Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Archana Dambal

"Journal of clinical and diagnostic research is a welcome change in publishing practices. It aims to reach out to the grass-root level researchers who do not lack in experience, clinical material and ideas, but lack in their knowledge in English language and statistics. The journal achieves it's aim by supporting in these exact domains.
It also gives due credit to all research designs like descriptive and qualitative studies while many journals ignore these important study designs. The rigorous review process does not allow any compromise in quality
It is indexed in many indexing agencies and the articles are available under creative commons licence free of cost
The frequency of publication supports many aspiring authors from India and other countries.
It's wide scope welcomes articles across various specialities in medicine. In an era when there is an unscientific insistence on speciality specific research by regulatory bodies in medical education, JCDR supports collaborative research across specialities. I wish the publisher all the best in his future endeavors."



Dr. Archana Dambal
Department of General Medicine,
Belgaum Institute of Medical Sciences,Belgaum, Karnataka,INDIA,
On 30 Nov 2018




Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Dentistry
Year : 2010 | Month : December | Volume : 4 | Issue : 6 | Page : 3632 - 3638

Prosthetic Rehabilitation Of Cleft Compromised Newborns: A Review

RIZWAAN A S*, SUJOY B**, RAJLAKSHMI B***, ATIF K****,

*M.D.S., Sr. Lecturer, Department of Prosthodontics, VSPM’s Dental College and Research Centre, Nagpur; **M.D.S., Sr. Lecturer, Department of Orthodontics, VSPM’s Dental College and Research Centre, Nagpur; ***M.D.S., Sr. Lecturer, Department of Prosthodontics, VSPM’s Dental College and Research Centre, Nagpur; ****Lecturer, Department of Prosthodontics, VSPM’s Dental College and Research Centre, Nagpur.

Correspondence Address :
Dr. Rajlakshmi Banerjee,
A-103, Ganesh Towers,
Bharat Nagar,
Amravati Road,
Nagpur, Maharashtra
INDIA
Pin Code: 440033
Phone Nos.: Office: 09890324934 Home: 0712-2551913
E-mail: drrajlakshmi1@rediffmail.com

Abstract

Cleft lip and palate is the most common congenital defect which affects the orofacial region. The treatment objective for patients with these defects is to restore the normal anatomy and function of the affected structures. Surgical closure of the defect is a viable option, but often, the approximation of the palatine halves has to be first achieved with orthopaedic appliances. A variety of appliances have been described for maxillary orthopaedics in infants. For the fabrication of such appliances, an impression of the defect is necessary. Impression making in infants with cleft lip and palate is a challenging task. This article briefly describes the appliances which are used for infant maxillary orthopaedics and the impression procedure for recording the defect.

Keywords

Cleft lip and palate, impression procedure, infant orthopaedics, nasoalveolar molding.

How to cite this article :

RIZWAAN A S, SUJOY B, RAJLAKSHMI B, ATIF K,. PROSTHETIC REHABILITATION OF CLEFT COMPROMISED NEWBORNS: A REVIEW. Journal of Clinical and Diagnostic Research [serial online] 2010 December [cited: 2019 Aug 26 ]; 4:3632-3638. Available from
http://jcdr.net/back_issues.asp?issn=0973-709x&year=2010&month=December&volume=4&issue=6&page=3632-3638&id=992

Introduction
Clefts of the lip and palate are common congenital abnormalities of the orofacial region. The oro-nasal communication due to the defect poses great problems for the newborn in the suckling of milk and speech and it may affect the overall physical and mental growth of the child. The rehabilitation of such infants primarily involves the closure of the defect (1). Surgical repair of the lip is usually performed during 3 to 6 months of age and palate closure is done between 12 and 18 months of age. However, surgery alone may not prove to be beneficial, especially in larger clefts, as surgical closure may lead to an increase in tissue tension at the surgical site, which is not desirable. (2). Infant maxillary orthopaedic procedures were pioneered by Burston (1) in Liverpool in the late 1950’s. Infant maxillary orthopaedics provides presurgical benefits and helps to bring the cleft segments into an acceptable alignment to resemble a more normal configuration prior to lip surgery (2). Molding facilitates the surgical team in easier lip repair, especially in bilateral cleft lip palate (BCLP) patients with a severely protruding premaxilla (3).

Prosthetic care of cleft patients
Prosthetic treatment in infants improves feeding, tongue function and speech development, it reduces the risk of aspiration as the oro-nasal communication is eliminated and it is an easier surgical procedure with aesthetic results. It reduces the severity of dental and skeletal deviations and provides a positive psychological impact on the patients as well as on their parents (4). According to a survey, cleft width was found to reduce and transverse maxillary arch width was found to remain unchanged posteriorly after orthopaedic treatment in unilateral cleft lip palate (UCLP) patients, probably due to the removal of the tongue influence, thus permitting the unrestricted growth of the palatal shelves (5). A study on UCLP (6) concluded that pre-surgical orthopaedic treatment is able to align the maxillary segments and diminish the anterior cleft width prior to lip closure, to a variable extent. However, the effect seems to disappear over time, suggesting that surgery might be a more important factor in the maxillary arch form than PSOT itself. The question whether PSOT has a long-term effect on maxillary growth, remains uncertain due to the lack of long-term studies that have evaluated maxillofacial growth subsequent to infant orthopaedics (6). There is also a lack of evidence as to whether pressure stimulation from presurgical orthopaedic treatment increases palatal growth beyond its inherent growth potential (7).

Many appliances have been described for infants with cleft palate. These appliances can be broadly grouped into active or passive, depending on whether the appliance places any force on the alveolar segments or not. The appliance to be used is decided after a proper evaluation of the case.

Passive plates
The passive plates (Table/Fig 1) do not apply any force, they serve to provide an artificial palate for the infant and permit functions like swallowing and feeding in a more normal manner (1). They also serve to prevent the widening of the cleft due to the activity of the tongue. These devices consist of a piece of acrylic plate which closes the defect and is used in conjunction with a tape across the cleft lip, to help bring the lip segments closer together. However, passive plates do not allow for any adjustment of cleft, unlike the active plate designs which exert force to move the palatal segments to an ideal location.
These devices also consist of a piece of acrylic which is formed to fit the palate and is used for the Presurgical Nasoalveolar Molding (PNAM) procedure. Acrylic is gradually added or removed to align the palate to a more normal configuration. The PNAM procedure, in addition to the repositioning of the alveolus and lengthening of the deficient columella, especially in BCLP, also actively molds the deformed nasal cartilages with the use of acrylic nasal stents which are lined with soft relining material (8). According to Matsuo et al (9), active soft tissue and cartilage molding therapy is possible, as neonatal levels of maternal oestrogen are high immediately after birth. This subsequently increases the levels of hyaluronic acid during the first three to four months after birth, resulting in high degree of plasticity in the neonatal cartilage during this period.

Latham's appliance
This is a type of “fixed” appliance (8) that is surgically attached to the palate under general anaesthesia and remains in place until the manipulation has been completed. This device (Table/Fig 2) consists of two acrylic pieces that fit over the alveolar segments. These pieces are connected posteriorly with a hinged bar. The palate is manipulated by rotating the hinged pieces. A screw is present in the area of the cleft. Over a period of 2-3 weeks, the screw is turned 3/4th of a turn, every day until tight. This appliance can be used in BCLP
infants to reposition the protruding premaxilla, while expanding the lateral maxillary segments.
The advantage of this device is that it allows the manipulation of the palatal segments to the desired location, thereby helping to bring the clefts together, thus making the cleft lip repair easier. The appliance however, does not provide an artificial palate as it does not cover the defect.

Jackscrew devices
These devices consist of acrylic pieces that fit over the alveolar segments. The acrylic pieces are manipulated by single or multiple jackscrews to adjust the position of the alveolar segments. They allow the manipulation of the palatal segments to the desired locations and the screws also keep the tongue out of the cleft. They however do not allow the rotation of the alveolar segments into desired locations, as seen with the molding plates.

Steps in the fabrication of feeding devices for infants
Feeding devices are mostly passive plates which are placed in the infant’s oral cavity to act as an artificial palate to aid in the infant’s suckling and swallowing. It has a great effect on the physical as well as the psychological growth of the infant and also helps in achieving the mother-child bond, which is very important to establish a sense of security and to enhance the mental abilities of the child. The most important and critical step is the making of the impression of the cleft palate for making the plate. Various techniques and materials can be used as described below, for making the impression of the cleft in infants.

The impression procedure for infants with cleft palate Patient position
The most important part of the rehabilitation of a patient with cleft lip and palate is the impression making procedure. The making of the impression in an infant with a cleft palate is a critical procedure. For an accurate and safe impression procedure, a proper patient and dentist position are vital. A number of positions have been adopted for cleft palate impression making in infants, including prone (5), face down (8), upright (8), and even upside down (9).

Selection of the impression tray
The impression tray should be of enough size transversely, to include the lateral maxillary segments, to posteriorly cover up to the maxillary tuberosities and to provide a good reproduction of the mucobuccal folds. The anterior tray border is not critical, as the impression material flows forward far enough to cover the structures as the tray is seated. Rimming of the entire tray with utility wax has been suggested to provide an additional bulk of material laterally, to avoid the sharp edges of the tray and also to provide a posterior dam to prevent the material from seeping posteriorly (8). After their size and shape have been roughly estimated, perforated custom acrylic trays can be fabricated. Prefabricated trays that are commercially available (Coe laboratories, Chicago) for cleft palate impressions in infants have also been described (4). Shatkin and Stark (10) have described the use of wax as impression trays in cleft lip and palate patients. Ice cream sticks can also be used to carry materials for infant impressions. While using elastomeric impression material in putty consistency or impression compound for making the impression of the cleft in infants, the materials can be supported with the fingers and placed in the patient’s mouth till the material sets.
Materials used for the impression
Heavy body silicone impression material, polyvinyl siloxane impression material, low fusing impression compound and alginate have been routinely employed for making impressions of neonates with orofacial clefts. According to a study, alginate and cartridge delivery silicones provided good replication of the surface detail. Though cartridge delivery systems were expected to be better in neonatal cleft impressions due to better mixing and reduced chances of cross infection, all the cartridge delivery silicones which were tested, were too fluid for use in cleft infants. The best results with least flow were obtained with the addition of cure silicones (11). The condensation cure silicones were messier to handle and difficult to mix. The bite registration materials which were used in the study (11) reproduced the least of the surface details. During the removal of the impression, the alginates tended to tear the most and the bite registration materials proved to be the most difficult to remove, as they set very hard. If the appliance which is decided uses the nasal undercuts for retention, then an adequate reproduction of these undercut areas is important. The use of fast setting colour timed alginates has been suggested in these cases. Alginates however have poor tear strength and may tear on removal, especially when the material extrudes deep into the cleft undercuts. The rapid rate of force application during removal improves tear strength and hence, a quick snap removal has been suggested. The impression compound has also been in use for the impressions of infants with oral clefts. The advantage of its use in infants with oral clefts are, that it can be removed before it sets in case of any emergency and it has better resistance to tearing as compared to other impression materials. Impression compound is a thermoplastic material and is usually heated in a water bath in a piece of cloth at around 60°C. This can lead to problems, as overheating can lead to scalding or burns in infants, the leaching out of volatile components of the compound can be harmful to the infants and the use of a water bath may compromise sterility (11). The putty wash impression can produce accurate impressions with good reproduction of the details and its biggest advantage is its greater tear strength and the possibility of making multiple casts with the same impression (Table/Fig 3), (Table/Fig 4)

After the making of the impression, a cast is prepared (Table/Fig 5) on which the feeding device can be fabricated in heat cure acrylic resin material (Table/Fig 6), by using a long curing cycle to minimize the leaching out of the residual monomer.
Possible complications
The complications which are encountered while making impressions in cleft lip and palate infants arise primarily due to the fact that they are obligatory nasal breathers (1). Chate (12) reported a difficulty in removal of the impression due to the engagement of the undercuts, the fragmentation of the impression during its withdrawal from the mouth, with subsequent respiratory obstruction due to its lodgment in the respiratory passage and cyanotic episodes due to asphyxiation as the common hazards which have been encountered by the dentists who are involved routinely in the care of CLP patients.

Precautions
As the old adage says, ‘prevention is better than cure’ and the same applies to impression making in cleft infants. A dental mouth mirror is an effective tool for depressing the tongue during the impression procedure, thereby maintaining airway patency. Clean cotton tipped ear buds may be used to clean the infant’s oral cavity before impression making and remove any intra oral remnants of impression material after the procedure.(13) The impressions for neonate/infants with clefts need to be taken in a hospital setting which is prepared to handle airway emergencies, with a surgeon present at all times. The impression is made when the infant is fully awake, without any anaesthesia or premedication [8-11]. Infants should be able to cry during the impression procedure and absence of crying may be indicative of airway blockage. A finger motion may be used to clear the unset material which is posterior to the tray, to prevent the infant from closing down on the tray and compromising the airway. High volume suction should also be ready at all times, in case of regurgitation of the stomach contents. It is preferable that the infant has not had food for at least two hours prior to the procedure (8).

The management of complications during the impression procedure [14,15]
The aspiration of the fragments of the impression material that inadvertently tear during the procedure may cause airway obstruction in infants. The obstruction may be partial or complete. Three stages of symptoms result from the aspiration of any object into the airway.

Initial event – violent paroxysms of coughing, choking, gagging and possibly airway obstruction occur immediately when the foreign body is aspirated.
Asymptomatic interval – the foreign body becomes lodged, reflexes fatigue, and immediate irritating symptoms subside.
Complications – obstruction, erosion or infection develops. The signs of complete airway obstruction include effective cough, increased respiratory difficulty accompanied by stridor, the development of cyanosis and the loss of consciousness. The maneouvers which are used to relive foreign body obstruction in infants include back blows (Table/Fig 7), chest thrusts (Table/Fig 8), and finger sweeps. When conscious, the infant is straddled over the arm with face down and with head lower than the trunk. The infant’s head is supported with the rescuer’s hand around the chest and the jaw.
When the support is adequate, 4-5 back blows are rapidly delivered with the heel of the hand between the infant’s shoulder blades. Following this, the free hand is placed over the infant’s back, holding the infant’s head. The infant is effectively sandwiched between the two arms and the hands of the rescuer. The infant is turned and held supine on the rescuer’s thigh. The infant’s head is expected to remain lower than the trunk all this time. Up to 5 quick downward chest thrusts are given in the same location and manner, as the external chest compressions which are given for cardiac arrest. The airway may now be opened by using the head tilt chin lift maneouver and if spontaneous breathing is absent and the chest does not rise on rescue breathing, then the maneouvers may be repeated till the foreign body is expelled or the child loses consciousness. When the infant is unconscious, the airway is opened by using the tongue jaw lift maneouver and if a foreign body is seen, it is removed with a finger sweep. Blind finger sweeps should not be performed in infants, as it poses the risk of further pushing the fragments into the airway. Rescue breathing is then attempted. If the chest does not rise adequately, the back blows and chest thrusts are repeated till ventilation is established. The adjuncts for airway and ventilation include oxygen delivery devices, suction devices, appropriately sized oropharyngeal airways, bag valve mask systems and in rare situations, cricothyrotomy.

Conclusion

Cleft lip and palate forms a part of many syndromic and non-syndromic disorders like the Pierre-Robin sequence(16), etc. Early intervention provides a positive impact on the development of the infants with clefts(17). As multidisciplinary care is essential for the cleft patient, the role of the prosthodontist, pedodontist, orthodontist and the oral surgeon amongst the various other medical specialists, is becoming more defined. Adequate knowledge of the appliances which are available and the impression procedures which should be followed, leads to a better understanding, preparation and coordination of the efforts of the various specialties which are involved in cleft lip and palate care. A basic knowledge on managing complications makes us better equipped in handling emergencies if they arise.

References

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Grayson B, Brecht LE, Cutting CB. Nasoalveolar Molding in Early Management of Cleft Lip and Palate. In: Taylor TD, editor. Clinical maxillofacial prosthetics. Chapter 5. Quintessence; 63- 84.
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An Integrated Approach to the Primary Lip/Nasal Repair in Bilateral cleft Lip and Palate – Operative Syllabus DVD. Noordhoff Craniofacial Foundation.
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