[The influence of the Tübingen soft palate plate and early cleft closure on swallowing and Eustachian tube function in children with Pierre Robin sequence]

Functional cleft palate surgery

Cleft lip and palate (CLP) as a dislocation malformation confronts parents with a malformation of their child that could not be more central and visible: the face. In addition to the stigmatizing appearance, however, in cases of a CLP, food intake, physiological breathing, speech and hearing are also affected. In this paper, the principles of morphofunctional surgical reconstruction of the cleft palate are presented. With the closure of the palate, and restoration of the anatomy, a situation is achieved enabling nasal respiration, normal or near normal speech without nasality, improved ventilation of the middle ear, normal oral functions with coordinated interaction of the tongue with the hard and soft palate important for the oral and pharyngeal phases of feeding. With the establishment of physiological function, in the early phases of the infant and toddler, these activities initiate essential growth stimulation, leading to normalisation of facial and cranial growth. If these functional considerations are disregarded during primary closure, lifelong impairment of one or more of the abovementioned processes often follows. In many cases, despite secondary surgery and revision, it might not be possible to correct and achieve the best possible outcomes, especially if critical stages of development and growth have been missed or there has been significant tissue loss due to resection of existing tissue while primary surgery. This paper describes functional surgical methods and reviews long term, over many decades, results of children with cleft palate.

Developmental outcome of children with Robin sequence: How does the question arise?

Robin sequence (RS) is a heterogeneous congenital condition characterized by retrognathia, glossoptosis, upper airway obstruction, and very often, posterior U-shape cleft palate. Half the children with RS have an underlying syndrome, either identified (syndromic RS) or not (RS+). Long-term intellectual developmental outcome first depends on the underlying diagnosis and is often poor in syndromic cases. On the contrary, the rare studies that analysed the long-term developmental outcome of children with isolated RS who received effective treatment of their respiratory and feeding difficulties early in life, showed intellectual and academic results close to or within the normal range. Speech outcome in RS is often delayed with phonation disorders. Speech difficulties depend on intellectual level, hearing and velar function after palate repair. It affects most children with RS and deserves active monitoring and care.

Technical note on introducing a digital workflow for newborns with craniofacial anomalies based on intraoral scans - part II: 3D printed Tübingen palatal plate prototype for newborns with Robin sequence

Background

Orthodontic treatment of newborns and infants with Robin-Sequence using the Tübingen Palatal Plate (TPP) is a complex procedure that could benefit from simplification through digitalization. The design of the velar extension (spur) and the palatal base determines the success of the treatment. Therefore, a prototype must be produced and inserted under endoscopic supervision in order to determine the appropriate shape, length and position of the spur. This technical note demonstrates a fully digital workflow for the design and manufacturing of a functional TPP prototype, based on an intraoral scan. This prototype can be altered and individualized digitally for each patient. After the shape and position of the spur have been optimized, the prototype is duplicated using a silicone mold. Then the definitive TPP is manufactured and inserted. We aim to present a workflow which facilitates the fitting procedure and does not require a conventional impression or a physical model to create the appliance.

Methods

As described in part I of this series, the intraoral scan is performed using the 3Shape TRIOS3 scanner and its corresponding acquisition software. The virtual model is rendered in the 3Shape ortho appliance designer and the base of the palatal plate is designed in the 3Shape dental designer. The palatal plate and the virtual model are then imported into Autodesk Meshmixer and a standardized spur is positioned and merged with the base. The TPP is exported in Standard Tessellation Language (STL) format and manufactured on a W2P Solflex 170 DLP printer using VOCO VPrint Splint material (MDR Class IIa).

Results

Based on an intraoral scan, the TPP prototype could be successfully manufactured and proved suitable for the patients’ treatment.

Conclusion

The new digital workflow for the design of the TPP can been successfully implemented into daily clinical routine in our facility. Patients could be alleviated from having to undergo conventional impression procedures and fitting of the TPP could be facilitated by producing multiple functional prototypes for endoscopic evaluation. Through rapid prototyping, the expenditure of the fitting process was reduced, which makes the TPP therapy more efficient and accessible to a wider range of clinicians.

Pierre Robin sequence from orthodontic and surgical perspective

Pierre Robin sequence (PRS) is a triad of micrognathia, glossoptosis, and cleft palate that results in an obstruction of the airway on inspiration and impeding feeding. The tongue of infants with PRS fall back toward the posterior pharyngeal wall (glossoptosis) due to receding chin produced by mandibular micrognathia (small jaw) or retrognathia. This causes a serious condition with potentially severe, life-threatening airway obstruction. If untreated, this problem can lead to exhaustion, cardiac failure, and ultimately death, especially during the early months of life. Actually, in the majority of PRS infants, these symptoms can be managed by placing the infant in the prone position until adequate growth of the jaw occurs. If this type of treatment fails, the infant then should be considered for other conservative therapies or surgical interventions. This paper reviews surgical interventions such as tongue-lip adhesion, mandibular traction, mandibular distraction, tracheotomy and conservative orthodontic approaches, and presents a baby treated successfully with an orthodontic appliance.

The influence of the Tübingen soft palate plate and early cleft closure on the nasopharyngeal airway for the management of airway obstruction in an infant with Pierre Robin sequence: A case report

INTRODUCTION

A Tübingen palate plate and early cleft closure for successful airway management is described in a newborn with Pierre Robin sequence.

PRESENTATION OF CASE

A three-day-old newborn with an acute airway obstruction underwent primary treatment with a Tübingen soft palate plate.

DISCUSSION

After stabilization of the airway, the cleft soft palate was closed after three months.

CONCLUSION

The Tübingen soft palate plate proved to be a very satisfactory treatment for the infant.

Repaired Cleft Palate and Ventilation Tubes and Their Associations with Cholesteatoma in Children and Adults

Objective:

To determine the influence of ventilation tubes (VTs) on the formation of cholesteatoma and hearing in operated cleft palate patients with chronic ear problems.

Design:

Retrospective 72-month follow-up of 116 operated cleft palate patients.

Patients and Interventions:

Demographic data, clinical examination, and hearing were evaluated. The patients were divided according to age and type of cleft and subdivided in a subgroup with (VT+) or without ventilation tube (VT−).

Main Outcome Measures:

The effect of ventilation tubes (VT) on the incidence of cholesteatoma formation and degree of hearing loss in operated cleft palate patients with chronic ear problems.

Results:

The overall incidence of cholesteatoma was 15.5% (VT+, 14.0%; VT−, 16.7%; not significant). Bilateral hearing loss of >20 dB remained in 14.0% of the VT+ patients and in 22.7% of the VT− patients (p < .05). Submucous cleft palate (SM CP) adults (n  =  15) developed high rates of cholesteatoma and hearing loss of >20 dB (both 26.7%).

Conclusions:

Tube insertion had no influence on the development of cholesteatoma. Adults with submucous cleft palate especially require periodic otologic evaluation because they have Eustachian tube–related otologic disease and hearing loss at a higher rate than expected.