A report on the hazards encountered when taking neonatal cleft palate impressions (1983-1992).

A questionnaire was sent to 193 United Kingdom Hospital Consultant Orthodontists, in order to survey their individual involvement and clinical protocols for neonatal cleft palate impressions. Information regarding any untoward events that might have been experienced with this procedure during the period 1983-1992 was sought. Sixteen episodes where withdrawal of an impression had been extremely difficult and five respiratory obstructions due to an impression fragment were reported. Eighty-nine cyanotic events were reported, of which four resulted in asphyxiation, although none progressed to a fatality. Factors such as the level of consultants' experience or the choice of impression material used did not appear to be contributory.