Caring for Infants with Robin Sequence Treated with the Tübingen Palatal Plate: A Review of Personal Practice

Abstract

The Tübingen Palatal Plate (TPP) is a minimally invasive yet highly effective functional orthodontic treatment for upper airway obstruction in infants with Robin Sequence (RS). It consists of a palatal plate to cover the cleft and a velar extension that shifts the root of the tongue forward. We review our practical experience with this approach. First, upon admission, our local orthodontists perform an (3-D) intraoral scan of the maxilla. Based on the scan data, the TPP is manufactured in a semi-digital workflow. The length and angulation of its extension is checked via awake laryngoscopy and the effectiveness confirmed by a sleep study. Plates are kept in place by adhesive cream. When inserting the TPP, the tip of the tongue must be visible. Next, metal fixation bows should be secured to the forehead using tape and elastic bands. Plates are removed daily for cleaning, and the oral mucosa is then checked for pressure marks. Feeding training (initially only via finger feeding) may even start before plate insertion. Breathing often normalizes immediately once the plate is inserted. For isolated RS, we have never had to perform a tracheostomy. This has largely been possible through our highly dedicated and competent team, particularly the nursing staff, and the early involvement of parents.

Keywords: Pierre Robin sequence; cleft palate; feeding; functional treatment; intraoral scanning; mandibular retrognathia; upper airway obstruction.

Figure 1

(a) RS patient with inserted TPP and extraoral adhesive tapes; (b) profile picture of a patient with RS and TPP showing the mandibular retrognathia; (c) example of a TPP with its characteristic velopharyngeal extension (blue) attached to a standard palatal base plate (orange) that covers the cleft. The two metal fixation bows are attached to the forehead using tape to improve plate retention, and a wire inside the extension ensures no breakage occurs that might cause aspiration. The extension is colored blue to make it easily visible against the mucosa during endoscopy.

Figure 2

Materials needed for inserting and removing the TPP: Two adhesive tapes, e.g., (1a) Steri-Strip (3M Health Care, Saint Paul, MN, USA) or (1b) special tape for infants with hypersensitive skin, width depending on the required traction; (2) two orthodontic elastic bands, stretched over two nails hammered into a wooden board (3a), with the end of one tape being poked through an elastic band, bent back, and then fixed (3b); (4) adhesive enhancer, e.g., benzoin tincture 90% 1:5; (5) adhesive cream; (6) gauze swabs for oral care; (7) dexpanthenol solution; (8) adhesive releaser; (9) toothbrush and toothpaste; (10) small flashlight.

Figure 3

Pressure mark at the mucco-buccal fold of a patient with RS with its typical appearance: a round/oval shaped white spot with a red edge.

Figure 4

Feeding an infant with RS using the Playtex™ system. Here, the nurse can control the milk flow (photo used with parental permission).