHES TO FEED THE BABIES WITH
CLEFT PALATE
• Used only for limited times
Orogastric / nasogastric tubes
• Allow the flow of formula with less effort
Specially designed nipples with enlarged
openings
• Prosthetic aid designed to obturate the cleft so that the
infant can generate negative pressure within the oral cavity,
and can suck the milk/formula
Feeding plate
Feeding plate for a newborn with Cleft Palate.pptx
ADVANTAGES OF USING FEEDING APPLIANCE
 It helps to maintain adequate
nutrition by covering the defect and
providing rigid platform toward
which the infant can press the
breast or extract milk
 It assists in normal suckling and
thus leads to the development of
normal oromotor and swallowing
reflexes
 Reduces feeding difficulties such
as nasal regurgitation, choking, and
shortens the feeding time
 It positions the tongue in the correct position which
prevent it to enter into the defect, thus helps in the
growth of the maxilla and maxillary shelves together
 Reduces the passage of milk into the nasopharynx
and thus reduces the incidence of nasopharyngeal
infections and otitis media
 Also helps in pre surgical nasoalveolar molding
 After cheiloplasty provides cross arch stability and
prevents maxillary arch to collapse
CASE REPORTS
 A single-visit feeding plate for a 14-day-old
neonate with cleft palate
Imthiyas SM, Subramanian B, Karupiah P, Urjan K, Karthik VC, Karthik R. A
single-visit feeding plate for a 14-day-old neonate with cleft palate. Indian
Journal of Multidisciplinary Dentistry. 2019 Jan 1;9(1):64.
 A 14-day-old infant, with no contributory medical and family
history, was referred to the department of prosthodontics. The
mother reported that the infant was not able to suckle milk
properly even with the use of typical cleft nipples or
squeezable bottles. Intraoral examinations revealed a cleft in
the uvula, soft palate, and secondary hard palate (Veau's
Classification Type 2).
 First, the defect was filled with a piece of Vaseline gauze,
and then, the green stick was softened in warm water and
kneaded with caution to avoid thermal injury.
 A stainless steel spoon was used to carry the impression
material into the neonate's mouth, and the material was
gently pressed against the hard palate and into the buccal
and labial vestibules, while the baby was held in the prone
position in the mother's lap
Primary impression
Primary model
 A 2-mm wax spacer was adapted to the primary model,
and the special tray was constructed with the use of a
self-curing fast-setting acrylic resin
 The final impression was made with very high-viscosity
condensation silicone rubber base impression material
 During the process, a hook was fabricated using 21-
gauge wire for knotting. Approximately 3-inch cotton
thread was passed through and tied to the eyelet
(made by 21-gauge wire) of the feeding plate.
o The prosthesis was
trimmed, finished,
and polished
 The feeding plate was checked in
the dental clinic, and the patient's
mother was asked to feed the
baby .Instructions were provided on
how to use, clean, function, and
maintain the feeding appliance.
 Monthly follow-ups were planned
after 1st, 3rd, and 6th months
respectively, and the mother was
informed that the feeding plate could
be replaced to accommodate the
craniofacial growth before surgical
intervention.
 A feeding appliance for a newborn baby with
cleft lip and palate
Agarwal A, Rana V, Shafi S. A feeding appliance for a newborn baby with cleft
lip and palate. National journal of maxillofacial surgery. 2010 Jan;1(1):91.
 A 3-day-old neonate reported, with a
chief complaint of feeding.
 On examination, it was found that the
child was born with unilateral cleft lip
and palate on right side .After
discussion with the child's parents, it
was found that the mother had difficulty
in breast feeding the newborn; hence, a
feeding appliance was planned for
feeding the newborn
Preoperative view
A preliminary impression was made with an impression
compound material.
A cast was poured on the preliminary impression obtained
Secondary impression with
rubber base impression
material
Custom tray
Feeding appliance made by using
pressure moulding technique in
biostar machine
Final cast
Feeding appliance of ethylene vinyl
acetate attached with floss
 Ethylene vinyl acetate was used for fabrication of the feeding
appliance. Ethylene vinyl acetate is available in market as
bioplast® (thickness 1 mm). A floss was attached to the feeding
appliance because it prevents swallowing and easy retrieval of
appliance.
Advantages of Feeding appliance
made with ethylene vinyl acetate over
acrylic feeding appliance, are as
follows:
1. smoother surface
2. soft in nature
3. no need of retentive wire
• Then, the feeding appliance was
placed in the oral cavity of the
newborn and child was easily fed with
the help of the appliance
 Pressure-molded Modified Feeding Plate for
Cleft Palate in a Two-month-old Infant: A Case
Report
Fernandes VA, Nadig B, Poojary AV, Bellal S, Neelakantappa HM. Pressure-
molded Modified Feeding Plate for Cleft Palate in a Two-month-old Infant: A
Case Report. Journal of Health Sciences & Research. 2021 Apr 6;11(2):64-7.
 A 2-month-old, female infant,
came with a chief complaint of
difficulty while feeding and the
presence of nasal regurgitation
since birth.
 On examining intraorally, a
cleft was seen, which was
involving the uvula, soft palate,
and secondary hard palate
(Veau’s classification: type II)
A 2-mm ethylene vinyl acetate
(EVA) sheet was used for the
fabrication of the appliance
using the Biostar device. It was
done using the pressure
molding technique.
1. Two retentive arms with dimensions of 8 × 4 mm
were fabricated with cold cure acrylic.
2. The exact location of the retentive arms was
ascertained clinically and adequately secured to
the feeding plate with cold cure acrylic and
positioned anteriorly at 40° angulation to the
plate.
 To help in added retention, 2-mm-deep grooves were placed on
the retentive arms at a distance of 1 mm each. The feeding
plate was then placed in the infant’s mouth and retained with the
help of orthodontic elastics (inner diameter of 0.25 inch) and
horizontal skin barrier tapes (3M Transpore) that had
dimensions of 1/4 inch in width and about 4 inches in length.
 This helped in the stabilization of the feeding plate during the
feeding process.
Fabricating feeding plate in CLP infants
with two different material: A series of
case report
 Gupta R, Singhal P, Mahajan K, Singhal A. Fabricating feeding plate in
CLP infants with two different material: A series of case report. Journal of
Indian Society of Pedodontics and Preventive Dentistry. 2012 Oct
1;30(4):352.
CASE 2
CASE 1
 Two infants (2-day old, case-l and 1-month old, case-ll)
with CLP was referred to Department of Prosthodontics
for prosthetic management at different times as they were
to be operated after few months.
 On examination both infants were found to be of same
classification i.e., Vaeu's-3 type .
 After consulting with the respective parents it was
decided to fabricate feeding appliances for both the cases
Elastomeric impression was
made in custom made
impression tray
Impression in
putty
Cast showing the defect
Thermoplastic resin sheet was
adapted using thermal vaccum
machine
Excess portions were
trimmed and nylon thread
was attached
CASE 1
Elastomeric impression was
made in custom made
impression tray
Impression in putty Cast showing the
defect
• Separating media was
applied.
• Using auto-
polymerizing resin the
obturator was
fabricated following
sprinkle on method of
polymerization
CASE 2
 two different materials (thermoplastic resin sheets, EVA and
autopolymerising acrylic resin) were used and analysed, to
fabricate feeding obturators in two different CLP infants.
 Both materials have pros and cons.
EVA
• Smooth and soft, so
minimal chances of
injury
• these obturators did
not provide rigid
platform for suckling
which is desirable
AUTOPOLYMERISING
ACRYLIC RESIN
• not soft in nature, can
harm the patient
• provide rigid platform
for suckling
• less expensive than
EVA obturators
 The Effects of Lactation Education and a
Prosthetic Obturator Appliance on Feeding
Efficiency in Infants with Cleft Lip and Palate
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. The Cleft palate-
craniofacial journal. 2001 Sep;38(5):519-24.
A Baseline – fed by breast
B1 Fed with a Haberman bottle
B2 Lactation education – palatal obturartor
C1 Palatal obturator + lactation education
C2 Palatal obturator + lacation support
This prospective study examined the effect of lactation
instruction and palatal obturation in decreasing time to feed,
increasing intake, and on growth, in eight breast milk bottle-
fed newborn infants with cleft lip, cleft palate, or both.
Lactation education – information given to mothers to
recognize infant feeding cues and to have infant led feedings
 The combined use of a palatal obturator and
lactation education reduced feeding time and
increased volume intake and was associated with
good growth.
 Mothers who had desired to breast-feed elected to
use the obturator to support high-volume intake,
decrease infant fatigue, and provide breast milk for
nutrition.
Mean Feeding time Volume
B1 (Haberman bottle only) 34.4 36.5 mL
B2 (Haberman bottle only) 32.3 37 mL
C1 (obturator and lactation
education)
15.1 67 mL
C2 (obturator and lactation
education)
15.6 76 mL
RESULT -
 Case series of undetected intranasal
impression material in patients with
clefts
Jones SD, Drake DJ. Case series of undetected intranasal impression
material in patients with clefts. British Journal of Oral and Maxillofacial
Surgery. 2013 Apr 1;51(3):e34-6.
• A 29-year-old woman had bilateral
cleft lip and palate repair as a
baby.
• The operation had been
uneventful but the bone graft failed
and a palatal fistula subsequently
formed.
• Twenty years after the initial
operation she started to complain
of a nasty smell and discharge
from the nose.
• She had an examination under
anesthetic of the whole nasal
cavity and a large calcified mass,
histologically confirmed as
impression material, was removed
from the right nasal floor.
• Removal resulted in complete
resolution of her symptoms.
CASE 1
• A 24-year-old woman had also had surgery
for bilateral cleft lip and palate as a baby.
• Again, the initial operation had been
uneventful but a palatal fistula formed
subsequently.
• She had several further procedures, which
included the placement of dental implants,
and multiple impressions were taken
• CBCT was also done, but no cause was
identified
• Impression material was lodged in the left
nostril and removal resulted in complete
resolution of her symptoms.
CASE 2
 Unnoticed aspiration of palate plate
impression material in a neonate:
Diagnosis, therapy, outcome
Reichert F, Amrhein P, Uhlemann F. Unnoticed aspiration of palate plate
impression material in a neonate: Diagnosis, therapy, outcome.
Pediatric pulmonology. 2017 Oct;52(10):E58-60.
 A 7 week old female infant was admitted to the hospital
with dyspnea and cyanosis. Two days prior she had a
presumed viral upper- and lower airway infection with
rhinitis and coughing, treated with saline nose drops
and supplemental oxygen for one night.
 She had a cleft palate (provided with a plate) and lip
dysplasia, but otherwise no neurologic, respiratory, or
cardiac abnormalities had been detected. The day
before readmittance she started showing dyspnea and
could only sleep in an upright position. Fluid intake was
increasingly hindered due to respiratory distress
 Further history was obtained: during the 1st week of life,
a plate for the cleft palate was fitted in two steps: first an
impression for a fitting tray was taken, 3 days later this
tray was used for the final cleft impression, using
polyvinylsiloxane
 Two days after admittance they conducted the
endoscopic removal in the pediatric thoracic-cardiac
operating theatre
 In the rigid endoscopy they found a blue foreign body in
right mainstem bronchus, which was removed in four
pieces (length up to 1.5 cm, Fig. 2). The mucosa
showed granulation and swelling, which still obstructed
the right superior lobar bronchus
 Caring for cleft lip and palate infants:
Impression materials, procedures and
appliances in use
Sabarinath VP, Hazarey PV, Ramakrishna Y, Vasanth R, Girish K. Caring
for cleft lip and palate infants: impression procedures and appliances in
use. The Journal of Indian Prosthodontic Society. 2009 Apr 1;9(2):76.
IMPRESSION MATERIALS
• Poor tear strength which
usually tear on removal,
esp. when alginate
extrudes deep into the
cleft undercuts
Irreversible
hydrocolloid
impression
material
• Cartridge delivery
silicones provide
excellent replication of
the surface detail
Putty
elastomeric
impression
material
• Can be removed before
it sets in case of
emergency.
• Better resistance to
tearing as compared to
other impression
materials.
Impression
compound
• The rate of force application during
removal improves tear strength and
hence, a quick snap removal is
suggested
• Use of fast setting chromatic
alginates has been suggested in
these cases
• Cartridge delivery systems
were expected to be better in
neonatal cleft impressions due
to better mixing and reduced
chances of cross infection
• Overheating can lead to scalding or
burns in infants, the leaching out of
volatile components of the
compound can be harmful to the
infants and the use of water bath
may compromise sterility
IMPRESSION PROCEDURES
Patient positioning
 For an accurate impression proper
patient and dentist position are vital.
 A number of positions have been
adopted for cleft palate impression
making in infants including
1. prone,
2. face down,
3. upright,
4. even upside down.
 Some authors prefer the impression of
the newborn infant to be taken in the
hospital crib as it provides good work
surface at a convenient height.
 As with any impression procedure tray selection
is an important step.
 The tray should be of enough size to include all
the borders.
 Rimming of the entire tray with utility wax has
been suggested to provide additional bulk of
material laterally,
 avoid sharp edges of the tray and also provide
a posterior dam preventing material from
seeping posteriorly.
 After size and shape have been roughly
estimated, perforated custom acrylic trays can
be fabricated.
 Prefabricated trays that are commercially
available (Coe laboratories, Chicago) for cleft
palate
 Shatkin and Stark have described the use of
wax for impression trays in cleft lip and palate
patients.
 Anecdotal reports also mention the use of ice
cream sticks or spoons to carry materials for
infant impressions.
TRAY SELECTION
APPLIANCES
Passive
plates
Naso alveolar
Molding plates
Latham’s
appliance
Jackscrew
devices
POSSIBLE COMPLICATIONS
 Complications encountered when taking impressions in
cleft lip and palate infants arise primarily due to the fact that
they are obligatory nasal breathers.
 Chate reported the following hazards have been
encountered by dentists involved routinely in the care of
CLP patients:
1. Difficulty in removal of impression due to engagement of
undercuts
2. Fragmentation of the impression during withdrawal from
the mouth with subsequent respiratory obstruction due to
lodgment in the respiratory passage
3. Cyanotic episodes of which few resulted in asphyxiation
Precautions
 As it is rightly said that, prevention is better than cure and the
same applies to impression making in cleft infants.
 A dental mouth mirror is an effective tool for depressing the
tongue during the impression procedure thereby maintaining
airway patency.
 Clean cotton tipped ear buds may be used to clean the infant oral
cavity before impression making and remove any intra oral
remnants of impression material after the procedure.
 Impressions for neonate/infants with clefts need to be taken in a
hospital setting prepared to handle airway emergencies with a
surgeon present at all times.
 The impression is made when the infant is fully awake without any
anesthesia or premedication.
 Infants should be able to cry during the impression procedure and
absence of crying may be indicative of airway blockage.
 A finger motion may be used to clear unset material posterior to
the tray to prevent the infant from closing down on the tray and
compromising the airway.
 High volume suction should also be ready at all times in case of
regurgitation of the stomach contents.
 It is preferable that the infant has not eaten for at least two hours
prior to the procedure.
 Aspiration of fragments of impression material that
inadvertently tear during the procedure may cause airway
obstruction in infants.
 The obstruction may be partial or complete. Three stages of
symptoms result from aspiration of any object into the airway.
1. Initial event - violent paroxysms of coughing, choking,
gagging and possibly airway obstruction occur immediately
when the foreign body is aspirated.
2. Asymptomatic interval - foreign body becomes lodged,
reflexes fatigue, and immediate irritating symptoms subside.
3. Complications - obstruction, erosion or infection develop.
 Signs of complete airway obstruction include ineffective
cough, increased respiratory difficulty accompanied by stridor,
development of cyanosis and loss of consciousness.
Management Of Complications
 Maneuvers to relive foreign body obstruction in
infants include-
1. back blows,
2. chest thrusts
3. finger sweeps.
 When conscious, the infant is straddled over the
arm with face down and head lower than the trunk
 The infants head is supported with the rescuers hand around the chest and
the jaw.
 When support is adequate 4-5 back blows are rapidly delivered with the heel
of the hand between the infants shoulder blades.
 Following this the free hand is placed over the infants back, holding the
infants head.
 The infant is effectively sandwiched between the two arms and hands of the
rescuer.
 The infant is turned and held supine on the rescuers thigh.
 The infants head remains lower than the trunk all this while.
 Up to 5 quick downward chest thrusts are given in the same location.
 The airway may now be opened by using the
head tilt chin lift and if spontaneous breathing
is absent and chest does not rise on rescue
breathing ,the maneuvers may be repeated till
the foreign body is expelled or child loses
conscious.
 When the infant is unconscious the airway is
opened using the tongue jaw lift and if a foreign
body is seen it is removed with a finger sweep.
 Blind finger sweeps should not be performed in
infants as it poses the risk of further pushing
the fragments into the airway.
 Rescue breathing is then attempted. If the
chest does not rise adequately the back blows
and chest thrusts are repeated till ventilation is
established.
 Adjuncts for airway and ventilation include
oxygen delivery devices, suction devices,
appropriately sized oropharyngeal airways, bag
valve mask systems and in rare situations
cricothyrotomy.
CONCLUSION
 Oro-facial clefts have been identified to have a
multifactorial etiology and therefore require an
interdisciplinary treatment approach, comprising
various specialists to provide the best possible line of
treatment with a individualized treatment approach,
i.e. to minimize , if not eliminate, the physical, social,
and the emotional hardships that a person with oro-
facial clefts suffer.
 Inadequate nourishment due to difficulty in feeding
affects the health and acts as a stumbling block in the
milestones of normal development. A feeding
appliance given to the infant effectively separates the
oral cavity from the nasal cavity and is of great help in
feeding
REFERENCES
 Textbook of paediatric dentistry – Nikhil Marwah- 3rd edition
 Textbook of orthodontics- S Gowri shankar- 1st revised edition
 Imthiyas SM, Subramanian B, Karupiah P, Urjan K, Karthik VC, Karthik R. A single-visit
feeding plate for a 14-day-old neonate with cleft palate. Indian Journal of Multidisciplinary
Dentistry. 2019 Jan 1;9(1):64
 Agarwal A, Rana V, Shafi S. A feeding appliance for a newborn baby with cleft lip and
palate. National journal of maxillofacial surgery. 2010 Jan;1(1):91.
 Fernandes VA, Nadig B, Poojary AV, Bellal S, Neelakantappa HM. Pressure-molded
Modified Feeding Plate for Cleft Palate in a Two-month-old Infant: A Case Report. Journal
of Health Sciences & Research. 2021 Apr 6;11(2):64-7.
 Gupta R, Singhal P, Mahajan K, Singhal A. Fabricating feeding plate in CLP infants with two
different material: A series of case report. Journal of Indian Society of Pedodontics and
Preventive Dentistry. 2012 Oct 1;30(4):352.
 Jones SD, Drake DJ. Case series of undetected intranasal impression material in patients
with clefts. British Journal of Oral and Maxillofacial Surgery. 2013 Apr 1;51(3):e34-6.
 Sabarinath VP, Hazarey PV, Ramakrishna Y, Vasanth R, Girish K. Caring for cleft lip and
palate infants: impression procedures and appliances in use. The Journal of Indian
Prosthodontic Society. 2009 Apr 1;9(2):76.
 Reichert F, Amrhein P, Uhlemann F. Unnoticed aspiration of palate plate impression
material in a neonate: Diagnosis, therapy, outcome. Pediatric pulmonology. 2017
Oct;52(10):E58-60.
Feeding plate for a newborn with Cleft Palate.pptx

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Feeding plate for a newborn with Cleft Palate.pptx

  • 1. FEEDING PLATE FOR A NEWBORN WITH CLEFT PALATE DR. SATVIKA PRASAD MDS (1ST YEAR) MM COLLEGE OF DENTAL SCIENCES & RESEARCH, MULLANA JOURNAL CLUB PRESENTATION
  • 2. CONTENTS  Introduction  Timing and sequence of orthodontic care  Feeding  Different approaches to feed  Advantages of using feeding appliance  Case reports  Caring for cleft lip and palate infants: Impression procedures and appliances in use  Complications and its management  References
  • 4. CLEFT PALATE – a congenital split of the palate that may extend through the uvula, soft palate, and onto the hard palate ; the lip may or may not be involved in the cleft palate -GPT 9
  • 5.  In India, 1. Cleft lip alone- 15% 2. Cleft lip and palate- 45% 3. Cleft palate alone- 40%  The ideal treatment of cleft palate is closure by bone graft and orthodontics , when this is not feasible, many cases are solved by prosthodontic rehabilitation.  In 1764, Le Monnier, 1st operated a cleft of the palate surgically, mainy to facilitate eating and drinking Acc. to MAZAHERI, 60% of individuals with clefts will require some type of denture, and this % tends to increase if clefts affects the alveolar ridge.
  • 6. CAUSES  The exact reason why this happens to some babies is often unclear.  In a few cases, cleft lip and palate is associated with: 1. the genes a child inherits from their parents (although most cases are a one- off) 2. smoking during pregnancy or drinking alcohol during pregnancy 3. obesity during pregnancy 4. a lack of folic acid during pregnancy 5. taking certain medicines in early pregnancy, such as some anti-seizure medications and steroid tablets
  • 7. PROBLEMS RELATED TO CLEFT LIP AND PALATE  A cleft lip and cleft palate can cause a number of issues, particularly in the first few months after birth, before surgery is done.  difficulty feeding – a baby with a cleft lip and palate may be unable to breastfeed or feed from a normal bottle because they cannot form a good seal with their mouth  hearing problems – some babies with a cleft palate are more vulnerable to ear infections and a build-up of fluid in their ears (glue ear), which may affect their hearing  dental problems – a cleft lip and palate can mean a child's teeth do not develop correctly and they may be at a higher risk of tooth decay  speech problems – if a cleft palate is not repaired, it can lead to speech problems such as unclear or nasal- sounding speech when a child is older  Most of these problems will improve after surgery and with treatments such as speech and language therapy.
  • 8. CLASSIFICATION  Davis and Ritchie classification (1922)  Veau’s classificaation (1931)  Fogh Andersen (1942)  G Sanvenero and Rosseli (1967)  American Cleft Palate Association Classification (1962)  Schuchardt and Pfeifer’s symbolic classification  Kernahan’s striped “Y” classification (1971)  Millard’s classification (1977)  Lashal classification  Nagpur classification
  • 9. VEAU’S CLASSIFICATION Classified into 4 groups –  Group 1 – cleft of soft palate only  Group 2 - cleft of hard + soft palate, extending NO further than the incisive foramen, thus involving the secondary palate alone  Group 3 – complete unilateral cleft of soft + hard palate +lip + alveolar ridge  Group 4 – complete bilateral cleft of soft + hard palate +lip + alveolar ridge on both sides
  • 10. LASHAL CLASSIFICATION [L] [A] [H] [S] [H] [A] [L] RIGHT LEFT L – lip A –alveolus H – hard palate S – soft palate
  • 11. TIMING AND SEQUENCING OF ORTHODONTIC CARE -  It is divided into 4 distinct developmental periods  These periods are defined by age and dental developmental, and, should be considered as time frames in which to accomplish specific objectives. 1. Stage I : Neonate and Infant [ birth to 18 months] 2. Stage II : Primary dentition [ 18 months to 6 yrs ] 3. Stage III : Late primary or early mixed dentition[6-12 yrs ] 4. Stage IV : Late mixed or permanent dentition [ 12-18 yrs ]
  • 13. • Achieved by the time the infant is 2-6 months old Lip repair • Delayed until 12 months – 2yrs of age • Early repair of the palate may have a negative effect on growth and development of the maxilla due to the resulting scar tissue may be seen Palate repair until, the surgical intervention, maintenance of adequate nutrition is essential to allow normal growth of the newborn and to prepare the infant for the corrective surgery
  • 14. The advantage of dealing with the child in these separate stages, with distinct targets in mind, within set time scales, is to avoid the parent and the child making frequent visits throughout the child’s developing years. All clinicians involve in the treatment should recognize that above all the child should be allowed and encouraged to live life as normally as possible
  • 15. FEEDING - Difficulty in feeding can result in Delayed development of newborn Parental anxiety If complicated feeding can result in Nasal regurgitation of oral fluids Frequent burping due to excessive air intake during deglutition Oro-nasal communication diminishes the ability to create negative pressure, which is a necessary part of sucking but it can lead to Choking
  • 16. DIFFERENT APPROACHES TO FEED THE BABIES WITH CLEFT PALATE • Used only for limited times Orogastric / nasogastric tubes • Allow the flow of formula with less effort Specially designed nipples with enlarged openings • Prosthetic aid designed to obturate the cleft so that the infant can generate negative pressure within the oral cavity, and can suck the milk/formula Feeding plate
  • 18. ADVANTAGES OF USING FEEDING APPLIANCE  It helps to maintain adequate nutrition by covering the defect and providing rigid platform toward which the infant can press the breast or extract milk  It assists in normal suckling and thus leads to the development of normal oromotor and swallowing reflexes  Reduces feeding difficulties such as nasal regurgitation, choking, and shortens the feeding time
  • 19.  It positions the tongue in the correct position which prevent it to enter into the defect, thus helps in the growth of the maxilla and maxillary shelves together  Reduces the passage of milk into the nasopharynx and thus reduces the incidence of nasopharyngeal infections and otitis media  Also helps in pre surgical nasoalveolar molding  After cheiloplasty provides cross arch stability and prevents maxillary arch to collapse
  • 20. CASE REPORTS  A single-visit feeding plate for a 14-day-old neonate with cleft palate Imthiyas SM, Subramanian B, Karupiah P, Urjan K, Karthik VC, Karthik R. A single-visit feeding plate for a 14-day-old neonate with cleft palate. Indian Journal of Multidisciplinary Dentistry. 2019 Jan 1;9(1):64.
  • 21.  A 14-day-old infant, with no contributory medical and family history, was referred to the department of prosthodontics. The mother reported that the infant was not able to suckle milk properly even with the use of typical cleft nipples or squeezable bottles. Intraoral examinations revealed a cleft in the uvula, soft palate, and secondary hard palate (Veau's Classification Type 2).
  • 22.  First, the defect was filled with a piece of Vaseline gauze, and then, the green stick was softened in warm water and kneaded with caution to avoid thermal injury.  A stainless steel spoon was used to carry the impression material into the neonate's mouth, and the material was gently pressed against the hard palate and into the buccal and labial vestibules, while the baby was held in the prone position in the mother's lap Primary impression Primary model
  • 23.  A 2-mm wax spacer was adapted to the primary model, and the special tray was constructed with the use of a self-curing fast-setting acrylic resin  The final impression was made with very high-viscosity condensation silicone rubber base impression material  During the process, a hook was fabricated using 21- gauge wire for knotting. Approximately 3-inch cotton thread was passed through and tied to the eyelet (made by 21-gauge wire) of the feeding plate. o The prosthesis was trimmed, finished, and polished
  • 24.  The feeding plate was checked in the dental clinic, and the patient's mother was asked to feed the baby .Instructions were provided on how to use, clean, function, and maintain the feeding appliance.  Monthly follow-ups were planned after 1st, 3rd, and 6th months respectively, and the mother was informed that the feeding plate could be replaced to accommodate the craniofacial growth before surgical intervention.
  • 25.  A feeding appliance for a newborn baby with cleft lip and palate Agarwal A, Rana V, Shafi S. A feeding appliance for a newborn baby with cleft lip and palate. National journal of maxillofacial surgery. 2010 Jan;1(1):91.
  • 26.  A 3-day-old neonate reported, with a chief complaint of feeding.  On examination, it was found that the child was born with unilateral cleft lip and palate on right side .After discussion with the child's parents, it was found that the mother had difficulty in breast feeding the newborn; hence, a feeding appliance was planned for feeding the newborn Preoperative view A preliminary impression was made with an impression compound material. A cast was poured on the preliminary impression obtained
  • 27. Secondary impression with rubber base impression material Custom tray Feeding appliance made by using pressure moulding technique in biostar machine Final cast Feeding appliance of ethylene vinyl acetate attached with floss
  • 28.  Ethylene vinyl acetate was used for fabrication of the feeding appliance. Ethylene vinyl acetate is available in market as bioplast® (thickness 1 mm). A floss was attached to the feeding appliance because it prevents swallowing and easy retrieval of appliance. Advantages of Feeding appliance made with ethylene vinyl acetate over acrylic feeding appliance, are as follows: 1. smoother surface 2. soft in nature 3. no need of retentive wire • Then, the feeding appliance was placed in the oral cavity of the newborn and child was easily fed with the help of the appliance
  • 29.  Pressure-molded Modified Feeding Plate for Cleft Palate in a Two-month-old Infant: A Case Report Fernandes VA, Nadig B, Poojary AV, Bellal S, Neelakantappa HM. Pressure- molded Modified Feeding Plate for Cleft Palate in a Two-month-old Infant: A Case Report. Journal of Health Sciences & Research. 2021 Apr 6;11(2):64-7.
  • 30.  A 2-month-old, female infant, came with a chief complaint of difficulty while feeding and the presence of nasal regurgitation since birth.  On examining intraorally, a cleft was seen, which was involving the uvula, soft palate, and secondary hard palate (Veau’s classification: type II)
  • 31. A 2-mm ethylene vinyl acetate (EVA) sheet was used for the fabrication of the appliance using the Biostar device. It was done using the pressure molding technique. 1. Two retentive arms with dimensions of 8 × 4 mm were fabricated with cold cure acrylic. 2. The exact location of the retentive arms was ascertained clinically and adequately secured to the feeding plate with cold cure acrylic and positioned anteriorly at 40° angulation to the plate.
  • 32.  To help in added retention, 2-mm-deep grooves were placed on the retentive arms at a distance of 1 mm each. The feeding plate was then placed in the infant’s mouth and retained with the help of orthodontic elastics (inner diameter of 0.25 inch) and horizontal skin barrier tapes (3M Transpore) that had dimensions of 1/4 inch in width and about 4 inches in length.  This helped in the stabilization of the feeding plate during the feeding process.
  • 33. Fabricating feeding plate in CLP infants with two different material: A series of case report  Gupta R, Singhal P, Mahajan K, Singhal A. Fabricating feeding plate in CLP infants with two different material: A series of case report. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2012 Oct 1;30(4):352.
  • 34. CASE 2 CASE 1  Two infants (2-day old, case-l and 1-month old, case-ll) with CLP was referred to Department of Prosthodontics for prosthetic management at different times as they were to be operated after few months.  On examination both infants were found to be of same classification i.e., Vaeu's-3 type .  After consulting with the respective parents it was decided to fabricate feeding appliances for both the cases
  • 35. Elastomeric impression was made in custom made impression tray Impression in putty Cast showing the defect Thermoplastic resin sheet was adapted using thermal vaccum machine Excess portions were trimmed and nylon thread was attached CASE 1
  • 36. Elastomeric impression was made in custom made impression tray Impression in putty Cast showing the defect • Separating media was applied. • Using auto- polymerizing resin the obturator was fabricated following sprinkle on method of polymerization CASE 2
  • 37.  two different materials (thermoplastic resin sheets, EVA and autopolymerising acrylic resin) were used and analysed, to fabricate feeding obturators in two different CLP infants.  Both materials have pros and cons. EVA • Smooth and soft, so minimal chances of injury • these obturators did not provide rigid platform for suckling which is desirable AUTOPOLYMERISING ACRYLIC RESIN • not soft in nature, can harm the patient • provide rigid platform for suckling • less expensive than EVA obturators
  • 38.  The Effects of Lactation Education and a Prosthetic Obturator Appliance on Feeding Efficiency in Infants with Cleft Lip and Palate 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. The Cleft palate- craniofacial journal. 2001 Sep;38(5):519-24.
  • 39. A Baseline – fed by breast B1 Fed with a Haberman bottle B2 Lactation education – palatal obturartor C1 Palatal obturator + lactation education C2 Palatal obturator + lacation support This prospective study examined the effect of lactation instruction and palatal obturation in decreasing time to feed, increasing intake, and on growth, in eight breast milk bottle- fed newborn infants with cleft lip, cleft palate, or both. Lactation education – information given to mothers to recognize infant feeding cues and to have infant led feedings
  • 40.  The combined use of a palatal obturator and lactation education reduced feeding time and increased volume intake and was associated with good growth.  Mothers who had desired to breast-feed elected to use the obturator to support high-volume intake, decrease infant fatigue, and provide breast milk for nutrition. Mean Feeding time Volume B1 (Haberman bottle only) 34.4 36.5 mL B2 (Haberman bottle only) 32.3 37 mL C1 (obturator and lactation education) 15.1 67 mL C2 (obturator and lactation education) 15.6 76 mL RESULT -
  • 41.  Case series of undetected intranasal impression material in patients with clefts Jones SD, Drake DJ. Case series of undetected intranasal impression material in patients with clefts. British Journal of Oral and Maxillofacial Surgery. 2013 Apr 1;51(3):e34-6.
  • 42. • A 29-year-old woman had bilateral cleft lip and palate repair as a baby. • The operation had been uneventful but the bone graft failed and a palatal fistula subsequently formed. • Twenty years after the initial operation she started to complain of a nasty smell and discharge from the nose. • She had an examination under anesthetic of the whole nasal cavity and a large calcified mass, histologically confirmed as impression material, was removed from the right nasal floor. • Removal resulted in complete resolution of her symptoms. CASE 1
  • 43. • A 24-year-old woman had also had surgery for bilateral cleft lip and palate as a baby. • Again, the initial operation had been uneventful but a palatal fistula formed subsequently. • She had several further procedures, which included the placement of dental implants, and multiple impressions were taken • CBCT was also done, but no cause was identified • Impression material was lodged in the left nostril and removal resulted in complete resolution of her symptoms. CASE 2
  • 44.  Unnoticed aspiration of palate plate impression material in a neonate: Diagnosis, therapy, outcome Reichert F, Amrhein P, Uhlemann F. Unnoticed aspiration of palate plate impression material in a neonate: Diagnosis, therapy, outcome. Pediatric pulmonology. 2017 Oct;52(10):E58-60.
  • 45.  A 7 week old female infant was admitted to the hospital with dyspnea and cyanosis. Two days prior she had a presumed viral upper- and lower airway infection with rhinitis and coughing, treated with saline nose drops and supplemental oxygen for one night.  She had a cleft palate (provided with a plate) and lip dysplasia, but otherwise no neurologic, respiratory, or cardiac abnormalities had been detected. The day before readmittance she started showing dyspnea and could only sleep in an upright position. Fluid intake was increasingly hindered due to respiratory distress  Further history was obtained: during the 1st week of life, a plate for the cleft palate was fitted in two steps: first an impression for a fitting tray was taken, 3 days later this tray was used for the final cleft impression, using polyvinylsiloxane  Two days after admittance they conducted the endoscopic removal in the pediatric thoracic-cardiac operating theatre  In the rigid endoscopy they found a blue foreign body in right mainstem bronchus, which was removed in four pieces (length up to 1.5 cm, Fig. 2). The mucosa showed granulation and swelling, which still obstructed the right superior lobar bronchus
  • 46.  Caring for cleft lip and palate infants: Impression materials, procedures and appliances in use Sabarinath VP, Hazarey PV, Ramakrishna Y, Vasanth R, Girish K. Caring for cleft lip and palate infants: impression procedures and appliances in use. The Journal of Indian Prosthodontic Society. 2009 Apr 1;9(2):76.
  • 47. IMPRESSION MATERIALS • Poor tear strength which usually tear on removal, esp. when alginate extrudes deep into the cleft undercuts Irreversible hydrocolloid impression material • Cartridge delivery silicones provide excellent replication of the surface detail Putty elastomeric impression material • Can be removed before it sets in case of emergency. • Better resistance to tearing as compared to other impression materials. Impression compound • The rate of force application during removal improves tear strength and hence, a quick snap removal is suggested • Use of fast setting chromatic alginates has been suggested in these cases • Cartridge delivery systems were expected to be better in neonatal cleft impressions due to better mixing and reduced chances of cross infection • Overheating can lead to scalding or burns in infants, the leaching out of volatile components of the compound can be harmful to the infants and the use of water bath may compromise sterility
  • 48. IMPRESSION PROCEDURES Patient positioning  For an accurate impression proper patient and dentist position are vital.  A number of positions have been adopted for cleft palate impression making in infants including 1. prone, 2. face down, 3. upright, 4. even upside down.  Some authors prefer the impression of the newborn infant to be taken in the hospital crib as it provides good work surface at a convenient height.
  • 49.  As with any impression procedure tray selection is an important step.  The tray should be of enough size to include all the borders.  Rimming of the entire tray with utility wax has been suggested to provide additional bulk of material laterally,  avoid sharp edges of the tray and also provide a posterior dam preventing material from seeping posteriorly.  After size and shape have been roughly estimated, perforated custom acrylic trays can be fabricated.  Prefabricated trays that are commercially available (Coe laboratories, Chicago) for cleft palate  Shatkin and Stark have described the use of wax for impression trays in cleft lip and palate patients.  Anecdotal reports also mention the use of ice cream sticks or spoons to carry materials for infant impressions. TRAY SELECTION
  • 51. POSSIBLE COMPLICATIONS  Complications encountered when taking impressions in cleft lip and palate infants arise primarily due to the fact that they are obligatory nasal breathers.  Chate reported the following hazards have been encountered by dentists involved routinely in the care of CLP patients: 1. Difficulty in removal of impression due to engagement of undercuts 2. Fragmentation of the impression during withdrawal from the mouth with subsequent respiratory obstruction due to lodgment in the respiratory passage 3. Cyanotic episodes of which few resulted in asphyxiation
  • 52. Precautions  As it is rightly said that, prevention is better than cure and the same applies to impression making in cleft infants.  A dental mouth mirror is an effective tool for depressing the tongue during the impression procedure thereby maintaining airway patency.  Clean cotton tipped ear buds may be used to clean the infant oral cavity before impression making and remove any intra oral remnants of impression material after the procedure.  Impressions for neonate/infants with clefts need to be taken in a hospital setting prepared to handle airway emergencies with a surgeon present at all times.  The impression is made when the infant is fully awake without any anesthesia or premedication.  Infants should be able to cry during the impression procedure and absence of crying may be indicative of airway blockage.  A finger motion may be used to clear unset material posterior to the tray to prevent the infant from closing down on the tray and compromising the airway.  High volume suction should also be ready at all times in case of regurgitation of the stomach contents.  It is preferable that the infant has not eaten for at least two hours prior to the procedure.
  • 53.  Aspiration of fragments of impression material that inadvertently tear during the procedure may cause airway obstruction in infants.  The obstruction may be partial or complete. Three stages of symptoms result from aspiration of any object into the airway. 1. Initial event - violent paroxysms of coughing, choking, gagging and possibly airway obstruction occur immediately when the foreign body is aspirated. 2. Asymptomatic interval - foreign body becomes lodged, reflexes fatigue, and immediate irritating symptoms subside. 3. Complications - obstruction, erosion or infection develop.  Signs of complete airway obstruction include ineffective cough, increased respiratory difficulty accompanied by stridor, development of cyanosis and loss of consciousness. Management Of Complications
  • 54.  Maneuvers to relive foreign body obstruction in infants include- 1. back blows, 2. chest thrusts 3. finger sweeps.  When conscious, the infant is straddled over the arm with face down and head lower than the trunk
  • 55.  The infants head is supported with the rescuers hand around the chest and the jaw.  When support is adequate 4-5 back blows are rapidly delivered with the heel of the hand between the infants shoulder blades.  Following this the free hand is placed over the infants back, holding the infants head.  The infant is effectively sandwiched between the two arms and hands of the rescuer.  The infant is turned and held supine on the rescuers thigh.  The infants head remains lower than the trunk all this while.  Up to 5 quick downward chest thrusts are given in the same location.
  • 56.  The airway may now be opened by using the head tilt chin lift and if spontaneous breathing is absent and chest does not rise on rescue breathing ,the maneuvers may be repeated till the foreign body is expelled or child loses conscious.  When the infant is unconscious the airway is opened using the tongue jaw lift and if a foreign body is seen it is removed with a finger sweep.  Blind finger sweeps should not be performed in infants as it poses the risk of further pushing the fragments into the airway.  Rescue breathing is then attempted. If the chest does not rise adequately the back blows and chest thrusts are repeated till ventilation is established.  Adjuncts for airway and ventilation include oxygen delivery devices, suction devices, appropriately sized oropharyngeal airways, bag valve mask systems and in rare situations cricothyrotomy.
  • 57. CONCLUSION  Oro-facial clefts have been identified to have a multifactorial etiology and therefore require an interdisciplinary treatment approach, comprising various specialists to provide the best possible line of treatment with a individualized treatment approach, i.e. to minimize , if not eliminate, the physical, social, and the emotional hardships that a person with oro- facial clefts suffer.  Inadequate nourishment due to difficulty in feeding affects the health and acts as a stumbling block in the milestones of normal development. A feeding appliance given to the infant effectively separates the oral cavity from the nasal cavity and is of great help in feeding
  • 58. REFERENCES  Textbook of paediatric dentistry – Nikhil Marwah- 3rd edition  Textbook of orthodontics- S Gowri shankar- 1st revised edition  Imthiyas SM, Subramanian B, Karupiah P, Urjan K, Karthik VC, Karthik R. A single-visit feeding plate for a 14-day-old neonate with cleft palate. Indian Journal of Multidisciplinary Dentistry. 2019 Jan 1;9(1):64  Agarwal A, Rana V, Shafi S. A feeding appliance for a newborn baby with cleft lip and palate. National journal of maxillofacial surgery. 2010 Jan;1(1):91.  Fernandes VA, Nadig B, Poojary AV, Bellal S, Neelakantappa HM. Pressure-molded Modified Feeding Plate for Cleft Palate in a Two-month-old Infant: A Case Report. Journal of Health Sciences & Research. 2021 Apr 6;11(2):64-7.  Gupta R, Singhal P, Mahajan K, Singhal A. Fabricating feeding plate in CLP infants with two different material: A series of case report. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2012 Oct 1;30(4):352.  Jones SD, Drake DJ. Case series of undetected intranasal impression material in patients with clefts. British Journal of Oral and Maxillofacial Surgery. 2013 Apr 1;51(3):e34-6.  Sabarinath VP, Hazarey PV, Ramakrishna Y, Vasanth R, Girish K. Caring for cleft lip and palate infants: impression procedures and appliances in use. The Journal of Indian Prosthodontic Society. 2009 Apr 1;9(2):76.  Reichert F, Amrhein P, Uhlemann F. Unnoticed aspiration of palate plate impression material in a neonate: Diagnosis, therapy, outcome. Pediatric pulmonology. 2017 Oct;52(10):E58-60.

Editor's Notes

  1. Parents were taught about the cleaning and placing the appliance in baby’s mouth. Follow up was done after 1 month and baby gained weight