OAP Treatment for Newborns With Robin Sequence (RS)

What is an OAP?

An orthodontic airway plate (OAP) is a customized nonsurgical device, something like an orthodontic retainer, that can be worn in an infant’s mouth to help correct defects in the baby’s airway and jaw. OAP treatment is an effective, noninvasive option for many babies born with airway disorders and for whom surgery was once the only treatment option. In particular, OAP treatment is helpful for patients with a condition called Pierre Robin sequence (RS).

What is Pierre Robin sequence?

Pierre Robin sequence is a rare birth defect identified by an abnormally small lower jaw (micrognathia) or a drastically receding chin (retrognathia). Because of their small lower jaw, children with RS also have a displaced tongue (glossoptosis), which tends to fall back into the throat and can block the airway. About 80% of children with RS also have cleft palate, an abnormal U-shaped opening in the roof of their mouth, which makes mouth feeding very difficult. Some newborns with RS can’t breathe at all; their airway is too narrow or is entirely blocked by their tongue. Some infants with RS also have difficulty mouth feeding and swallowing and must be fed through a tube.

Some babies with severe RS need a breathing tube insertion (endotracheal intubation) or surgical opening of a hole on the neck (tracheostomy) immediately after birth to allow them to breathe. Others can be treated with a high-flow nasal canula (HFNC) or continuous positive airway pressure (CPAP), which pumps oxygen or air into their lungs through their nose and/or mouth or lower jaw elongation surgery called mandibular distraction osteogenesis to bring the lower jaw and tongue forward.

How does OAP treatment work?

The upper part of the orthodontic airway plate (OAP) is fitted into a baby’s mouth, something like an upper-arch retainer or a complete denture. A stiff plastic “tail” attached to that upper plate extends about an inch down into the throat. The tail keeps the baby’s tongue from falling backward and obstructing the airway. The plate not only holds the tongue in a safe position, keeping the airway open, but also positions the tongue farther forward, which stimulates the lower jaw to rapidly grow forward. As the jaw grows forward, the airway naturally enlarges too, and the facial form moves into balance.

The forward tongue position stimulated by the OAP helps the baby suck the nipple of a bottle or breast, strengthening the tongue and helping the newborn learn to suck and swallow effectively on its own.

It typically takes only a couple of days for a baby to get used to wearing an OAP. After that, it is neither uncomfortable nor bothersome. The OAP is removed from the mouth for cleaning just once a day. Otherwise, the baby wears it at all times until the end of treatment, which typically lasts six to eight months. The treating orthodontist will check the fit of the OAP on a regular basis to make sure the upper arch growth is not restricted and the cleft palate is getting smaller.

Parents learn how to put the OAP in and take it out of the baby’s mouth while the baby is still in the hospital. Watching the orthodontist do it may be, at first, a little daunting. But with a little practice, it is not at all difficult. It takes parents about a week to get good at handling the OAP.

Orthodontic airway plate (OAP) before and afterOrthodontic airway plate (OAP) before and after

What to expect when getting an OAP.

Pierre Robin sequence may first be discovered by ultrasound during pregnancy, shortly after birth, or a few weeks after birth. Once a definitive diagnosis of airway and feeding difficulties is reached, a team of specialists will meet to discuss how to navigate the best way forward for the baby. These specialists may include an ENT surgeon, a craniofacial airway orthodontist, and a plastic surgeon, as well as a neonatologist. In some cases, the best treatment to start with will be an OAP. In others it may be mandibular distraction osteogenesis (MDO), a surgery that cuts the lower jaw and implants extending screws that apply pressure to the jaw, making it elongate more quickly than it otherwise would, so that it comes to match or go beyond the upper jaw and broaden the airway. In another cases, tracheostomy may be an option, although it is often reserved as the last resort.

If the team, including the parents, decide that an OAP is the best option, the baby will be admitted to the NICU and the craniofacial orthodontist will make a mold of the baby’s mouth. The baby is awake for this procedure and anesthesia is usually unnecessary. A CT scan of the baby’s face also helps with the creation of the OAP’s tail. Once the mold is made and the images are taken, it takes a day or two for the orthodontist to fashion the OAP itself.

As soon as it is ready, the orthodontist and ENT surgeon will fit the OAP inside the baby’s mouth under nasal endoscopy (a tiny camera entering through the nose and showing the inside of the throat) so that the OAP’s tail can be adjusted into its optimal position while the baby is awake. The baby will be encouraged to feed by mouth on its own, in order to exercise its tongue and cheek muscles. The hospital stay typically lasts between two and three weeks after the OAP treatment is begun, unless the baby has other syndromic complications in addition to RS. Breathing problems resolve as soon as the OAP is put in. A sleep study conducted a few days into the OAP treatment helps to confirm that the OAP is working.

The baby will need to wear the OAP for six to eight months on average. During that time, the lower jaw will typically grow fast enough to restore the proper balance in size between the upper and lower jaws (catch-up growth), and the baby’s airway will enlarge enough that even without the OAP, the baby can eat and breathe without incident.

What are the advantages of OAP?

OAP does not require surgery or anesthesia. OAP is gentle, painless, and noninvasive, so it does not leave any scars on the baby’s face. And OAP uses the baby’s own natural growth potential to enlarge and restructure the airway, to lengthen the jaw, and to strengthen the tongue and encourage nursing through the mouth.

Who can OAP help?

Every baby should be able to breathe and eat comfortably at all times. If a baby has difficulty with breathing and feeding, OAP should be considered before surgical options.

Who oversees OAP treatment?

OAP treatment requires a team with expertise in neonatology, nursing, pediatric ENT, pediatric plastic surgery, infant feeding, and craniofacial and airway orthodontics (a subspecialty of orthodontics that focuses on the treatment of patients with congenital abnormalities such as cleft lip and palate). Craniofacial and airway orthodontists have the training and experience to custom-fabricate and adjust the OAP as needed in close collaboration with the entire team during treatment. Stanford Children’s Health is currently offering OAP treatment.