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Brief Report

Korean J Orthod 2022; 52(4): 308-312   https://doi.org/10.4041/kjod21.238

First Published Date April 22, 2022, Publication Date July 25, 2022

Copyright © The Korean Association of Orthodontists.

Split orthodontic airway plate: An innovation to the utilization method of conventional orthodontic airway plate for neonates with Robin sequence

HyeRan Chooa , Seong-Hun Kimb, Hyo-Won Ahna,b, Christian F. Poetsc, Kyu-Rhim Chungb

aDepartment of Surgery, Division of Plastic and Reconstructive Surgery, Pediatric Craniofacial and Airway Orthodontics and Dental Sleep Medicine, Stanford University School of Medicine, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA, USA
bDepartment of Orthodontics, Kyung Hee University School of Dentistry, Seoul, Korea
cDepartment of Neonatology, Interdisciplinary Center for Craniofacial Malformations, University Hospital, Tübingen University, Tübingen, Germany

Correspondence to:HyeRan Choo.
Clinical Assistant Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, Pediatric Craniofacial and Airway Orthodontics and Dental Sleep Medicine, Stanford University School of Medicine, Lucile Packard Children’s Hospital Stanford, 730 Welch Rd, 1F, Palo Alto, CA 94304, USA.
Tel +1-650-736-7117 e-mail hchoo@stanford.edu

How to cite this article: Choo HR, Kim SH, Ahn HW, Poets CF, Chung KR. Split orthodontic airway plate: An innovation to the utilization method of conventional orthodontic airway plate for neonates with Robin sequence. Korean J Orthod 2022;52(4):308-312. https://doi.org/10.4041/kjod21.238

Received: September 14, 2021; Revised: January 11, 2022; Accepted: January 24, 2022

Abstract

Since the emergence of neonatal infant orthodontics for treatments of cleft lip and palate with or without Robin sequence (RS) in Europe in the 1950s, advancements in design and scope of its application have been remarkable. As the first institution to adopt orthodontic airway plate (OAP) treatment in the United States in 2019, we saw a need for innovation of the original design to streamline the most labor-intensive and time-consuming aspects of OAP utilization. A solution is introduced using a systematic split expansion mechanism to re-size the OAP periodically to accommodate the neonate’s maxillary growth. To date, seven RS patients have received this modified treatment protocol at our institution. Each patient completed full treatment using only one OAP. This innovative utilization method is aptly named the split orthodontic airway plate (S-OAP). Details of the S-OAP and its modifications from conventional OAP are reported.

Keywords: Airway, Craniofacial anomalies, Cleft lip and palate, Infant obstructive sleep apnea

INTRODUCTION

Robin sequence (RS) is a rare congenital condition with remarkable phenotypic heterogeneity due to its association with various craniofacial malformations. A recent clinical consensus report defines the triad of RS as micrognathia, glossoptosis, and upper airway obstruction (UAO).1 A palatal cleft is present in 80–90% of infants with RS.2 Severe feeding and breathing difficulties are the two primary concerns in the management of neonates with RS. Discordance of the suck-swallow-breath mechanism in infants with RS often results from unsecured upper airway during swallowing due to tongue base obstruction.3 Interceptive treatment to separate the tongue base away from the posterior pharyngeal wall, therefore, can be an effective mechanism in reclaiming the pharyngeal airway space.

Orthodontic airway plate (OAP) treatment, first introduced in Europe in 1967,4 is a nonsurgical option among various surgical and nonsurgical treatments for neonates with RS with tongue-base UAO. Tübingen palatal plate (TPP) and pre-epiglottal baton plate (PEBP) are examples of conventional OAPs with varying iterations in design and application.5,6 Briefly, an OAP is comprised of three components: palatal, pharyngeal, and extraoral (Figure 1). The palatal component (palatal plate) blocks the tongue from passing through the palatal cleft, separates the nasal cavity and the oral cavity, and provides a solid surface for efficient bottle feeding. The pharyngeal component (velar spur) prevents the tongue from prolapsing, establishes a secure pharyngeal airway, and enables the anterior tongue positioning for bottle feeding. Mandibular catch-up growth of RS infants treated with the OAP has been suggested to be a positive association with the anterior positioning of the tongue by an OAP.7 The extraoral component (a pair of anterior extension wires) functions as hooks connecting to the facial tapes for additional retention of an OAP. Figure 1 illustrates an example of a conventional OAP and how it is situated inside a RS patient’s mouth to enlarge the airway.

Figure 1. Conventional orthodontic airway plate (OAP). A, Schematic illustration of the oropharyngeal structure of a neonate with Robin sequence showing upper airway obstruction resulting from glossoptosis; maxilla (Mx), mandible (Mn), tongue (T), and airway (A). B, Lateral view of an OAP showing the extraoral, palatal, and pharyngeal components. C, Schematic illustration with an OAP inside the mouth. The black arrow in A and C indicates the proximity of the tongue relative to the posterior pharyngeal wall. Enlarged pharyngeal airway by an OAP is noticeable.

Despite the proven efficacy, craniofacial orthodontists are often hesitant to initiate OAP treatment because the overall process is extremely time-consuming and labor-intensive requiring multiple periodic adjustments to accommodate a neonate’s rapid maxillary growth during several months of treatment. This article reports an innovative method of manufacturing and utilizing an OAP to increase efficiency over current clinical and procedural challenges.

SPLIT ORTHODONTIC AIRWAY PLATE

The innovation of split orthodontic airway plate (S-OAP) begins with an installation of a mini-expansion screw (Dentaurum, Ispringen, Germany) at the center of the palatal component of the OAP during fabrication in an orthodontic laboratory (Figure 2A).8,9 Only after placing an expansion screw is the splint acrylic (Great Lakes Orthodontics Ltd., Tonawanda, NY, USA) poured to build the palatal component, followed by connecting the pharyngeal component as previously described.10 A S-OAP is adjusted and installed inside a RS baby’s mouth following the same protocol as conventional OAP delivery.11 As the patient grows, an appearance of a linear continuous pressure mark on the labial slope of the maxillary alveolar ridge is an indication that the palatal plate is becoming too small for the growing maxillary arch. At this time, the S-OAP is split in half and slightly expanded by turning the embedded jackscrew (Figure 2B). The split is then re-sealed using fresh splint acrylic (Great Lakes Orthodontics Ltd.) to maintain the structural integrity and rigidity of the S-OAP prior to reinsertion inside the patient’s mouth (Figure 2C). Figure 2D shows a facial frontal view of an infant wearing the S-OAP. This enlargement mechanism is precise and quantifiable in contrast to the existing conventional method of arbitrarily grinding the palatal acrylic. The internal anatomy of the palatal plate is preserved, which continues to provide intimate and continuous contact between the palatal plate and alveolar ridge despite the enlargement of the palatal plate. The acrylic at areas where enlargement is not desirable (palatal cleft and lateral surfaces of the velar spur) must be ground off to maintain its original width. This cycle of split enlargement is repeated every 1–2 weeks at the neonatal intensive care unit (NICU) and every 3–4 weeks at the ambulatory craniofacial airway orthodontic clinic following the neonate’s hospital discharge.

Figure 2. Split orthodontic airway plate (S-OAP). A, A mini-expansion screw is embedded at the center of the palatal component of an orthodontic airway plate (OAP). B, The S-OAP is split in half and the expansion screw is activated to enlarge the OAP. C, The enlarged split is re-unified by fresh splint acrylic. D, An example of the facial frontal view of a 3-month-old infant with Robin sequence wearing a S-OAP connected to facial tapes. Photos are used with the written consent from the patient.

At our institution, using this S-OAP protocol, seven infants with RS were able to complete the treatment using just one device per patient; hence, the conventional requirement of re-impression, re-fabrication, and re-delivery of multiple OAPs as mid-course corrections was avoided. Figure 3 shows an exemplary patient with isolated RS treated using a S-OAP. As expected with any OAPs, this infant’s mandible demonstrated catch-up growth over 6 months of treatment. The palatal plate was periodically enlarged using the S-OAP protocol. Five turns of expansion screw activation were applied at a 4-week interval. A significant reduction of the size of palatal cleft was also noticeable.

Figure 3. An exemplary patient with isolated Robin sequence whose orthodontic airway plate treatment was completed using one split orthodontic airway plate (S-OAP) during the 6 months of treatment. A, On the day of the S-OAP delivery at the age of 5 weeks. B, 6 months after wearing the S-OAP requiring no further use of the S-OAP for feeding and breathing difficulties. C, Pre-treatment intraoral photo of the maxillary arch. D, Post-treatment intraoral photo. Photos are used with the written consent from the patient.

DISCUSSION

The safety and effectiveness of nonsurgical OAP treatment in improving breathing and oral feeding difficulties of neonates with RS have been well documented in previous literature.11-14 Its pharyngeal component dictates the posterior limit of the tongue base and serves as the anterior border of the pharynx, thereby guaranteeing the patency of upper airway for infants with RS. Although clinical data suggest that the OAP treatment may stimulate the mandibular catch-up growth in infants with RS, it is only speculated that the growth may occur in the context of the Melvin Moss’ functional matrix theory postulating reactive nature of the bone growth to specific functional demands such as the guided anterior tongue movement.7,15

In conventional OAP treatments using PEBP or TPP, periodic adjustments to accommodate an infant’s rapid maxillary growth are achieved by subjectively grinding off acrylic layers from the tissue side of the palatal plate. Excessive grinding can compromise the intimate adaptation between the gingivopalatal tissue and the OAP, greatly reducing the OAP’s intraoral retention and comfort. Conversely, insufficient and uneven grinding may lead to restricted maxillary growth and can cause intraoral pressure marks. Inevitably, it is often required that the initial OAP be replaced by a new larger OAP every two to three months, which means obtaining a new maxillary impression, fabricating a new custom-fit device, and appliance delivery under awake nasopharyngoscopy in collaboration with pediatric otolaryngology at the NICU. All these repetitive procedures exhaust significant amounts of resources from the family, insurance payors, and healthcare professionals of the transdisciplinary high-risk care unit.5,6

In 2019, our institution adopted the OAP treatment for the first time in the United States and recognized the need for modifying the existing utilization protocol in order to reduce labor-intensive and time-consuming aspects of its application. The S-OAP is the product of our efforts to avoid repeated hospital admission, maxillary impression, fabrication, delivery, and adjustments of new OAPs in the NICU. The innovative concept was conceived following the philosophy of Biocreative Orthodontic Strategy with an emphasis on simplicity, efficacy, and comfort of orthodontic devices for patients.16 Installation of a mini-expansion screw on the mid-sagittal plane at the center of the palatal plate of a conventional OAP provides a mechanism for a quick and quantifiable enlargement of the palatal plate and eliminates guesswork of grinding the acrylic. The intimate but evenly spacious contact between the tissue and the S-OAP appears to be critical for providing optimal retention of the device and sufficient room for infant maxillary growth.

It is noteworthy that the palatal seal will leak at the expansion screw segment. However, nutritious suckling of infants with palatal cleft is accomplished by effective expression of milk against a solid palatal surface using a Dr. Brown's® specialty nipple/bottle system (DrBrowns, St. Louis, MO, USA) with an infant-paced feeding valve, which does not require complete palatal seal. All isolated RS babies (without associations with other anomalies) treated using a S-OAP at our institution showed successful oral feeding with excellent weight gain trajectory, achieving 100% oral feeding within a few months of wearing a S-OAP. Similar to conventional OAPs, a S-OAP also triggers a gagging reflex when the device is inserted inside the mouth. Although it no longer triggers a gagging reflex when the device remains inside the mouth, caregivers are recommended to perform the daily cleaning and reinsertion of the device approximately 30–60 minutes prior to the next scheduled feeding in order to avoid risks of emesis or aspiration.

With aggregate expertise in orthodontics, medicine, surgery, and engineering using health innovation technologies, our team continues to investigate modalities for creating more user-friendly and patient-centered procedural protocols in the implementation of OAP treatment for neonates with RS.

CONCLUSIONS

The OAP is a safe and effective nonsurgical treatment for RS. A craniofacial orthodontist’s leading role in a transdisciplinary management team for neonates and infants with RS is critical to the success of OAP treatments. Despite extensive evidence of the therapeutic efficacy, OAP treatments are still infrequently offered around the world. This may be due to demands of laborious and time-consuming adjustments and re-fabrication requirements for rapidly growing patients. Innovation of a S-OAP protocol may mitigate a craniofacial orthodontist’s apprehension to initiate OAP treatment and serve to remind our profession of the importance of craniofacial orthodontics in the management of growth and development of very young patients.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge the generous support by the Lucile Packard Children’s Hospital Stanford in producing the medical illustration that was used in our article.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Breugem CC, Evans KN, Poets CF, Suri S, Picard A, Filip C, et al. Best practices for the diagnosis and evaluation of infants with robin sequence: a clinical consensus report. JAMA Pediatr 2016;170:894-902.
    Pubmed CrossRef
  2. Gorlin RJ, Cervenka J, Pruzansky S. Facial clefting and its syndromes. Birth Defects Orig Artic Ser 1971;7:3-49.
    Pubmed
  3. Sher AE. Mechanisms of airway obstruction in Robin sequence: implications for treatment. Cleft Palate Craniofac J 1992;29:224-31.
    Pubmed CrossRef
  4. Pielou WD. Non-surgical management of Pierre Robin syndrome. Arch Dis Child 1967;42:20-3.
    Pubmed KoreaMed CrossRef
  5. Bacher M, Sautermeister J, Urschitz MS, Buchenau W, Arand J, Poets CF. An oral appliance with velar extension for treatment of obstructive sleep apnea in infants with Pierre Robin sequence. Cleft Palate Craniofac J 2011;48:331-6.
    Pubmed CrossRef
  6. Schmidt G, Hirschfelder A, Heiland M, Matuschek C. Customized pre-epiglottic baton plate-a practical guide for successful, patient-specific, noninvasive treatment of neonates with Robin sequence. Cleft Palate Craniofac J 2021;58:1063-9.
    Pubmed KoreaMed CrossRef
  7. Wiechers C, Buchenau W, Arand J, Oertel AF, Peters K, Müller-Hagedorn S, et al. Mandibular growth in infants with Robin sequence treated with the Tübingen Palatal Plate. Head Face Med 2019;15:17.
    Pubmed KoreaMed CrossRef
  8. Choo H, Maguire M, Low DW. Modified technique of presurgical infant maxillary orthopedics for complete unilateral cleft lip and palate. Plast Reconstr Surg 2012;129:249-52.
    Pubmed CrossRef
  9. Choo H, Maguire M, Low DW. Modified technique of presurgical infant maxillary orthopedics for complete bilateral cleft lip and palate. Plast Reconstr Surg 2012;129:244-8.
    Pubmed CrossRef
  10. Müller-Hagedorn S, Arand J, Scholz T, Poets CF, Wiechers C. An innovative method for manufacturing the Tuebingen palatal plate for infants with Robin sequence. BMC Pediatr 2020;20:103.
    Pubmed KoreaMed CrossRef
  11. Choo H, Khosla RK, Meister KD, Wan DC, Lin HC, Feczko R, et al. Nonsurgical orthodontic airway plate treatment for newborns with Robin sequence. Cleft Palate Craniofac J. doi: 10.1177/ 10556656211007689. [Epub ahead of print].
    Pubmed CrossRef
  12. Maas C, Poets CF. Initial treatment and early weight gain of children with Robin Sequence in Germany: a prospective epidemiological study. Arch Dis Child Fetal Neonatal Ed 2014;99:F491-4.
    Pubmed CrossRef
  13. Poets CF, Maas C, Buchenau W, Arand J, Vierzig A, Braumann B, et al. Multicenter study on the effectiveness of the pre-epiglottic baton plate for airway obstruction and feeding problems in Robin sequence. Orphanet J Rare Dis 2017;12:46.
    Pubmed KoreaMed CrossRef
  14. Poets CF, Koos B, Reinert S, Wiechers C. The Tübingen palatal plate approach to Robin sequence: summary of current evidence. J Craniomaxillofac Surg 2019;47:1699-705.
    Pubmed CrossRef
  15. Moss ML. The functional matrix. In: Kraus BS, Riedel RA, eds. Vistas in orthodontics. Philadelphia: Lea & Febiger; 1962. p. 85-98.
    CrossRef
  16. Chung KR. Biocreative therapy: new era in contemporary orthodontics. Seoul: Myung Mun Publishing Co.; 2009.
    CrossRef

Article

Brief Report

Korean J Orthod 2022; 52(4): 308-312   https://doi.org/10.4041/kjod21.238

First Published Date April 22, 2022, Publication Date July 25, 2022

Copyright © The Korean Association of Orthodontists.

Split orthodontic airway plate: An innovation to the utilization method of conventional orthodontic airway plate for neonates with Robin sequence

HyeRan Chooa , Seong-Hun Kimb, Hyo-Won Ahna,b, Christian F. Poetsc, Kyu-Rhim Chungb

aDepartment of Surgery, Division of Plastic and Reconstructive Surgery, Pediatric Craniofacial and Airway Orthodontics and Dental Sleep Medicine, Stanford University School of Medicine, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA, USA
bDepartment of Orthodontics, Kyung Hee University School of Dentistry, Seoul, Korea
cDepartment of Neonatology, Interdisciplinary Center for Craniofacial Malformations, University Hospital, Tübingen University, Tübingen, Germany

Correspondence to:HyeRan Choo.
Clinical Assistant Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, Pediatric Craniofacial and Airway Orthodontics and Dental Sleep Medicine, Stanford University School of Medicine, Lucile Packard Children’s Hospital Stanford, 730 Welch Rd, 1F, Palo Alto, CA 94304, USA.
Tel +1-650-736-7117 e-mail hchoo@stanford.edu

How to cite this article: Choo HR, Kim SH, Ahn HW, Poets CF, Chung KR. Split orthodontic airway plate: An innovation to the utilization method of conventional orthodontic airway plate for neonates with Robin sequence. Korean J Orthod 2022;52(4):308-312. https://doi.org/10.4041/kjod21.238

Received: September 14, 2021; Revised: January 11, 2022; Accepted: January 24, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Since the emergence of neonatal infant orthodontics for treatments of cleft lip and palate with or without Robin sequence (RS) in Europe in the 1950s, advancements in design and scope of its application have been remarkable. As the first institution to adopt orthodontic airway plate (OAP) treatment in the United States in 2019, we saw a need for innovation of the original design to streamline the most labor-intensive and time-consuming aspects of OAP utilization. A solution is introduced using a systematic split expansion mechanism to re-size the OAP periodically to accommodate the neonate’s maxillary growth. To date, seven RS patients have received this modified treatment protocol at our institution. Each patient completed full treatment using only one OAP. This innovative utilization method is aptly named the split orthodontic airway plate (S-OAP). Details of the S-OAP and its modifications from conventional OAP are reported.

Keywords: Airway, Craniofacial anomalies, Cleft lip and palate, Infant obstructive sleep apnea

INTRODUCTION

Robin sequence (RS) is a rare congenital condition with remarkable phenotypic heterogeneity due to its association with various craniofacial malformations. A recent clinical consensus report defines the triad of RS as micrognathia, glossoptosis, and upper airway obstruction (UAO).1 A palatal cleft is present in 80–90% of infants with RS.2 Severe feeding and breathing difficulties are the two primary concerns in the management of neonates with RS. Discordance of the suck-swallow-breath mechanism in infants with RS often results from unsecured upper airway during swallowing due to tongue base obstruction.3 Interceptive treatment to separate the tongue base away from the posterior pharyngeal wall, therefore, can be an effective mechanism in reclaiming the pharyngeal airway space.

Orthodontic airway plate (OAP) treatment, first introduced in Europe in 1967,4 is a nonsurgical option among various surgical and nonsurgical treatments for neonates with RS with tongue-base UAO. Tübingen palatal plate (TPP) and pre-epiglottal baton plate (PEBP) are examples of conventional OAPs with varying iterations in design and application.5,6 Briefly, an OAP is comprised of three components: palatal, pharyngeal, and extraoral (Figure 1). The palatal component (palatal plate) blocks the tongue from passing through the palatal cleft, separates the nasal cavity and the oral cavity, and provides a solid surface for efficient bottle feeding. The pharyngeal component (velar spur) prevents the tongue from prolapsing, establishes a secure pharyngeal airway, and enables the anterior tongue positioning for bottle feeding. Mandibular catch-up growth of RS infants treated with the OAP has been suggested to be a positive association with the anterior positioning of the tongue by an OAP.7 The extraoral component (a pair of anterior extension wires) functions as hooks connecting to the facial tapes for additional retention of an OAP. Figure 1 illustrates an example of a conventional OAP and how it is situated inside a RS patient’s mouth to enlarge the airway.

Figure 1. Conventional orthodontic airway plate (OAP). A, Schematic illustration of the oropharyngeal structure of a neonate with Robin sequence showing upper airway obstruction resulting from glossoptosis; maxilla (Mx), mandible (Mn), tongue (T), and airway (A). B, Lateral view of an OAP showing the extraoral, palatal, and pharyngeal components. C, Schematic illustration with an OAP inside the mouth. The black arrow in A and C indicates the proximity of the tongue relative to the posterior pharyngeal wall. Enlarged pharyngeal airway by an OAP is noticeable.

Despite the proven efficacy, craniofacial orthodontists are often hesitant to initiate OAP treatment because the overall process is extremely time-consuming and labor-intensive requiring multiple periodic adjustments to accommodate a neonate’s rapid maxillary growth during several months of treatment. This article reports an innovative method of manufacturing and utilizing an OAP to increase efficiency over current clinical and procedural challenges.

SPLIT ORTHODONTIC AIRWAY PLATE

The innovation of split orthodontic airway plate (S-OAP) begins with an installation of a mini-expansion screw (Dentaurum, Ispringen, Germany) at the center of the palatal component of the OAP during fabrication in an orthodontic laboratory (Figure 2A).8,9 Only after placing an expansion screw is the splint acrylic (Great Lakes Orthodontics Ltd., Tonawanda, NY, USA) poured to build the palatal component, followed by connecting the pharyngeal component as previously described.10 A S-OAP is adjusted and installed inside a RS baby’s mouth following the same protocol as conventional OAP delivery.11 As the patient grows, an appearance of a linear continuous pressure mark on the labial slope of the maxillary alveolar ridge is an indication that the palatal plate is becoming too small for the growing maxillary arch. At this time, the S-OAP is split in half and slightly expanded by turning the embedded jackscrew (Figure 2B). The split is then re-sealed using fresh splint acrylic (Great Lakes Orthodontics Ltd.) to maintain the structural integrity and rigidity of the S-OAP prior to reinsertion inside the patient’s mouth (Figure 2C). Figure 2D shows a facial frontal view of an infant wearing the S-OAP. This enlargement mechanism is precise and quantifiable in contrast to the existing conventional method of arbitrarily grinding the palatal acrylic. The internal anatomy of the palatal plate is preserved, which continues to provide intimate and continuous contact between the palatal plate and alveolar ridge despite the enlargement of the palatal plate. The acrylic at areas where enlargement is not desirable (palatal cleft and lateral surfaces of the velar spur) must be ground off to maintain its original width. This cycle of split enlargement is repeated every 1–2 weeks at the neonatal intensive care unit (NICU) and every 3–4 weeks at the ambulatory craniofacial airway orthodontic clinic following the neonate’s hospital discharge.

Figure 2. Split orthodontic airway plate (S-OAP). A, A mini-expansion screw is embedded at the center of the palatal component of an orthodontic airway plate (OAP). B, The S-OAP is split in half and the expansion screw is activated to enlarge the OAP. C, The enlarged split is re-unified by fresh splint acrylic. D, An example of the facial frontal view of a 3-month-old infant with Robin sequence wearing a S-OAP connected to facial tapes. Photos are used with the written consent from the patient.

At our institution, using this S-OAP protocol, seven infants with RS were able to complete the treatment using just one device per patient; hence, the conventional requirement of re-impression, re-fabrication, and re-delivery of multiple OAPs as mid-course corrections was avoided. Figure 3 shows an exemplary patient with isolated RS treated using a S-OAP. As expected with any OAPs, this infant’s mandible demonstrated catch-up growth over 6 months of treatment. The palatal plate was periodically enlarged using the S-OAP protocol. Five turns of expansion screw activation were applied at a 4-week interval. A significant reduction of the size of palatal cleft was also noticeable.

Figure 3. An exemplary patient with isolated Robin sequence whose orthodontic airway plate treatment was completed using one split orthodontic airway plate (S-OAP) during the 6 months of treatment. A, On the day of the S-OAP delivery at the age of 5 weeks. B, 6 months after wearing the S-OAP requiring no further use of the S-OAP for feeding and breathing difficulties. C, Pre-treatment intraoral photo of the maxillary arch. D, Post-treatment intraoral photo. Photos are used with the written consent from the patient.

DISCUSSION

The safety and effectiveness of nonsurgical OAP treatment in improving breathing and oral feeding difficulties of neonates with RS have been well documented in previous literature.11-14 Its pharyngeal component dictates the posterior limit of the tongue base and serves as the anterior border of the pharynx, thereby guaranteeing the patency of upper airway for infants with RS. Although clinical data suggest that the OAP treatment may stimulate the mandibular catch-up growth in infants with RS, it is only speculated that the growth may occur in the context of the Melvin Moss’ functional matrix theory postulating reactive nature of the bone growth to specific functional demands such as the guided anterior tongue movement.7,15

In conventional OAP treatments using PEBP or TPP, periodic adjustments to accommodate an infant’s rapid maxillary growth are achieved by subjectively grinding off acrylic layers from the tissue side of the palatal plate. Excessive grinding can compromise the intimate adaptation between the gingivopalatal tissue and the OAP, greatly reducing the OAP’s intraoral retention and comfort. Conversely, insufficient and uneven grinding may lead to restricted maxillary growth and can cause intraoral pressure marks. Inevitably, it is often required that the initial OAP be replaced by a new larger OAP every two to three months, which means obtaining a new maxillary impression, fabricating a new custom-fit device, and appliance delivery under awake nasopharyngoscopy in collaboration with pediatric otolaryngology at the NICU. All these repetitive procedures exhaust significant amounts of resources from the family, insurance payors, and healthcare professionals of the transdisciplinary high-risk care unit.5,6

In 2019, our institution adopted the OAP treatment for the first time in the United States and recognized the need for modifying the existing utilization protocol in order to reduce labor-intensive and time-consuming aspects of its application. The S-OAP is the product of our efforts to avoid repeated hospital admission, maxillary impression, fabrication, delivery, and adjustments of new OAPs in the NICU. The innovative concept was conceived following the philosophy of Biocreative Orthodontic Strategy with an emphasis on simplicity, efficacy, and comfort of orthodontic devices for patients.16 Installation of a mini-expansion screw on the mid-sagittal plane at the center of the palatal plate of a conventional OAP provides a mechanism for a quick and quantifiable enlargement of the palatal plate and eliminates guesswork of grinding the acrylic. The intimate but evenly spacious contact between the tissue and the S-OAP appears to be critical for providing optimal retention of the device and sufficient room for infant maxillary growth.

It is noteworthy that the palatal seal will leak at the expansion screw segment. However, nutritious suckling of infants with palatal cleft is accomplished by effective expression of milk against a solid palatal surface using a Dr. Brown's® specialty nipple/bottle system (DrBrowns, St. Louis, MO, USA) with an infant-paced feeding valve, which does not require complete palatal seal. All isolated RS babies (without associations with other anomalies) treated using a S-OAP at our institution showed successful oral feeding with excellent weight gain trajectory, achieving 100% oral feeding within a few months of wearing a S-OAP. Similar to conventional OAPs, a S-OAP also triggers a gagging reflex when the device is inserted inside the mouth. Although it no longer triggers a gagging reflex when the device remains inside the mouth, caregivers are recommended to perform the daily cleaning and reinsertion of the device approximately 30–60 minutes prior to the next scheduled feeding in order to avoid risks of emesis or aspiration.

With aggregate expertise in orthodontics, medicine, surgery, and engineering using health innovation technologies, our team continues to investigate modalities for creating more user-friendly and patient-centered procedural protocols in the implementation of OAP treatment for neonates with RS.

CONCLUSIONS

The OAP is a safe and effective nonsurgical treatment for RS. A craniofacial orthodontist’s leading role in a transdisciplinary management team for neonates and infants with RS is critical to the success of OAP treatments. Despite extensive evidence of the therapeutic efficacy, OAP treatments are still infrequently offered around the world. This may be due to demands of laborious and time-consuming adjustments and re-fabrication requirements for rapidly growing patients. Innovation of a S-OAP protocol may mitigate a craniofacial orthodontist’s apprehension to initiate OAP treatment and serve to remind our profession of the importance of craniofacial orthodontics in the management of growth and development of very young patients.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge the generous support by the Lucile Packard Children’s Hospital Stanford in producing the medical illustration that was used in our article.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

Fig 1.

Figure 1.Conventional orthodontic airway plate (OAP). A, Schematic illustration of the oropharyngeal structure of a neonate with Robin sequence showing upper airway obstruction resulting from glossoptosis; maxilla (Mx), mandible (Mn), tongue (T), and airway (A). B, Lateral view of an OAP showing the extraoral, palatal, and pharyngeal components. C, Schematic illustration with an OAP inside the mouth. The black arrow in A and C indicates the proximity of the tongue relative to the posterior pharyngeal wall. Enlarged pharyngeal airway by an OAP is noticeable.
Korean Journal of Orthodontics 2022; 52: 308-312https://doi.org/10.4041/kjod21.238

Fig 2.

Figure 2.Split orthodontic airway plate (S-OAP). A, A mini-expansion screw is embedded at the center of the palatal component of an orthodontic airway plate (OAP). B, The S-OAP is split in half and the expansion screw is activated to enlarge the OAP. C, The enlarged split is re-unified by fresh splint acrylic. D, An example of the facial frontal view of a 3-month-old infant with Robin sequence wearing a S-OAP connected to facial tapes. Photos are used with the written consent from the patient.
Korean Journal of Orthodontics 2022; 52: 308-312https://doi.org/10.4041/kjod21.238

Fig 3.

Figure 3.An exemplary patient with isolated Robin sequence whose orthodontic airway plate treatment was completed using one split orthodontic airway plate (S-OAP) during the 6 months of treatment. A, On the day of the S-OAP delivery at the age of 5 weeks. B, 6 months after wearing the S-OAP requiring no further use of the S-OAP for feeding and breathing difficulties. C, Pre-treatment intraoral photo of the maxillary arch. D, Post-treatment intraoral photo. Photos are used with the written consent from the patient.
Korean Journal of Orthodontics 2022; 52: 308-312https://doi.org/10.4041/kjod21.238

References

  1. Breugem CC, Evans KN, Poets CF, Suri S, Picard A, Filip C, et al. Best practices for the diagnosis and evaluation of infants with robin sequence: a clinical consensus report. JAMA Pediatr 2016;170:894-902.
    Pubmed CrossRef
  2. Gorlin RJ, Cervenka J, Pruzansky S. Facial clefting and its syndromes. Birth Defects Orig Artic Ser 1971;7:3-49.
    Pubmed
  3. Sher AE. Mechanisms of airway obstruction in Robin sequence: implications for treatment. Cleft Palate Craniofac J 1992;29:224-31.
    Pubmed CrossRef
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