Feeding Plate Using Digital Intraoral Impression for Cleft Care in an Infant: A Case Report
Corresponding Author: Gaurav Gupta, Department of Pedodontics and Preventive Dentistry, Jaipur Dental College; Private Practice, Wisdom Dental Clinics, Jaipur, Rajasthan, India, Phone: +91 9829560606, e-mail: firstname.lastname@example.org
Received on: 12 May 2023; Accepted on: 10 June 2023; Published on: 23 August 2023
Orofacial clefts are the most frequent craniofacial abnormalities found in humans. A neonate with orofacial cleft which is developed due to incomplete fusion of facial as well as palatal structures might experience difficulties while feeding. The present case aims to depict digital impression-taking for the fabrication of a feeding obturator for a 7-day-old infant who was reported with a unilateral cleft. Treatment was given when the infant turned 3-weeks-old after parents’ compliance. The case highlights the importance of digital intraoral impression protocol in a newborn patient because of its accuracy, minimal invasiveness, and good clinical acceptability. The digital workflow could escalate the fabrication procedure of the feeding plate with a quick transfer of the digitally taken impression to the laboratory, maintaining the precision level thereby minimizing the invasiveness of impression taking and escaping the possibility of material aspiration. Digital impression satisfies the benefits of conventional feeding obturator/appliance reducing the discomfort and difficulties of the direct impression-taking and fabricating process.
How to cite this article: Nanduri MK, Gupta G, Valasingam SK, et al. Feeding Plate Using Digital Intraoral Impression for Cleft Care in an Infant: A Case Report. J South Asian Assoc Pediatr Dent 2023;6(1):82-85.
Source of support: Nil
Conflict of interest: None
Keywords: Case report, Cleft palate, Digital workflow, Feeding appliance, Impression-making, Obturator.
Orofacial clefts are one of the most commonly found craniofacial anomalies, having a prevalence of 0.28–3.74/1,000 childbirths.1 A feeding obturator is an artificial replacement that is designed to restore the separation of nasal and oral cavities. The presurgical nasoalveolar frame results in persistent clinical advantages for the patient and medical profits.2,3
Digital impression allows for the contactless acquisition of intraoral as well as lip and nose morphology of the patient as opposed to the traditional technique of physical impressions which could accompany a risk of endangering the airway obstruction of the infants with impression material.4
The intraoral scanners (IOS) may upgrade the traditional tray and putty technique of impression-making in cleft infants.5 IOS consists of a camera that takes various images of the desired area consecutively, and then finally converts these two-dimensional pictures, taken from distinct angles, into a three-dimensional (3D) reconstructive framework. This reconstruction can be digitally moved and used for various computer-assisted manufacturing procedures.6
Here case depicts of fabrication of a feeding plate in an infant with a unilateral cleft palate using the intraoral digital method of impression showing its precision, invasiveness, and acceptability. In an attempt for improving the fitting and reduce in level of discomfort of the prosthesis, an alternative approach has been taken in the present case to fabricate a feeding palatal obturator.
A 7-day-old neonate female child came to the pediatric hospital for consultation with the primary complaint of a problem while feeding. Upon clinical examination, the neonate was born with left-side unilateral cleft involving the lip, nasal cavity, and alveolar process with soft and hard palate (Fig. 1).
After discussion with parents, the urgent need at that moment was feeding and nutrition of the child, the choice to fabricate a feeding obturator/appliance was taken using the intraoral digital impression.
The treatment procedure was explained to the parents and informed consent was taken, treatment was begun when the parents agreed and bought the infant to the clinic for the treatment, at that time infant was 3 weeks old. The digital impression was taken by an IOS (Trios3, 3Shape) (Figs 2A and B).
The scanned images were sent for digital surveying, and the appliance design was planned. Impressions were taken in gaps to avoid discomfort to the patient. In just 5 minutes, multiple impressions were taken as desired.
With digital impressions desired area images can be taken easily and quickly. The scanned HyperText Markup Language file is further designed for 3D models with (Excocad, DentalCAD version 3.0 Galway) software. The framework’s final design was 3D printed out in a resin with surgical guide resin (JAMG HE, 3D printer photopolymer resin) as a material of choice. On the 3D model, the cleft defect was blocked using modeling wax (Hindustan Dental Products), separating media (Vaseline) was applied on the surface, with this model molding plate was fabricated using conventional acrylic dental resin (cold-cure/self-cure), (DPI) with dough method to obtain sufficient rigidity. The edges of the acrylic plate were trimmed and polished (Fig. 3).
After the construction of the plate, the patient’s parents were recalled with the newborn, and the appliance was placed into the mouth of the newborn noting not to irritate any tissues or activate the gag reflex. Proper fitting of the plate and a suckling response were examined by positioning a finger inside the mouth of the patient. The neonate created a negative force on the finger and the neonate could suck. The feeding plate had a loose fit compared to a tight or snug fit, which is preferred considering the tender oral tissues in infant (Fig. 4).
For easy retrieval of the feeding plate, a hole was made on the plate and was secured with floss and also to prevent swallowing of the appliance. The appliance was delivered and timely follow-up for a month was kept to assess the proper functioning of the feeding obturator/appliance. Parents were educated about the placement, removal, and cleaning of the plate. Cleaning instructions were given after feeding the newborn (Fig. 5).
A feeding appliance/obturator separates the space between oronasal cavities. Feeding appliances become vital in cleft cases as surgery could be performed at 2–3 months of the age of neonate.7
The “digital revolution” that has affected the field of dentistry, now consists of most of the distinctive dental branches making an increasing number of physical jobs effortless and quick to execute.3
A digital protocol might optimize the impression method as the captured data are at the fingertips of the dental laboratory for computer-aided design—approximately 3 minutes, are required for the reconstruction of one dental arch.8,9 IOS precision has increased in the present years and is comparable to conventional polyvinylsiloxane materials.10,11 Here in our case impression was taken in just a few minutes easily and accurately.
The IOS offers several advantages as compared to conventional impression methods inclusive of:
Prevention of discomfort as actual impression material is not used.
Preventing distortion of materials during cast fabrication.
Easy storage and transfer of scanned images.
Quick and accurate with only desired area impression can be taken.
Patients with orofacial defects and their families are confronted with a series of treatment steps for cleft care. Any advancement in order to reduce burden and risk, and enhance treatment outcomes is exceptionally valuable, especially at an early age. Therefore, alternatives to conventional impressions are in need.4
One of the studies done on a 10-month-old neonate depicts a digital impression technique for obtaining impression incorporating silicon elastomer for the fabrication of a feeding plate in cleft patients supports the use of this technique.12 Ideally for making an obturator feeding plate impression is taken with the tray and putty method which has disadvantages like patient discomfort, time-consuming, inhalation, and aspiration of impression material; therefore, to avoid this digital intraoral impression protocol was planned.
However, there are some limitations—in cases of deep defects and soft tissue border areas (i.e., denture flange and defect margin region) and maxillary defect continuity is lost due to the size of the probe as it is a little large sometimes conventional impression is needed additively. Resilience is not perfectly recorded as it is a digital impression, but in this case, as the purpose is to facilitate feeding, unlike dentures; resilience and retention are little compromised.
Nevertheless, this case indicates that this digital workflow could escalate the fabrication procedure of making the passive molding plate with the quick transmission of digital impressions to the laboratory. Keeping the equal fidelity levels of conventional methods, thereby lowering the invasiveness of the impression-making method, preventing the possibility of impression material intake. In the present case, the neonate could suck and create negative pressure with the feeding appliance comfortably.
The benefits of digital intraoral impressions in neonates are multifaceted:
Airway safe use for digital image acquisition for neonates with clefts defects.
Simplifies the treatment procedure and is quick due to direct digitally storable data acquisition.
Scanning can be performed in dental clinics by surgeons to evaluate their outcomes.
Produce high-quality digital images along with additional useful information.
Medical records can be kept.
The advantage of digital impression in this case is far superior to conventional rubber base impression as the later may need to be taken under general anesthesia increasing the overall risk to the child or may need repetition of impression if part of the tissues are not recorded. Impressions obtained by digital scanners can be beneficiary for the treatment of children with cleft malformations for diagnostic purposes, treatment planning, anatomical analysis, and fabrication of presurgical orthopedic appliances. Other than the practical aspect, additionally digital documentation enables healthcare providers to leverage the recent advancement in digital technologies at the forefront to further improve the treatment strategies for such cases.
Though using self-cure is one of the restraints but to avoid multiple visits fast setting self-cure resin was used. To facilitate feeding and avoid conventional impressions with chances of material aspiration in infants we opted for self-cure resin.
Digital intraoral impression retains the precision level of a conventional feeding plate. The satisfactory outcome demonstrates that the digital impression decreases the time and invasiveness of impression-making in a child with a cleft palate. This case reports support for the substitution of traditional impressions with intraoral 3D scans in cases with orofacial clefts.
Gaurav Gupta https://orcid.org/0000-0003-3895-059X
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12. Jamayet NB, Rahman AM, Nizami MI, et al. A novel method of obtaining impression from three-dimensionally printed skull and incorporating medical grade silicone elastomer in fabricating silicone palatal feeding obturators for cleft lip and palate cases. J Int Oral Health 2018;10(1):40–43. DOI: 10.4103/jioh.jioh_182_17
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