Case Report
From birth till palatoplasty: Prosthetic procedural
limitations and safeguarding infants with
palatal cleft
Sudhir Bhandari, Bhavita Wadhwa Soni, Shiv Sajan Saini1
Oral Health Sciences Centre, Unit of Prosthodontics, PGIMER, 1Department of Neonatology, PGIMER, Chandigarh, India
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
Introduction
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
© 2018 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
Address for correspondence:
Dr. Sudhir Bhandari,
Oral Health Sciences Centre, Unit of Prosthodontics,
PGIMER, Chandigarh, India.
E‑mail: drsudhirbhandari@yahoo.co.in
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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.[5‑9] 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
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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.
101
Bhandari, et al.: Complication free time to palatoplasty for infants with cleft palate
tongue from entering the defect thereby; stimulating
the normal growth of the maxillary segments toward
each other.[10‑17]
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
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.
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
102 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 1 | January-March 2018 |
Figure 1: Mid palatine cleft involving hard and soft palate (Veau
Group II)
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
 Bhandari, et al.: Complication free time to palatoplasty for infants with cleft palate
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.
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.
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
Figure 2: Hand impressed polyvinyl siloxane putty and light body
impression of the maxillary arch
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 1 | January-March 2018 |
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].
Discussion
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.[10‑17,21] 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
Figure 3: Final prosthesis after relining with soft liner
103
Bhandari, et al.: Complication free time to palatoplasty for infants with cleft palate
Figure 4: Master models prepared at 40 days, 5 months, and 8 months
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.
104 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 1 | January-March 2018 |
Figure 5: Corrected palatal cleft at 12 months
Conclusion
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.
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