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MANAGEMENT OF FEEDING PROBLEMS IN A CLEFT LIP AND

PALATE PATIENT WITH FEEDING APPLIANCE: A CASE REPORT
Dr Nadeem Yunus Associate Professor

ABSTRACT

Cleft lip and cleft palate are one of the most common congenital defects of the oral
cavity, although their prevalence is very low. Exposure of mother to some medications or
substances during pregnancy, infections and some syndromes may lead to cleft lip and palate in
infants. One of the major difficulties in cleft palate patients is that they can not create negative
pressure in side the oral cavity which is necessary for feeding due to oro-nasal communication.
Also these patients don’t have a solid platform to press the nipple to extract the milk. To improve
the feeding ability of the cleft patients, for proper nourishment before surgical correction, a
feeding appliance is recommended as early as possible after birth of the child with cleft palate. In
the present article, a case of 7 days old infant with cleft lip and palate and chief complaints of
poor feeding ability and regurgitation of milk from nose is presented who was successfully
treated with feeding appliance.

Key words:- Cleft lip and palate, feeding appliance, autosomal dominance.

INTRODUCTION

Cleft lip and cleft palate are the most

AFFILIATION common congenital defects of the oral
cavity. Their prevalence ranges from 0.28 to
DEPARTMENT OF PROSTHODONTICS 0.37 for each thousand births.1 Cleft lip and
palate are commonly seen in Asian neonates
FACULTY OF DENTISTRY,
as these are strongly affected by race. In
JAMIA MILLIA ISLAMIA, NEW
case of isolated cleft lip the male infants are
DELHI-25, INDIA
affected more whereas isolated cleft palate
condition is seen more frequently in female
infants.2 Etiology of cleft lip and palate
includes exposure of mother to some
medications or substances during pregnancy,

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C AS E R E PO R T
infections and association with
syndromes.3 Some examples of syndromes
which show relationship with cleft lip and
palate conditions are Treacher Collins
syndrome, Pierre Robin Syndrome, Apert’s
syndrome, Stickler’s syndrome
Waardenburg’s syndrome. Non syndromic
clefts show a polygenic multifactorial
inheritance.
Cleft of lip and palate pose many
difficulties to these patients; even, they may
be life threatening to them. Existence of oro-
nasal communication in these patents
prevents production of the negative pressure
4,5
in oral cavity necessary for suckling.
when baby presses the nipple to squeeze the
milk it is entrapped inside the cleft. All these
lead to prolonged and tiring feeding for both
mother and patient. Further more, the
feeding becomes more complicated when
there is nasal regurgitation of the milk. One
more complication associated with this
condition is the tendency of the tongue to go
inside the cleft area resulting in hampered
spontaneous growth of palatal shelves
towards the midline. Other complications
include deficient growth of the face, missing
and malformed teeth, delayed speech with
articulation defects, otologic problems like
eustachian tube dysfunction etc, leading to
psychological problems in these patients.
JOURNAL OF MAXILLOFACIAL REHABILITATION AND SCIENCES
some The feeding appliance restores the
separation between oral and nasal cavities
by obturating the cleft. This helps in creating
negative pressure in oral cavity necessary
for feeding and it also provide a solid
and platform for the baby to press the nipple and
extract the milk. All these make feeding
easy for baby and mother.7 Also, the
problem of regurgitation of milk through
nose is resolved. This appliance also
prevents the tongue to enter the defect7 and
facilitates the spontaneous normal growth of
the palatal halves towards the midline.8
Tongue comes to its correct normal position
Also, to perform its functional role in jaw
development and development of speech.
Thus a feeding appliance restores basic
functions feeding, mastication, deglutition
and speech till the defect is surgically
repaired.
CASE REPORT
A 7 days old healthy infant was referred to
our department with chief complaints of
poor feeding ability and regurgitation of
milk from nose (Fig. 1). On examination it
was found that the infant was born with
unilateral cleft lip and palate on left side.
History of the pregnancy of the mother was
not significant and no other infant in the
6
family was having this problem.
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Figure 1: Intraoral view of the infant with
cleft lip and palate
After thorough examination, fabrication of a
feeding appliance was planned for the
infant.
Primary impression of the maxillary arch of
the infant was made with polyvinyl siloxane
putty material using two ice cream sticks as
stock tray. During impression making infant
was held in the lap of the mother with his
face facing downward. Mother was holding
the infant from his chest while the head of
the infant was supported by the fingers of
the clinician. This position prevents
accidental aspiration of any extra impression
material. Cry of the infant indicates patency
of the airway and it should not stop during
9
whole procedure. The procedure of the
impression making was performed in the
presence of a surgeon and proper
armamentarium to manage any emergency.
When impression material was set it was
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NADEEM Y. 2013, ISSUE 2, VOLUME 1
removed from the mouth and was poured in
dental stone. In this way primary cast was
obtained.
The undercuts in the cleft region of
the palate in primary cast were blocked with
modeling wax and a customizing special
tray was fabricated with auto-polymerizing
acrylic on this cast. All the borders were
made smooth and free of any sharpness.
Now, the secondary impression of the
maxillary arch was made on special tray
using medium body polyvinyl siloxane
following the same procedure and was
poured with dental stone with high strength.
The secondary or master cast was obtained
with finer surface details and was inspected
for any undercuts. All the undercuts were
blocked with dental plaster. A double layer
of properly finished modeling wax was
adopted on the master cast making a wax
pattern for feeding appliance. Flasking of
the cast with wax pattern followed by de-
waxing was done. Separating media was
applied on the cast and surrounding areas
and packing of the heat activated clear
acrylic was done. After completion of the
curing of acrylic, the flask was kept for
overnight cooling. Appliance was retrieved
from the cast and proper trimming, finishing
and polishing was done.
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A button shaped extension was
attached in the anterior region of the
appliance for the attachment of the elastics
and tape which will be helping in gaining
the retention (Fig. 2).
Figure 2: Feeding appliance.
After performing the final finishing, the
feeding appliance was tried into the patient’s
mouth and minor adjustments were made
(Fig. 3). Patient’s mother was told to feed
the patient with feeding appliance in mouth.
Figure 3: Frontal view of the infant with
feeding appliance
Patient was feeding comfortably and there
was no regurgitation of milk from the nose.
Infant’s mother was instructed properly
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regarding method of insertion and removal,
cleaning and maintenance of the feeding
appliance. Parents were told to come after
24 hours for post insertion follow up of the
patient.
On next appointment thorough
examination of the oral cavity of the patient
was done for any inflammation or abrasion
and adjustments in the appliance were made
accordingly. 3 to 4 weekly follow-ups were
scheduled for next nine months and
fabrication of a new feeding appliance was
planned after every three months.5
DISCUSSION
Patients with cleft lip and palate
require multiple disciplinary efforts in a co-
ordinated manner from birth throughout
adolescence. Environmental factors which
may predispose this condition include
maternal epilepsy, some drugs like steroid,
diazepam, phenytoin and deficiency of folic
acid, maternal smoking , maternal alcohol
abuse and exposure to illegal drugs (cocaine,
crack cocaine, heroin, etc). Early care is
utmost essential in these patients as they
require numerous health care needs related
to feeding problems, speech disorders, ear
infections, problems related to facial &
dental development etc.
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Plastic surgeons and prosthodontists
have general opinion that pre-surgical
management of this condition should be
undertaken as soon as possible after birth.
Numerous bottles and nipples of
specialized design have been developed to
allow a cleft lip and palate infant to feed
adequately, yet Choi et al.10 Mizuno et al.11
12
and Reid et al. have reported difficulties in
feeding associated with cleft palate.
Chang and Wang13 recommended
feeding appliance for cleft palate and
described a simplified technique for the
fabrication of it. The procedure
fabrication of feeding appliance was easy
and simple with minimal risks to the infant
during the procedure.
There are many types of materials
which can be used to make feeding
appliances. Banu K et al14 used auto
polymerizing clear acrylic resin
combination with a piece of tulle; tulle is a
flexible material hence it was used in soft
palate area.
15
Pooja M et al treated a cleft patient
with a feeding appliance which was
fabricated with auto polymerizing acrylic
resin. They lined this appliance with soft
liner in the centre to give a cushioning
effect.
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We made our feeding appliance with
heat polymerizing acrylic instead of auto
polymerizing acrylic resin because there are
more chances of leaching of the monomer
from auto polymerizing acrylic resin which
may be harmful for the infant.
Frequent follow up visits are
required in feeding appliance patients as the
mucosa of the infant is very delicate and it
may be damaged easily. Also, the arches are
continuously growing the appliance requires
time to time adjustments at bilateral sides of
the borders. To accommodate this growing
of maxillary arch, a new feeding appliance was
advised after every three months.
The mother was advised to hold the
infant in an upright position during feeding
so that the swallowed air can be expelled
easily during the feeding process.6,16
in CONCLUSION
A multidisciplinary team approach is
required for a comprehensive management
of children born with cleft lip and palate.
Dental surgeon plays an important role in
this team who works closely with other
medical specialties. Fabrication of feeding
plate can eliminate the immediate problems
like inability to feed, regurgitation of the
milk from nose and prevention of infections
for the already debilitated infant.
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