This document describes a case report of fabricating a modified feeding plate for a newborn infant with cleft palate. A traditional feeding plate can injure soft tissues due to rigidity. The presented case fabricated a plate with a soft, flexible bulb covering the cleft palate to allow synchronized movement and prevent irritation. The plate helped the infant feed adequately and gain weight normally until surgical correction could be performed. Adjustments were made regularly to the border to allow dental arch growth without interference.

1. Modified Feeding Plate for a Newborn With Cleft Palate
A MUSTAFA ERKAN, S¸ENIZ KARAC¸AY, ARZU ATAY, YUMUS¸HAN
GUNAY
Presented by
NAMITHA AP
MDS II nd year
Dept of prosthodontics

2. CONTENTS
INTRODUCTION
CASE REPORT
PROCEDURE
DISCUSSION
CONCLUSION
RELATED ARTICLES
REFERENCES

3. SURGERY
DENTISTRY
SPEECH
THERAPIST
AUDIOLOGISTENT
PEDIATRICS
PSYCHOLOGIST
INTRODUCTION
PROSTHODONTICS ORTHODONTICS
PEDODONTIST
MAXILLOFACIAL
SURGERY
The ideal treatment of cleft area is closure
by bone graft and orthodontics, when this
not feasible, many cases are solved with
prosthetic rehabilitations.
According to mazaheri, 60% of individuals
with clefts will require some type of
denture, and this percentage tends to
increase if cleft affects the alveolar ridge
Treatment depends upon severity

4. TIMING AND SEQUENCING OF
ORTHODONTIC CARE
infant orthopedics (birth
to 2 years), primary
Priary dentition stage (2
to 6 years of age)
Mixed dentition stage (7
to 12 years of age)
Permanent dentition
stage
using an acrylic plate - Hotz and Gnoinski
initiated during the first week of life
temporary effect on the maxillary arch dimensions, and its
effect did not last beyond surgical soft palate closure.
effect of lip and
palatal surgery was much
greater than the effect of
infant
Orthopedics
BONGAARTS 2006
severity of the width of the cleft
significantly affected the efficiency of infant orthopedics.
Efficiency was greater in more severe patients than in
mild patients.

5. • achieved by the time the infant is 2 to 6 months old
Lip repair
• delayed until 12 months to 2 years of age
• early repair of the palate may have a negative effect on the growth
and development of the maxilla due to the resulting scar tissue
Palate repair
Until surgical intervention, maintenance of adequate nutrition is essential to
allow normal growth of the newborn and to prepare the infant for the
corrective surgery.

6. Feeding
Oronasal communication
diminishes the ability to create negative pressure, a
necessary part of sucking
make the feeding complicated for
both the cleft
baby and the parent
Nasal regurgitation
of oral liquid
Frequent burping
due to excessive air
intake during
deglutition
choking
delay the
development of
the newborn
parental
anxiety
Difficulty in feeding, which may lead to
failure to thrive

7. Different approaches to feed babies with
cleft palate
• used only for limited times
Orogastric/nasogastric tubes
• allow the flow of formula with less effort
• not a good choice for some patients
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, which is necessary for sucking.
Feeding plate

8. Advantages of using feeding appliance
1. It helps to maintain adequate nutrition by covering the cleft palate and providing a rigid platform
toward which the infant can press the breast and extract milk
2. It assists in normal suckling and thus leads to the development of normal oromotor and swallowing
reflexes
3. Reduces feeding difficulties such as nasal regurgitation, choking, and shortens the feeding time
4. It positions the tongue in correct posture preventing it to enter into the defect, thus helps in the
growth of the maxilla and maxillary shelves toward each other
5. Reduces the passage of milk into the nasopharynx and thus reduces the incidence of
nasopharyngeal infections and otitis media
6. It also helps in presurgical nasoalveolar molding
7. After cheiloplasty provides cross arch stability and prevents maxillary arch collapse.

9. Traditional feeding plate
cover the hard palate and extend posterior to contact the soft palate.
synchronized movement of the part covering the soft palate during swallowing is
not possible because the material used for conventional feeding plates is rigid.
It frequently injures the soft tissue due to this rigidity
In this case report, the
fabrication of a
modified feeding plate that can
adapt to the changing
palatal and velopharyngeal
morphology during function is
presented.
The bulb part of the feeding plate that extended
to the soft palate was constructed using a soft plastic.
(flexible and permitted synchronized
movement with the soft palate during function)

10. Case report
The patient was a 3-day-old female infant
with cleft lip and palate
Weigth 2.5 kg.
Pediatrician referred - mother was
unable to feed her using typical cleft
nipples or squeezable bottles.
Intraoral examination
cleft of the uvula and soft palate.
a defect of the alveolus on the left side

11. IMPRESSSION MAKING
The face of the infant was positioned downward to prevent airway obstruction and aspiration of
impression material while the first and second impressions were being taken with viscous vinyl
polysiloxane impression material under the supervision of a pediatrician.
Dental plaster was poured into the impression and a dental cast model was obtained for the
construction of the feeding plate.

12. Prior to the fabrication of the feeding plate, lac was applied
on the dental cast model and in the Biostar device
A 1-mm Bioplast clear plate (soft plate) was pressed on the
model and the plate was cut so as to cover the palatal vault
and the cleft region
The Bioplast clear plate was a soft plate and was used to
construct a flexible bulb obturating the cleft region.
After trimming the edges of this soft plate, several retentive
holes were made in it to allow for later attachment to the
hard plate.
The soft plate was placed back on the cast, and portions that
were not to come in contact with the hard plate were filled
with plaster, including the alveolar gap and the soft palate
extension

13. Acrylic resin was
put on the
retentive holes
2-mm Biocryl C
Rosa-transparent
plate (hard plate)
was pressed
The edges of the
plate were
trimmed and
polished
Small hole was drilled
in the anterior flange
of the appliance with
round bur
a piece of thread was
attached through this
hole for safety.
feeding plate was
inserted into the
mouth
necessary adjustments
were made
polished again

14. evaluation using nasal endoscopy revealed that this part was
moving in a synchronized manner with the soft palate during
swallowing.
Parents were educated about insertion,removal and cleaning
of the appliance
soft extension of the feeding plate eliminated the risk of
irritation and the adaptation of the infant to the appliance was
good.
The feeding plate provided adequate nutrient intake, and her
weight gain was normalized.
RECALL VISITS AND ADJUSTMENTS
• on alternate days, the infant
should be monitored for
possible tissue irritation.
1ST WEEK
• should be adjusted
EVERY 2-3 WEEKS
• replaced
EVERY 2-3 MONTHS
To avoid interfering with the growth of the dental arch, the
border of the obturator must be trimmed regularly until the
retention becomes insufficient

15. Flexible feeding obturator
for early intervention in
infants with Pierre Robin
sequence
Jadhav et al
J Prosthet Dent. 2017
Dec;118(6):778-782
Pierre Robin sequence (PRS) is a sporadic congenital condition
Characterized by glossoptosis and mandibular hypoplasia with or without cleft palate, this ailment
presents clinically with severe upper airway obstruction (UAO), obstructive sleep apnea, and feeding
complications

16. INTRODUCTION
hypoplastic mandible prevents the normal descent of the
tongue between the palatal processes, causing lack of fusion
between the palatal shelves.
This results in a single midline palatal cleft, which varies in its
extent from bifid uvula to a complete cleft involving both hard
and soft palate.
Endoscopic studies have suggested that retrognathia causes the
posterior displacement of the chin, which permits the tongue
to fall back into the posterior pharyngeal wall, resulting in an
airway obstruction.
Thus, respiration and feeding become arduous for the neonate,
resulting in exhaustion, choking, prolonged feeding causing
fatigue, and even premature death

17. Infant mortality –
high in PRS
• 25-50%
Major functional
problems faced by
these patients
before surgical
interventions
• UPPER AIRWAY
OBSTRUCTION
• FAILURE TO THRIVE
DUE TO FEEDING
DIFFICULITIES
Lack of intact
palate
impossible for an
infant to
generate
sufficient
negative intraoral
pressure
(suction)
Saunders et al suggested
specifically designed
feeding bottles with
enlarged openings.
• glossopexy, hyomandibulopexy, and mandibular distraction
osteogenesis for maintaining the tongue in a forward
position
Surgical options
• obturating the clefts without maintaining an anterior position
of the tongue
• flexible feeding obturator (FFO) made of thermoplastic
material can overcome these problems
Non surgical prosthodontics treatment options

18. CASE REPORT
A technique is presented to fabricate an FFO prosthesis in a preterm neonate diagnosed with PRS

20. DISCUSSION
The basic aim of treatment is to keep the infant healthy and alive through
the first few critical months of life.
A custom-made FFO helps to close the disunion between the oral and nasal
cavities to create an artificial palate that stimulates the physiologic sucking
reflex.
The prosthesis facilitates deglutition and thus reduces feeding difficulties. It
also diminishes regurgitation, the collection of vomitus in the nasal cavity
that causes rhinitis and middle ear infections, and feeding time.
The FFO has a flexible velopharyngeal extension that hooks over the base of
the tongue and pulls it forward to prevent the tongue from falling back into
the pharynx.
made of soft polyvinyl
acetate, which provides
exceptional retention,
adjusts easily to the
growth of infant’s arch,
and is easy to clean and
use.
Unlike hard acrylic resin
feeding appliances, an
FFO can easily be inserted
and removed from the
small oral cavity of a
neonate because the
device is flexible and
adaptable

21. CONCLUSION
This article describes a contemporary method for the fabrication of a FFO for an infant with PRS.
An FFO with velar extension has been shown to be a safe and viable alternative to more invasive
interventions in treating PRS until the cleft can be closed surgically.
It also reduces the anxiety levels of both parents and baby, and it helps in promoting the infant’s
weight gain, which is necessary in preparing it for future rehabilitative surgeries.

22. An innovative modified feeding appliance for an infant
with cleft lip and cleft palate: A case report
A 2-day-old neonate
chief complaint of difficulty in feeding.
O/E : child was born with unilateral cleft lip
and palate on the left side
Naveen BH, Prasad RS, Kashinath KR, Kumar S, Kalavathi SD,
Laishram N.
Journal of family medicine and primary care. 2019
Jun;8(6):2134.

23. PROCEDURE
A plastic disposable spoon of adequate size covering the entire
palate along with cleft was used. An impression was made
using polyvinyl siloxane putty material with the neonate held in
prone position to prevent aspiration of the impression
material.
The child kept crying during impression making, which had an
advantage of ensuring that the airway was patent
The impression was poured with die stone
The custom tray was fabricated on the primary cast, and the
final impression was made with light body impression material

24. Feeding appliance was made using heat cure
clear acrylic resin.
The appliance was trimmed, borders were
rounded, and polished to avoid trauma to the
surrounding tissue.
For emergency purpose, a thread was
attached to the appliance
mother was asked to hold the appliance
against resistance using thread while feeding
to avoid swallowing
For better retention, another appliance was
conceptualized wherein a small canal was
prepared in the appliance. Through this canal,
two copper wires were fitted for
the protection of the child to prevent from gag
reflex or from
swallowing the plate

25. Parents were recalled with their child and appliance was placed in the infant’s mouth taking care
not to irritate the surrounding soft tissues or activate gag.
Fit of the appliance was checked, thereafter suckling response was observed by placing a finger
in the child’s mouth
The child was able to suck and create a negative pressure onto the finger.
Mother was instructed to breastfeed the child.
(infant was able to breastfeed comfortably with the appliance in place.)
kept on a regular follow.up to assess the success of feeding
appliance by regular weight monitoring and for the periodic
adjustment in the feeding appliance.
Parents were instructed about the placement, removal, and cleaning of
the feeding appliance and replacement of gauze.
Advised to be used only during feeding and should be kept submerged in
the water when not in use.
After feeding, thorough cleaning of the oral cavity and cleft with soft
cloth or cotton soaked in warm water were advised.

26. Discussion
Adequate nutrition is the main priority in patients with cleft lip and palate, and technique
should be found so that feeding is as close to normal breastfeeding as possible
A feeding appliance bridges the gap between oral and nasal cavities.
Feeding obturator becomes urgent in cleft lip and palate infants as surgical treatment usually
starts at 2–3 months of age
A variety of impression materials such as alginate, low fusing compound, and polysulfide
material may be used to make a definite impression
In the present case, a putty type polyvinyl siloxane was used to make an impression because of
its high viscosity reduces the danger of aspiration or swallowing and its relatively good detail
registration property.

27. PRECAUTION TO BE TAKEN WHILE
IMPRESSION MAKING
A mouth mirror should be used to depress the tongue and maintain the airway patency all the
time.
After impression making, wet cotton should be used to clean the infant’s mouth to remove any
left remnants of impression material.
Owing to undercut engagement, difficulty in impression removal and fragmentation of the
impression material may occur, leading to aspiration and causing airway obstruction.
In case of inadvertent aspiration, the infant should be noted for the signs of airway obstruction.
Back blows, chest thrust, and finger sweeps maneuvers should be used to relieve the airway
obstruction.
Blind finger sweeps should never be performed as it poses the risk of further pushing the
fragments into the airways

28. A single-visit feeding plate for a 3-month-
old infant with cleft palate: A case report
Amro Mohammed Moness Ali • Abdullah KamelAM MA, Kamel A.
Journal of dental research, dental clinics, dental prospects. 2017 Dec 13;11(4):253-6.
to provide an infant with a properly functioning feeding prosthesis and to
reduce the parents’ anxiety originating from multiple dental visits.
3-month-old female infant, with non-contributory medical and family history
chief com-plaint of difficulty in feeding and nasal discharge.
mother reported that the infant was not able to suckle milk properly even
with the use of typical cleft nipples or squeezable bottles and the infant was
not gaining proper weight (only 7 pounds).

29. Case report
Intraoral examination revealed a cleft in the uvula,
soft palate and secondary hard palate (Veau’s
classification: Type II
There was no history of previous treatment or surgery
for the defect.

30. Fabrication of the feeding plate
Primary impression was made using low-fusing im-pression
compound
First the defect was filled with a piece of Vase-line gauze; then green
stick was softened in warm water and kneaded with caution to avoid
thermal injury.
An alginate spatula was used to carry the impression material into
the infant’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 prone position in the mother’s lap.
During this step the infant was crying.
The impression was inspected thoroughly; it had satisfactorily
covered all the supporting areas for the feeding plate

31. 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 followed by light-body wash
The secondary impression was poured with dental stone to obtain a master cast

32. blocking out the undercuts with pink wax
plate was fabricated using self-cured acrylic resin
Finally, the edges of this plate were trimmed
Approximately a 10-inch silk suture was passed
through and tied to the eyelet (made by small acrylic
stone) of the feeding plate.
The prosthesis was trimmed, finished and polished.
Then it was examined in the patient’s mouth;
thereafter minor adjustments and final polishing of
the feeding plate were carried out
feeding plate could be replaced to accommodate the
craniofacial growth

33. Prosthodontics Approach for the Fabrication of
Feeding Plates in Cleft Palate Patients
Shajahan P. A., Rohit Raghavan, Ritha Bos, Geethprasad T. S
This article deals with the impression materials and
impression methods used to fabricate a prosthesis
Factors affecting
the quality of a
cleft lip and palate
impression
1. Complete inclusion of the lateral maxillary segments with a good
reproduction of the mucobuccal fold
2. Adequate extension of the impression into the cleft area.
3. The impression must extend into the nasal chamber and every
available undercut.
It is these undercuts that provide the retention capability of the
appliance.

34. Commonly used
impression materials
• poor tear strength which usually
tear on removal, especially when
alginate extrudes deep into the
cleft undercuts.
Irreversible
hydrocolloid
impression
material
Putty elastomeric
impression
material
Impression
compund
use of fast setting
chromatic alginates has been suggested in these cases
alginate and cartridge
delivery
silicones provided excellent
replication of the surface
detail.
Cartridge delivery systems were expected to be better
in neonatal cleft impressions due to better mixing and
reduced chances of cross infection
The rate of force application during
removal improves tear strength and
hence, a quick snap
removal has been suggested.
can be removed before it sets in
case of any emergency
Better resistance to tearing as
compared to other impression
materials.
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 a water
bath may compromise sterility

35. IMPRESSION METHODS
All impressions were taken with the infant fully awake without anesthesia.
Instructions were given to the parents in the visit prior to impression taking not to feed their
baby for at least two hours.
If the impression will be taken in the first visit, it was advised to wait about two hours after the
last meal to prevent the infant from vomiting during the procedure.
Adequate suction apparatus should be available as a safety precaution, in the event that a piece
of alginate is torn from the impression as it is withdrawn.
This can be easily and quickly removed with a broad suction tip, avoiding the possibility of
aspiration of the fragment

36. PATIENT’S POSITION DURING
IMPRESSION MAKING
Prone Upright
Facedown
Upside
down
The best view and access is
obtained when the infant is lying back in a horizontal position.
As the tray is inserted, some of the material will
be expressed forward to envelop the premaxillary area
When the tray has been seated properly, the baby is raised
to a sitting position. It is during this stage that assistance,
usually by the mother, is quite necessary
The baby will
now be crying quite actively, which is the best
indicator for
the operator that the airway is clear.

37. SELECTION OF IMPRESSION TRAY
The tray size is a very important factor
A set of perforated custom acrylic trays of different shapes and sizes, both unilateral and
bilateral, can be easily made from different size casts, or size and shape can be roughly
estimated
Trays individually trimmed and perforated with a large round bur.
Prefabricated tray are used for impression making as it can be adjusted according to size of cleft
Rimming of the entire tray with utility wax (additional bulk of material laterally, avoid sharp
edges of the tray and posterior dam to prevent the material from seeping posteriorly )
Wax, ice cream sticks are also used as impression trays

38. Preliminary impression making
Before taking impression, deeper undercuts of cleft should be
blocked with wet gauze piece tied in suture thread so as to prevent
unnecessary flow of material into cleft.
The impression material is selected according to the case - Usually
color-timed alginate impression material
As the mix is first briskly spatulated, it turns a dark purple color,
gradually lightening to pink.
tray is loaded at this time.
The mix should feel rather thick in consistency, and is usually placed
in the tray so that most of the bulk is in the center.

39. Secondary impression making
The putty wash impression can produce
accurate impressions with good reproduction
of the details and its biggest advantage is its
greater tear strength and the possibility of
making multiple casts with the same
impression
After taking impression, cast was prepared and
unnecessary undercuts on the cast was blocked
with stone plaster.

40. Fabrication of prosthesis
A master cast was prepared using die stone
minimum thickness of Two mm
perforations were made on the peripherals of feeding plate
for retention of floss thread or two retention stops
These would facilitate the attachment of elastic traps on
both sides.

41. Management of complications during
impression procedure
The aspiration of the fragments of the 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 the aspiration of any object into the airway.
• Initial event – violent paroxysms of coughing, choking, gagging and possibly airway obstruction
occur immediately when the foreign body is aspirated.
• Asymptomatic interval – the foreign body becomes lodged, reflexes fatigue, and immediate
irritating symptoms subside.
• Complications – obstruction, erosion or infection develops.

42. The maneouvers which are used to relive when conscious,
the infant is straddled over the arm with face down and
with head lower than the trunk.
The infant’s head is supported with the rescuer’s hand
around the chest and the jaw.
When the support is adequate, 4-5 back blows are rapidly
delivered with the heel of the hand between the infant’s
shoulder blades.
Following this, the free hand is placed over the infant’s
back, holding the infant’s head.
The infant is effectively sandwiched between the two
arms and the hands of the rescue
Effective
cough
Incresed
respiratory
difficulty
stridor
Development
of cyanosis
Loss of
consciousness
The signs of complete airway
obstruction

43. The infant is turned and held supine on the rescuer’s thigh.
The infant’s head is expected to remain lower than the trunk all this time.
Up to 5 quick downward chest thrusts are given in the same location and manner, as the
external chest compressions which are given for cardiac arrest.
The airway may now be opened by using the head tilt chin lift maneouver and if spontaneous
breathing is absent and the chest does not rise on rescue breathing, then the maneouvers may
be repeated till the foreign body is expelled or the child loses consciousness

44. When the infant is unconscious
airway is opened by using the tongue jaw lift maneouver 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 foreign body
obstruction in infants include back blows, chest thrusts, and finger sweeps. 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.
The adjuncts for airway and ventilation include oxygen delivery devices, suction devices,
appropriately sized oropharyngeal airways, bag valve mask systems and in rare situations,
cricothyrotomy

45. Questionnaire evaluation of feeding methods
for cleft lip and palate neonates
Trenouth MJ, Campbell AN. International journal of paediatric dentistry. 1996 Dec;6(4):241-4.
 A questionnaire evaluation was undertaken of feeding methods used by the mothers of 25
neonates with cleft lip and/or palate
Most parents had problems feeding their babies
1. Quantity of food taken and especially with the time taken to feed; even after a period of 2
months over a quarter were still having problems with the quantity of feed
2. not established a regular feeding pattern
Just over a half needed to change the feeding method from the one with which they started

46. The Haberman feeder was the most
popular, being used by 18 mothers.
An acrylic feeding plate was
considered to be helpful by 6 of 11
mothers of babies with complete
clefts but by only 1 of 9 mothers of
babies with secondary palate clefts.
Almost all the mothers were
dissatisfied with the information
they had received while in hospital
and with the back-up when they
went home.

47. Assessment of nutrition and feeding
interventions in Turkish infants with
cleft lip and/or palate
◦ to highlight the feeding challenges of infants with cleft lip
and/or palate (CLP) that caregivers encounter
Parents of 200 infants with CLP were asked to
complete our questionnaire.
1. Prenatal feeding preparations
2. Preoperative processes
3. Feeding challenges
4. Modifications to overcome these
difficulties were evaluated.
Kucukguven A, Calis M, Ozgur F. Journal of pediatric nursing. 2020 Mar 1;51:e39-44.

48. 42% of the infants were
initially fed by
nasogastric or
orogastric tube.
Out of the 166 infants
with cleft palate, 31.9%
used palatal obturators.

49. CONCLUSIONS
Conclusions: We have reviewed the various feeding difficulties of the infants with clefts and
highlighted the results of the interventions performed to overcome these difficulties for better
nutrition and growth.
Practice implications: In the light of our findings, further studies should be conducted and
additional educational programs should be implemented for both healthcare providers and
parents to increase families' awareness regarding cleft feeding, prevent unnecessary and
improper feeding interventions in infants with clefts, and alleviate the burden of feeding
difficulties for both parents and infants.

50. REFERENCES
Erkan M, Karaçay Ş, Atay A, Günay Y. A modified feeding plate for a newborn with cleft palate. The Cleft Palate-
Craniofacial Journal. 2013 Jan;50(1):109-12.Kucukguven A, Calis M, Ozgur F. Assessment of nutrition and feeding
interventions in turkish infants with cleft lip and/or palate. Journal of pediatric nursing. 2020 Mar 1;51:e39-44.
Trenouth MJ, Campbell AN. Questionnaire evaluation of feeding methods for cleft lip and palate neonates.
International journal of paediatric dentistry. 1996 Dec;6(4):241-4.
Shajahan PA, Raghavan R, Bos R, Geethprasad TS. Prosthodontics Approach for the Fabrication of Feeding Plates
in Cleft Palate Patients. Science. 2016 May 19;5(4-1):31-6.
AM MA, Kamel A. A single visit feeding plate for 3 months old cleft palate infant. A case report. Journal of dental
research, dental clinics, dental prospects. 2017 Dec 13;11(4):253-6.
Naveen BH, Prasad RS, Kashinath KR, Kumar S, Kalavathi SD, Laishram N. An innovative modified feeding appliance
for an infant with cleft lip and cleft palate: A case report. Journal of family medicine and primary care. 2019
Jun;8(6):2134.
Jadhav R, Nelogi S, Rayannavar S, Patil R. Flexible feeding obturator for early intervention in infants with Pierre
Robin sequence. The Journal of prosthetic dentistry. 2017 Dec 1;118(6):778-82.