Nasomaxillary Expansion by Endoscopically-Assisted Surgical Expansion (EASE): An airway centric approach / Expansion nasomaxillaire chirurgicale assistée par endoscopie (EASE) : une approche centrée surles voies respiratoires

Introduction: The aim of this study was to analyze the skeletal, dental and airway changes with endoscopically assisted surgical expansion (EASE) to widen the nasomaxillary complex for the treatment of sleep apnea in adults. Methods: One hundred and five consecutive patients underwent EASE. Cone beam computed tomography (CBCT) was conducted preoperatively and within four weeks after the completion of the expansion process. Computational fluid dynamic (CFD) analysis was performed on 20 randomly selected patients to assess airway flow changes. Results: One hundred patients (67 males) with the mean age of 35.0±13.5 years (17-64 years) had completed pre- and post-expansion imaging. Ninety-six patients (96%) had successful expansion defined as separation of the midpalatal suture at least 1 mm from anterior nasal spine (ANS) to posterior nasal spine (PNS). The nasal cavity expansion was 3.12±1.11 mm at ANS, 3.64±1.06 mm at first molar and 2.39±1.15 mm at PNS. The zygoma expansion was 2.17±1.11 mm. The ratio of dental expansion to skeletal expansion was 1.23:1 (3.83 mm:3.12 mm) at canine and 1.31:1 (4.77 mm:3.64 mm) at first molar. CFD airway simulation showed a dynamic change following expansion throughout the airway. The mean negative pressure improved in the nasal airway (from -395.5±721.0 to -32.7±19.2 Pa), nasopharyngal airway (from -394.2±719.4 to -33.6±18.5 Pa), oropharyngeal airway (from -405.9±710.8 to -39.4±19.3 Pa) and hypopharyngeal airway (from -422.6±704.9 to -55.1±33.7 Pa). The mean airflow velocity within the nasal airway decreased from 18.8±15.9 to 7.6±2.0 m/s and the oropharyngeal airway decreased from 4.2±2.9 to 3.2±1.2 m/s. The velocity did not change significantly in the nasopharyngeal and hypopharyngeal regions. Conclusions: EASE results in expansion of the midpalatal suture from the ANS to PNS with a nearly pure skeletal movement of minimal dental effect. The expansion of the nasomaxillary complex resulted in the widening of the nasal sidewall throughout the nasal cavity. The improved air flow dynamics was demonstrated by CFD simulation.

Introduction: L'objectif de cette étude était d'analyser les modifications obtenues au niveau du squelette, des dents et des voies respiratoires lors d'une expansion nasomaxillaire chirurgicale assistée par endoscopie (EASE), visant à élargir le complexe nasomaxillaire pour le traitement de l'apnée du sommeil chez des adultes. Méthodes: Cent cinq patients consécutifs ont subi une EASE. Une tomographie à faisceau conique (CBCT) a été réalisée en préopératoire et dans les quatre semaines suivant la fin du processus d'expansion. Une analyse de la dynamique des fluides computationnelle (DFC) a été réalisée sur vingt patients sélectionnés au hasard pour évaluer les modifications du débit de leurs voies respiratoires. Résultats: Un bilan d'imagerie pré- et post-expansion a été réalisé chez cent patients (dont 67 hommes) d'un âge moyen de 35,0 ± 13,5 ans (17-64 ans). Quatre-vingt-seize patients (96 %) ont bénéficié d'une expansion réussie, définie comme une séparation de la suture médiopalatine d'au moins 1 mm, de l'épine nasale antérieure (ENA) à l'épine nasale postérieure (ENP). L'expansion de la cavité nasale était de 3,12 ± 1,11 mm au niveau de l'ENA, de 3,64 ± 1,06 mm au niveau de la première molaire et de 2,39 ± 1,15 mm au niveau de l'ENP. L'expansion zygomatique était de 2,17 ± 1,11 mm. Le rapport entre l'expansion dentaire et l'expansion squelettique était de 1,23 : 1 (3,83 mm : 3,12 mm) au niveau de la canine et de 1,31 : 1 (4,77 mm : 3,64 mm) au niveau de la première molaire. Après l'expansion, la simulation des voies respiratoires par DFC a montré un changement dynamique au niveau de l'ensemble des voies respiratoires. La pression négative moyenne s'est améliorée dans les voies nasales (de -395,5 ± 721,0 à -32,7 ± 19,2 Pa), les voies nasopharyngiennes (de -394,2 ± 719,4 à -33,6 ± 18,5 Pa), les voies aériennes oropharyngées (de -405,9 ± 710,8 à -39,4 ± 19,3 Pa) et les voies aériennes hypopharyngées (de -422,6 ± 704,9 à -55,1 ± 33,7 Pa). La vitesse moyenne du flux d'air dans les voies nasales a diminué de 18,8 ± 15,9 à 7,6 ± 2,0 m/s et de 4,2 ± 2,9 à 3,2 ± 1,2 m/s dans les voies oropharyngées. La vitesse n'a pas changé de manière significative dans les régions nasopharyngienne et hypopharyngienne. Conclusions: L'EASE entraîne une expansion de la suture médiopalatine, de l'ENA jusqu'à l'ENP avec un mouvement squelettique presque pur et un effet dentaire minimal. L'expansion du complexe nasomaxillaire a entraîné l'écartement des parois nasales latérales dans toute la cavité nasale. L'amélioration de la dynamique du flux d'air a été démontrée par une simulation DFC.

Persistent pediatric obstructive sleep apnea treated with skeletally anchored transpalatal distraction / SAOS pédiatrique persistant traité par distraction transpalatine à ancrage squelettique

Introduction: The aim of this study was to evaluate the impact of nasomaxillary expansion using skeletally anchored transpalatal distraction (TPD) in children without transverse maxillary deficiency that were previously treated by rapid palatal expansion (RPE). Materials and Methods: Twenty-nine consecutive children were treated by TPD. Twenty-five children, aged 10-16 years completed pre- and post-operative clinical evaluations, questionnaires (OSA-18), cone beam computed tomography (CBCT), and polysomnography (PSG). The pre- and post-operative CBCT data were used to reconstruct the 3-dimensional shape of the upper airway. Two measures of airflow function (pressure and velocity) were simulated by using computational fluid dynamics (CFD) at four different airway segments (nasal, nasopharyngeal, oropharyngeal and hypopharyngeal). Results: Twenty-three patients (92%) experienced improvement based on PSG. The apnea hypopnea index (AHI) improved from 6.72 ± 4.34 to 3.59 ± 5.11 (p<0.001) events per hour. Clinical symptoms based on OSA-18 scores were improved in all patients. Twenty-five patients (100%) had successful expansion defined as separation of the midpalatal suture at least 1mm from anterior nasal spine (ANS) to posterior nasal spine (PNS). The nasal sidewall widening was 2.59 ± 1,54 mm at canine, 2.91 ± 1,23 mm at first molar and 2.30 ± 1,29 mm at PNS. The ratio of dental expansion to nasal expansion was 1.12:1 (2.90mm:2.59mm) at canine and 1.37:1 (3.98mm:2.91mm) at first molar. The nasal airflow pressure reduced by 76% (-275.73 to -67.28 Pa) and the nasal airflow velocity reduced by over 50% (18.60 to 8.56 m/s). Conclusions: Nasomaxillary expansion by skeletally anchored TPD improves OSA in children without transverse maxillary deficiency that were previously treated by RPE. A nearly parallel anterior-posterior opening of the mid-palatal suture achieves enlargement of the entire nasal passage with improvement of the airflow characteristics in the nasal and pharyngeal airway. The improved airflow characteristic is significantly correlated with the improved polysomnographic findings, thus demonstrating that nasomaxillary expansion in previously expanded patients is a viable treatment option.

Introduction: L'objectif de cette étude était d'évaluer l'impact de l'expansion nasomaxillaire à l'aide d'une distraction transpalatine (DTP) à ancrage squelettique chez des enfants sans insuffisance maxillaire transversale et qui ont été précédemment traités par expansion palatine rapide (EPR). Matériels et méthodes: Vingt-neuf enfants enrôlés consécutivement ont été traités par DTP. Vingt-cinq enfants, âgés de 10 à 16 ans, ont été soumis à des évaluations cliniques pré- et postopératoires, des questionnaires (OSA-18), une tomographie à faisceau conique (CBCT) et une polysomnographie (PSG). Les données CBCT pré- et postopératoires ont été utilisées pour reconstruire la forme tridimensionnelle des voies aériennes supérieures. Deux mesures des caractéristiques d'écoulement de l'air (pression et vitesse) ont été simulées en utilisant la dynamique des fluides computationnelle (DFC) dans quatre segments différents des voies aériennes (nasal, nasopharyngé, oropharyngé et hypopharyngé). Résultats: Vingt-trois patients (92 %) ont bénéficié d'une rapide amélioration objectivée par la PSG. L'indice d'apnée-hypopnée (IAH) est passé de 6,72 ± 4,34 à 3,59 ± 5,11 (p<0,001) événements par heure. Les symptômes cliniques évalués avec les scores du questionnaire OSA-18 se sont améliorés chez tous les patients. Pour les vingt-cinq patients (100 %), l'expansion a été réussie, selon le critère d'une séparation de la suture médiopalatine d'au moins 1 mm, de l'épine nasale antérieure (ENA) jusqu'à l'épine nasale postérieure (ENP). L'élargissement de la distance entre les parois nasales latérales était de 2,59 ± 1,54 mm au niveau de la canine, de 2,91 ± 1,23 mm au niveau de la première molaire et de 2,30 ± 1,29 mm à l'épine nasale postérieure. Le rapport entre l'expansion dentaire et l'expansion nasale était de 1,12:1 (2,90 mm:2,59 mm) au niveau de la canine et de 1,37:1 (3,98 mm:2,91 mm) au niveau de la première molaire. La pression du flux d'air nasal a diminué de 76 % (-275,73 à -67,28 Pa) et la vitesse du flux d'air nasal a diminué de plus de 50 % (18,60 à 8,56 m/s). Conclusions: L'expansion nasomaxillaire à l'aide d'une distraction transpalatine à ancrage squelettique améliore le SAOS chez les enfants sans déficit maxillaire transverse et qui ont été auparavant traités par EPR. Une ouverture antéro-postérieure et presque parallèle de la suture médiopalatine permet d'élargir l'ensemble du passage nasal et d'améliorer les caractéristiques du flux d'air dans les voies aériennes nasales et pharyngées. L'amélioration des caractéristiques de l'écoulement d'air est significativement corrélée à l'amélioration des résultats polysomnographiques, démontrant ainsi que l'expansion nasomaxillaire chez des patients précédemment traités par EPR est une option thérapeutique viable.

Use of facial stereophotogrammetry as a screening tool for pediatric obstructive sleep apnea by dental specialists.

STUDY OBJECTIVES: To evaluate facial 3-dimensional (3D) stereophotogrammetry's effectiveness as a screening tool for pediatric obstructive sleep apnea (OSA) when used by dental specialists. METHODS: One hundred forty-four participants aged 2-17 years, including children fully diagnosed with pediatric OSA through nocturnal polysomnography or at high-risk or low-risk of pediatric OSA, participated in this study. 3D stereophotogrammetry, Craniofacial Index, and Pediatric Sleep Questionnaire were obtained from all participants. Ten dental specialists with interest in pediatric sleep breathing disorders classified OSA severity twice, once based only on 3D stereophotogrammetry and then based on 3D stereophotogrammetry, Craniofacial Index, and Pediatric Sleep Questionnaire. Intrarater and interrater reliability and diagnostic accuracy of pediatric OSA classification were calculated. A cluster analysis was performed to identify potential homogeneous pediatric OSA groups based on their craniofacial features classified through the Craniofacial Index . RESULTS: Intrarater and interrater agreement suggested a poor reproducibility when only 3D facial stereophotogrammetry was used and when all tools were assessed simultaneously. Sensitivity and specificity varied among clinicians, indicating a low screening ability for both 3D facial stereophotogrammetry, ranging from 0.36-0.90 and 0.10-0.70 and all tools ranging from 0.53-1.0 and 0.01-0.49, respectively. A high arched palate and reversed or increased overjet contributed to explaining how participating dental clinicians classified pediatric OSA. CONCLUSIONS: 3D stereophotogrammetry-based facial analysis does not seem predictive for pediatric OSA screening, alone or combined with the Pediatric Sleep Questionnaire and Craniofacial Index when used by dental specialists interested in sleep-disordered breathing. Some craniofacial traits, more specifically significant sagittal overjet discrepancies and an arched palate, seem to influence participating dental specialists' classification. CITATION: Fernandes Fagundes NC, Carlyle T, Dalci O, et al. Use of facial stereophotogrammetry as a screening tool for pediatric obstructive sleep apnea by dental specialists. J Clin Sleep Med. 2022;18(1):57-66.

Persistent pediatric obstructive sleep apnea treated with skeletally anchored transpalatal distraction

Introduction: The aim of this study was to evaluate the impact of nasomaxillary expansion using skeletally anchored transpalatal distraction (TPD) in children without transverse maxillary deficiency that were previously treated by rapid palatal expansion (RPE). Materials and Methods: Twenty-nine consecutive children were treated by TPD. Twenty-five children, aged 10-16 years completed pre- and post-operative clinical evaluations, questionnaires (OSA-18), cone beam computed tomography (CBCT), and polysomnography (PSG). The pre- and post-operative CBCT data were used to reconstruct the 3-dimensional shape of the upper airway. Two measures of airflow function (pressure and velocity) were simulated by using computational fluid dynamics (CFD) at four different airway segments (nasal, nasopharyngeal, oropharyngeal and hypopharyngeal). Results: Twenty-three patients (92%) experienced improvement based on PSG. The apnea hypopnea index (AHI) improved from 6.72±4.34 to 3.59±5.11 (p<0.001) events per hour. Clinical symptoms based on OSA-18 scores were improved in all patients. Twenty-five patients (100%) had successful expansion defined as separation of the midpalatal suture at least 1 mm from anterior nasal spine (ANS) to posterior nasal spine (PNS). The nasal sidewall widening was 2.59±1.54 mm at canine, 2.91±1.23 mm at first molar and 2.30±1.29 mm at PNS. The ratio of dental expansion to nasal expansion was 1.12:1 (2.90 mm:2.59 mm) at canine and 1.37:1 (3.98 mm:2.91 mm) at first molar. The nasal airflow pressure reduced by 76% (-275.73 to -67.28 Pa) and the nasal airflow velocity reduced by over 50% (18.60 to 8.56 m/s). Conclusions: Nasomaxillary expansion by skeletally anchored TPD improves OSA in children without transverse maxillary deficiency that were previously treated by RPE. A nearly parallel anterior-posterior opening of the mid-palatal suture achieves enlargement of the entire nasal passage with improvement of the airflow characteristics in the nasal and pharyngeal airway. The improved airflow characteristic is significantly correlated with the improved polysomnographic findings, thus demonstrating that nasomaxillary expansion in previously expanded patients is a viable treatment option.

Nasomaxillary Expansion by Endoscopically-Assisted Surgical Expansion (EASE): An airway centric approach

Introduction: The aim of this study was to analyze the skeletal, dental and airway changes with endoscopically assisted surgical expansion (EASE) to widen the nasomaxillary complex for the treatment of sleep apnea in adults. Methods: One hundred and five consecutive patients underwent EASE. Cone beam computed tomography (CBCT) was conducted preoperatively and within four weeks after the completion of the expansion process. Computational fluid dynamic (CFD) analysis was performed on 20 randomly selected patients to assess airway flow changes. Results: One hundred patients (67 males) with the mean age of 35.0±13.5 years (17-64 years) had completed pre- and post-expansion imaging. Ninety-six patients (96%) had successful expansion defined as separation of the midpalatal suture at least 1 mm from anterior nasal spine (ANS) to posterior nasal spine (PNS). The nasal cavity expansion was 3.12±1.11 mm at ANS, 3.64±1.06 mm at first molar and 2.39±1.15 mm at PNS. The zygoma expansion was 2.17±1.11 mm. The ratio of dental expansion to skeletal expansion was 1.23:1 (3.83 mm:3.12 mm) at canine and 1.31:1 (4.77 mm:3.64 mm) at first molar. CFD airway simulation showed a dynamic change following expansion throughout the airway. The mean negative pressure improved in the nasal airway (from -395.5±721.0 to -32.7±19.2 Pa), nasopharyngal airway (from -394.2±719.4 to -33.6±18.5 Pa), oropharyngeal airway (from -405.9±710.8 to -39.4±19.3 Pa) and hypopharyngeal airway (from -422.6±704.9 to -55.1±33.7 Pa). The mean airflow velocity within the nasal airway decreased from 18.8±15.9 to 7.6±2.0 m/s and the oropharyngeal airway decreased from 4.2±2.9 to 3.2±1.2 m/s. The velocity did not change significantly in the nasopharyngeal and hypopharyngeal regions. Conclusions: EASE results in expansion of the midpalatal suture from the ANS to PNS with a nearly pure skeletal movement of minimal dental effect. The expansion of the nasomaxillary complex resulted in the widening of the nasal sidewall throughout the nasal cavity. The improved air flow dynamics was demonstrated by CFD simulation.

Apraxia in children and adults with obstructive sleep apnea syndrome.

STUDY OBJECTIVES: Early in life impairment of orofacial growth leads to sleep-disordered breathing (SDB). Normal lingual gnosis and praxis are part of this early development related to the normal sensorimotor development of the tongue and surrounding oral musculature. The aim of this retrospective study was to explore if lingual praxia is impaired in both SDB children and adults and if there is an association to craniofacial morphology. METHODS: The ability to perform simple tongue maneuvers was investigated in 100 prepubertal SDB children and 150 SDB adults (shown with polysomnography). All individuals had a clinical investigation by specialists to assess any orofacial growth impairment and the elements potentially behind this impairment. In a subgroup of individuals both able and unable to perform the maneuvers, we also performed a blind recognition of forms placed in the mouth. RESULTS: A subgroup of pediatric and adult SDB patients presented evidence not only of orofacial growth impairment, but also apraxia independent of age and severity of OSA. CONCLUSIONS: By 3 years of age, children should be able to perform requested tongue maneuvers and have oral form recognition. Abnormal gnosis-praxis was noted, independent of age in SDB children and adults, demonstrating that an abnormal functioning of the tongue in the oral cavity during early development can be detected. Both children and adults with SDB may present similar absences of normal oral development very early in life and a similar presentation of apraxia, suggesting that the distinction of SDB in children versus adults may not be relevant.

Maxillary protraction to treat pediatric obstructive sleep apnea and maxillary retrusion: a preliminary report.

INTRODUCTION: Midface retrusion creates a size deficiency problem in the upper airway that has been improved in children using surgical midface advancement and orthopedic protraction of the maxilla. The results of these treatments have been mostly promising at enlarging the pharyngeal airway. Recently introduced bone anchored maxillary protraction (BAMP) uses implant inserted devices in the jaws to pull the maxilla forward against a backward pressure to the lower jaw. This is a pilot study that examines the use of BAMP as a strategy to treat maxillary retrusion, malocclusion and children with obstructive sleep apnea. METHODS: 15 children, ages 9-16 years with maxillary retrusion creating a skeletal malocclusion were treated with bone anchored maxillary protraction (BAMP) and the results were compared against an untreated control group. 8 children in the treatment group also had sleep disordered breathing/obstructive sleep apnea. All subjects had lateral cephalograms before and after BAMP therapy. The OSA cohort completed the pediatric sleep questionnaire (PSQ) and polysomnography prior to and at the end of BAMP. RESULTS: The majority of the OSA children (n = 5) showed improvement in their apnea-hypopnea index (AHI) and OSA symptoms after BAMP. Preliminary results of BAMP therapy show improvement in respiratory and airway parameters in OSA children with a highly significant change in the forward position of the upper jaw and enlargement in the nasopharyngeal to oropharyngeal junction as compared to an age and sex matched untreated control group. The outcomes were dependent on the age of treatment initiation and patient compliance. CONCLUSIONS: This preliminary work suggests that bone anchored maxillary protraction may be considered as an adjunctive treatment option in adolescents for improving midface retrusion and sleep apnea, but further work is needed to explore this therapy.

Endoscopically-assisted surgical expansion (EASE) for the treatment of obstructive sleep apnea.

OBJECTIVE: The aim of this retrospective study was to evaluate the results of an outpatient surgical procedure known as endoscopically-assisted surgical expansion (EASE) in expanding the maxilla to treat obstructive sleep apnea (OSA) in adolescent and adults. METHODS: Thirty-three patients (18 males), aged 15-61 years, underwent EASE of the maxilla. All patients completed pre- and post-operative clinical evaluations, polysomnography, questionnaires (Epworth Sleepiness Scale [ESS] and Nasal Obstruction Septoplasty Questionnaire [NOSE]) as well as cone beam computed tomography (CBCT). RESULTS: With EASE, the overall apnea hypopnea index (AHI) improved from 31.6 ± 11.3 to 10.1 ± 6.3. The oxygen desaturation index (ODI) improved from 11.8 ± 9.6 to 1.8 ± 3.7, with reduction of ESS scores from 13.4 ± 4.0 to 6.7 ± 3.1. Nasal breathing improved as demonstrated by reduction of the NOSE scores from 57.8 ± 12.9 to 15.6 ± 5.7. Expansion of the airway from widening of the nasal floor was consistently evident on all postoperative CBCT; the anterior nasal floor expanded 4.9 ± 1.2 mm, posterior nasal floor expanded 5.6 ± 1.2 mm, and the dental diastema created was 2.3 ± 0.8 mm. Mean operative time was 54.0 ± 6.0 min. All patients with mild to moderate OSA were discharged the same day; patients with severe OSA were observed overnight. All patients returned to school or work and regular activities within three days. CONCLUSIONS: EASE is an outpatient procedure that improves nasal breathing and OSA by widening the nasal floor in adolescents and adults. Compared to current surgical approaches for maxillary expansion, EASE is considerably less invasive and consistently achieves enlargement of the airway with minimal complications.

Bimaxillary expansion therapy for pediatric sleep-disordered breathing.

INTRODUCTION: The aim of this retrospective study was to evaluate the results of bimaxillary expansion as a treatment option for pediatric sleep-disordered breathing. METHODS: Forty-five children, aged 3-14 years, with sleep-disordered breathing underwent bimaxillary expansion. They were subjected to baseline clinical evaluations, cephalometric X-rays, and polygraphic sleep studies. Three to six months after bimaxillary expansion, posttreatment sleep studies were performed. Data were analyzed with nonparametric Wilcoxon signed-rank test, and Spearman's correlations were performed to correlate cephalometric facial structures to the effectiveness of treatment. RESULTS: The majority of the children (n = 30) showed improvement in their sleep scores and symptoms after bimaxillary expansion. The initial severity of the obstructive sleep apnea (OSA) indicated by the apnea-hypopnea index (AHI) was a much better predictor of positive results. However, in the "mild OSA" group, patients with smaller MP-SN or counterclockwise mandibular growth, worsened with bimaxillary expansion, while patients with clockwise mandibular growth showed greater improvement; in the "severe OSA" group, patients who initially had shorter mandibular base lengths showed lesser AHI improvements. CONCLUSIONS: Bimaxillary expansion can be a treatment option for improving respiratory parameters in children with sleep-disordered breathing. This study also suggests that retrognathia in an anterior growth rotation pattern may not respond to efforts of bimaxillary expansion.

It Is Just Attention-Deficit Hyperactivity Disorder or Is It?

CASE: Carly is a 5-year-old girl who presents for an interdisciplinary evaluation due to behaviors at school and home suggestive of attention-deficit hyperactivity disorder (ADHD). Parent report of preschool teacher concerns was consistent with ADHD. Psychological testing showed verbal, visual-spatial, and fluid reasoning IQ scores in the average range; processing speed and working memory were below average. Carly's behavior improved when her mother left the room, and she was attentive during testing with a psychologist. Tests of executive function (EF) skills showed mixed results. Working memory was in the borderline range, although scores for response inhibition and verbal fluency were average. Parent ratings of ADHD symptoms and EF difficulties were elevated.Carly's parents recently separated; she now lives with her mother and sees her father on weekends. Multiple caregivers with inconsistent approaches to discipline assist with child care while her mother works at night as a medical assistant. Family history is positive for ADHD and learning problems in her father. Medical history is unremarkable. Review of systems is significant for nightly mouth breathing and snoring, but no night waking, bruxism, or daytime sleepiness. She has enlarged tonsils and a high-arched palate on physical examination.At a follow-up visit, parent rating scales are consistent with ADHD-combined type; teacher rating scales support ADHD hyperactive-impulsive type. Snoring has persisted. A sleep study indicated obstructive sleep apnea. After adenotonsillectomy, Carly had significant improvement in ADHD symptoms. She developed recurrence of behavior problems 1 year after the surgery.

Missing teeth and pediatric obstructive sleep apnea.

BACKGROUND: Missing teeth in early childhood can result in abnormal facial morphology with narrow upper airway. The potential association between dental agenesis or early dental extractions and the presence of obstructive sleep apnea (OSA) was investigated. METHODS: We reviewed clinical data, results of polysomnographic sleep studies, and orthodontic imaging studies of children with dental agenesis (n = 32) or early extraction of permanent teeth (n = 11) seen during the past 5 years and compared their findings to those of age-, gender-, and body mass index-matched children with normal teeth development but tonsilloadenoid (T&A) hypertrophy and symptoms of OSA (n = 64). RESULTS: The 31 children with dental agenesis and 11 children with early dental extractions had at least 2 permanent teeth missing. All children with missing teeth (n = 43) had clinical complaints and signs evoking OSA. There was a significant difference in mean apnea-hypopnea indices (AHI) in the three dental agenesis, dental extraction, and T&A studied groups (p < 0.001), with mean abnormal AHI lowest in the pediatric dental agenesis group. In the children with missing teeth (n = 43), aging was associated with the presence of a higher AHI (R (2) = 0.71, p < 0.0001). CONCLUSION: Alveolar bone growth is dependent on the presence of the teeth that it supports. The dental agenesis in the studied children was not part of a syndrome and was an isolated finding. Our children with permanent teeth missing due to congenital agenesis or permanent teeth extraction had a smaller oral cavity, known to predispose to the collapse of the upper airway during sleep, and presented with OSA recognized at a later age. Due to the low-grade initial symptomatology, sleep-disordered breathing may be left untreated for a prolonged period with progressive worsening of symptoms over time.

Teenage sleep-disordered breathing: recurrence of syndrome.

OBJECTIVES: The study aims to better understand the reappearance of sleep apnoea in adolescents considered cured of obstructive sleep apnoea (OSA) following adenotonsillectomy and orthodontic treatment. STUDY DESIGN: The study employs a retrospective analysis of 29 adolescents (nine girls and 20 boys) with OSA previously treated with adenotonsillectomy and orthodontia at a mean age of 7.5years. During follow-up at 11 and 14years of age, patients were clinically evaluated, filled the Pediatric Sleep Questionnaire (PSQ) and had systematic cephalometric X-rays performed by orthodontists. Polysomnographic (PSG) data were compared at the time of OSA diagnosis, following surgical and orthodontic treatment and during pubertal follow-up evaluation. RESULTS: Following the diagnosis of OSA and treatment with adenotonsillectomy and rapid maxillary expansion (Apnea-Hypopnea Index (AHI) 0.4±0.4), children were re-evaluated at a mean age of 11years. During follow-up at 14years, all children had normal body mass indices (BMIs). Teenagers were subdivided into two groups based on complaints: Nine asymptomatic subjects (seven girls and two boys) and 20 subjects with decline in school performance, presence of fatigue, indicators of sleep-phase delays and, less frequently, specific symptoms of daytime sleepiness and snoring. Presence of mouth breathing, abnormal AHI and RDI and significant reduction of posterior airway space (PAS) was demonstrated during repeat polysomnography and cephalometry. Compared to cephalometry obtained at a mean of 11years of age, there was a significant reduction of PAS of 2.3±0.4mm at a mean age of 14years. CONCLUSION: Previously suggested recurrence of OSA during teenage years has again been demonstrated in this small group of subjects. Prospective investigations are needed to establish frequency of risk, especially in non-orthodontically treated children.

Adeno-tonsillectomy and rapid maxillary distraction in pre-pubertal children, a pilot study.

INTRODUCTION: When both narrow maxilla and moderately enlarged tonsils are present in children with obstructive sleep apnea, the decision of which treatment to do first is unclear. A preliminary randomized study was done to perform a power analysis and determine the number of subjects necessary to have an appropriate response. Thirty-one children, 14 boys, diagnosed with OSA based on clinical symptoms and polysomnography (PSG) findings had presence of both narrow maxillary complex and enlarged tonsils. They were scheduled to have both adeno-tonsillectomy and RME for which the order of treatment was randomized: group 1 received surgery followed by orthodontics, while group 2 received orthodontics followed by surgery. Each child was seen by an ENT, an orthodontist, and a sleep medicine specialist. The validated pediatric sleep questionnaire and PSG were done at entry and after each treatment phase at time of PSG. Statistical analyses were ANOVA repeated measures and t tests. RESULTS: The mean age of the children at entry was 6.5 ± 0.2 years (mean ± SEM). Overall, even if children presented improvement of both clinical symptoms and PSG findings, none of the children presented normal results after treatment 1, at the exception of one case. There was no significant difference in the amount of improvement noted independently of the first treatment approach. Thirty children underwent treatment 2, with an overall significant improvement shown for PSG findings compared to baseline and compared to treatment 1, without any group differences. CONCLUSION: This preliminary study emphasizes the need to have more than subjective clinical scales for determination of sequence of treatments.

Orthodontic expansion treatment and adenotonsillectomy in the treatment of obstructive sleep apnea in prepubertal children.

STUDY OBJECTIVE: Rapid maxillary expansion and adenotonsillectomy are proven treatments of obstructive sleep apnea (OSA) in children. Our goal was to investigate whether rapid maxillary expansion should be offered as an alternative to surgery in select patients. In addition, if both therapies are required, the order in which to perform these interventions needs to be determined. DESIGN: Prepubertal children with moderate OSA clinically judged to require both adenotonsillectomy and orthodontic treatment were randomized into 2 treatment groups. Group 1 underwent adenotonsillectomy followed by orthodontic expansion. Group 2 underwent therapies in the reverse sequence. SUBJECTS: Thirty-two children (16 girls) in an academic sleep clinic. METHOD: Clinical evaluation and polysomnography were performed after each stage to assess efficacy of each treatment modality. RESULTS: The 2 groups were similar in age, symptoms, apnea-hypopnea index, and lowest oxygen saturation. Two children with orthodontic treatment first did not require subsequent adenotonsillectomy. Thirty children underwent both treatments. Two of them were still symptomatic and presented with abnormal polysomogram results following both therapies. In the remaining 28 children, all results were significantly different from those at entry (P = 0.001) and from single therapy (P = 0.01), regardless of the order of treatment. Both therapies were necessary to obtain complete resolution of OSA. CONCLUSION: In our study, 87.5% of the children with sleep-disordered breathing had both treatments. In terms of treatment order, 2 of 16 children underwent orthodontic treatment alone, whereas no children underwent surgery alone to resolve OSA. Two children who underwent both treatments continued to have OSA.

A prospective study on the surgical outcomes of children with sleep-disordered breathing.

STUDY OBJECTIVE: To prospectively evaluate the outcome of surgical treatment decisions made by a multidisciplinary team for children aged 18 months to 12 years with sleep-disordered breathing (SDB). DESIGN AND SETTING: A multidisciplinary team evaluated children referred to a sleep clinic for suspicion of SDB using polysomnography, questionnaires, and clinical evaluations. Suggestions for treatment (surgical, medical, or orthodontic) were made and sent to referring providers. A follow-up evaluation, which included a repeat of all of the tests performed at baseline, was performed 3 months after treatment (and at 6 months for a subgroup of subjects). The clinical outcome of the recommended versus the performed treatment was compared. PATIENTS: 56 successively evaluated children. RESULTS: Based on insurance plans, 11 children were treated by a surgeon on the multidisciplinary team, who followed all treatment recommendations. After treatment, 1 of the 11 children still had SDB. Forty-five children were referred to other specialists. Only 1 of these children had the team's treatment recommendations implemented. Twenty-six of the 45 children had residual symptoms. Twelve children had polysomnographic abnormalities with or without symptoms or snoring. Sixteen children (28.6%) underwent a second surgical procedure. CONCLUSION: There are misconceptions in the pediatric and otolaryngologic communities about the rationale for the surgical treatment of SDB. Interactions between mouth breathing, maxillofacial growth, and clinical symptoms associated with SDB are not well understood. Multidisciplinary evaluations of the anatomic abnormalities of children with SDB lead to better overall treatment.