S Darshana, A Bagchi, B Dutta, KS Dhull

Abstract

Cleft lip and palate are among the most frequently occurring congenital craniofacial anomalies, resulting in a communication between the oral and nasal cavities. Affected neonates are unable to generate negative intraoral pressure, resulting in inefficient suckling, nasal regurgitation, aspiration, and poor weight gain. Early feeding intervention is essential for ensuring proper nutrition, reducing aspiration risk, and supporting infant growth. Feeding obturators serve as non-invasive prosthetic aids to restore oral-nasal separation and facilitate efficient feeding. This case report presents a simplified, single-visit chairside technique for fabricating a feeding plate using ethylene vinyl acetate, a biocompatible thermoplastic material. The report emphasizes the ease, safety, and effectiveness of this technique for neonatal feeding rehabilitation, especially in resource-constrained settings.

Introduction

Cleft lip and palate (CLP) refers to a range of congenital malformations caused by the failure of fusion of the facial processes during embryogenesis, generally between the 6th and 12th weeks of gestation. The global incidence of CLP is approximately 1 in 700 live births, with higher rates observed in Asian populations.¹ Due to the communication between the oral and nasal cavities, nasal regurgitation, difficulty latching, prolonged feeding times, and poor weight gain are seen.^2,3

Although several non-prosthetic feeding interventions, like modified feeding nipples, specialised feeding bottles, and assisted feeding methods, are available, research shows that there is no one feeding technique that is always better; instead, the choice is frequently influenced by the degree of cleft, caregiver compliance, and clinical knowledge.⁴ Prosthetic devices, such as feeding obturators, designed to temporarily close the cleft, enabling infants to generate the necessary intraoral pressure for suckling, also guide proper tongue positioning, support maxillofacial growth, and reduce aspiration risk.⁵

Traditionally, obturators were fabricated using cold-cure acrylic resin over multiple appointments, which is time-consuming and carries a higher risk of mucosal injury, particularly in neonates.⁶ Thermoplastic materials such as ethylene vinyl acetate (EVA) offer promising alternatives.^7,8

This report describes the single-visit fabrication of an EVA-based feeding plate in a neonate with a complete bilateral cleft lip and palate.

Case Report

A one-month-old female neonate was referred to the paediatric dentistry department for evaluation and management of feeding issues. She was born full-term via normal vaginal delivery with no systemic abnormalities or family history of congenital defects.

Breastfeeding was attempted immediately after birth, but didn't succeed due to poor latch and nasal regurgitation. Bottle-feeding was then tried with a regular infant bottle, but the feeding was prolonged, with frequent episodes of choking and regurgitation of milk through the nose. At the time of presentation, the family did not have access to any specialised cleft feeding bottles, such as the Haberman or Pigeon cleft palate baby bottle.

Clinical examination revealed a complete bilateral cleft involving the soft palate, hard palate, alveolus, and lip- Veau's Class IV (Figure 1A). Given the critical need to address feeding and growth, the treatment plan included fabricating a feeding obturator using a single-visit, chairside method.

A maxillary impression was taken using medical-grade addition silicone putty (Flexceed, GC, Japan) following the parents' informed consent. To enable controlled material placement while preserving airway safety, the operator's gloved index finger served as a personalised impression tray (Figure 1B). After it had set, the impression was carefully retrieved, checked for accuracy, and plaster beading was done to maintain the edges (Figure 1C). The maxilla master model was created by pouring a dental stone cast from the impression (Figure 1D).

Figure 1 (A) Pre-operative frontal view of the patient with cleft lip and palate. (B) Impression of the cleft using index finger as a tray. (C) Plaster beading of the impression made from addition silicone putty impression material. (D) Master cast obtained.

To make it easier to remove the appliance, undercuts on the cast were then blocked with clay material (Figure 2A). A BioStar pressure moulding machine was then used to heat and vacuum-adapt a 1-mm ethylene vinyl acetate (EVA) thermoplastic sheet over the prepared cast (Figure 2B & 2C). The adapted thermoplastic sheet was then carefully trimmed along the vestibular margins and around the palatal defect, finished, and polished after cooling to obtain a smooth, well-fitting feeding plate (Figure 2D). To prevent accidental aspiration of the appliance during use, a retrieval cord made from dental floss was attached to the appliance and secured to the cheeks with adhesive tape (Figure 2E).

Figure 2 (A) Blocking the master cast using clay material. (B) Heating the thermoplastic sheet for adaptation on the master cast in the vacuum former. (C) Thermoplastic sheet adapted on the master cast. (D) Thermoplastic sheet cut according to the vestibular extensions of the maxilla and the defect of the palate. (E) Adaptation of the feeding plate to the defect attached to the cheeks using dental floss and adhesive tape.

The infant showed immediate improvement during feeding with no nasal regurgitation and reduced feeding time. Parents were instructed to use the feeding plate only during feeding sessions and thorough cleaning after each use with mild soap and water, and once daily, using a diluted antiseptic solution was advised.

Follow-up was scheduled after one week. Weight gain of 180 g compared to baseline was reported, and the feeding time was reduced to approximately 20 minutes per session, which was 45 minutes per session earlier with frequent interruptions. Though periodic reassessment and appliance modification are essential to maintain fit and function, longer-term follow-up was not possible in this case, and the child was referred to a multidisciplinary cleft care team for ongoing management.

Discussion

Neonates with cleft lip and palate are at high risk of feeding difficulties due to an inability to form negative intraoral pressure, leading to ineffective suckling, fatigue, and aspiration.^2,5 For infants with CLP, modified nipples and special feeding bottles are frequently employed as first-line interventions. Although these techniques can work well for mild to moderate clefts, their effectiveness largely depends on the infant's cooperation and the skill of the caregiver. Obturators may offer a more consistent division between the nasal and oral cavities in cases of severe clefts, especially those involving both the primary and secondary palates.⁴

Traditionally, obturators are made from cold-cure acrylic resin. However, the process is cumbersome and may result in hard-edged appliances that can traumatize neonatal tissues. In this report, a simplified method was employed by using the operator's gloved index finger as a functional tray - aligning with existing literature.⁶

Thermoplastic materials such as EVA are biocompatible, flexible, soft, and mouldable under heat and pressure, making them ideal for quick, chairside fabrication of prostheses. Their cushioning effect prevents mucosal trauma, flexibility improves patient comfort, and shows less chance of distortion compared to acrylic based obturator. Cold-cure acrylic resin experiences polymerization shrinkage of approximately 0.5% to 1.0% during processing, and internal stresses may form during setting. EVA, on the other hand, exhibits very little polymerization shrinkage (about 0%) because it is a thermoplastic and does not undergo chemical polymerization.^7,8

Conclusion

Cleft lip and palate deformities present early challenges in feeding, and a prompt intervention to restore oral functionality, reduce aspiration risk, and parental anxiety is needed. This case demonstrated the successful single-visit fabrication of a feeding plate using EVA thermoplastic material and a finger-tray impression technique. In comparison with conventional cold-cure acrylic obturators, the EVA-based feeding plate described required significantly less chairside time, eliminated laboratory processing steps, and provided a softer, more flexible interface with neonatal tissues. While acrylic appliances may offer greater durability, EVA plates are particularly advantageous due to ease of fabrication and improved comfort, and are therefore recommended for short-term neonatal use.

Declaration of Interest

All authors have disclosed no conflicts of interest.

References

1. Dixon MJ, Marazita ML, Beaty TH, Murray JC. Cleft lip and palate: understanding genetic and environmental influences. Nat Rev Genet 2011;12:167-78.

2. Chandna P, Adlakha VK, Singh N, Malik P, Malik V. Rehabilitation of a cleft palate infant with a feeding obturator. J Clin Diagn Res 2011;5:646-8.

3. Reid J, Kilpatrick N. Cleft palate. Paediatr Child Health 2009;19:452-8.

4. Bessell A, Hooper L, Shaw WC, Reilly S, Reid J, Glenny AM. Feeding interventions for growth and development in infants with cleft lip, cleft palate, or cleft lip and palate. Cochrane Database Syst Rev 2011;(2):CD003315.

5. Koul R, Chatterjee S, Patil R, Gupta A. Feeding obturators for infants with cleft lip and palate. J Clin Pediatr Dent 2006;30:271-4.

6. Habel A, Sell D, Mars M. Management of cleft lip and palate. Arch Dis Child. 1996;74:360-6.

7. Lee JW, Tseng YC, Lo LJ. Three-dimensional printed feeding obturators for infants with cleft palate: a prospective study. Plast Reconstr Surg Glob Open 2018;6:e1928.

8. Aruna U, Thakur S, Reddy S. Single visit fabrication of feeding obturator for neonates with cleft palate using thermoplastic material. J Indian Soc Pedod Prev Dent 2018;36:104-7.