What changes in maxillary morphology from distraction osteogenesis maxillary expansion (DOME) correlate with subjective and objective OSA measures?

OBJECTIVES: To correlate skeletal and airway measures on imaging with polysomnographic and self-reported measures after distraction osteogenesis maxillary expansion (DOME), in the effort to identify clinically relevant sites of expansion to guide treatment for adult patients with obstructive sleep apnea (OSA). MATERIALS AND METHODS: This is a retrospective study reviewing subjects who underwent DOME and had the complete set of the following data: peri-treatment cone-beam computed tomography (CBCT) scans, polysomnography (PSG), Epworth Sleepiness Scale (ESS), and nasal obstruction symptom (NOSE) scores. RESULTS: Of 132 subjects who underwent DOME, 35 met inclusion criteria (71% men, mean age 27.7 ± 6.5 years, mean BMI 26.0 ± 6.4 kg/m2) and were enrolled in the study. There was a significant reduction in the NOSE score from 11.4 ± 5.5 to 3.6 ± 3.1, in the ESS score from 12.0 ± 4.6 to 7.1 ± 4.7, and in the apnea-hypopnea index (AHI) from 17.1 ± 15.8 to 7.01 ± 6.2 (p < 0.0001), after DOME. Nasal floor width at the nasopalatine canal level showed a statistically significant correlation with AHI reduction (p < .0001). CONCLUSIONS: DOME is significantly associated with reduction of nasal obstruction, sleepiness, and severity of OSA. The findings suggest that expansion at the anterior third of the bony nasal passage, specifically where the nasopalatine canal is located predicts its clinical efficacy. This site may be a useful target anatomically via imaging.

Changes in craniofacial and airway morphology as well as quality of life after passive myofunctional therapy in children with obstructive sleep apnea: a comparative cohort study.

PURPOSE: To examine the craniofacial and airway morphology as well as the quality of life before and after passive myofunctional therapy (PMFT) for 1 year in children with obstructive sleep apnea (OSA). METHODS: Forty children with OSA wearing an oral device nightly (treatment group) and seventeen without the device (control group) were followed up for 1 year. Lateral cephalometric radiography, polysomnography (without participants wearing the oral device), and quality of life survey (OSA-18) were performed before and after the study period. RESULTS: The apnea-hypopnea index (AHI) during sleep, REM AHI, hypopnea count, and desaturation count in the treatment group dropped significantly, compared with the control group. The craniofacial linear measurements increased significantly in both groups, while the length of mandible (Co-Gn) and anterior facial height (N-Me) became significantly larger in the treatment group. For the airway morphology, the intergroup comparison showed that OPha-Ophp (distance between anterior and posterior sides of oropharynx) increased significantly in the treatment group. For quality of life, the intergroup comparison found statistically significant improvements in the following in the treatment group, based on the OSA-18 survey: loud snoring, dysphagia, mood swings, discipline problems, difficulty awakening, total score for the emotional distress portion, and total survey score. CONCLUSIONS: Preliminary evidence is substantiated for the benefits of 1-year PMFT using an oral device with a built-in tongue bead, including improvements in nasal breathing during sleep, mandible linear growth (Co-Gn and N-Me), airway morphology (OPha-Ophp), and patients' quality of life.

Clear Aligner Treatments in Orthoperio Patients.

INTRODUCTION: Orthodontic treatment is a recognized approach to support specific periodontal issues thanks to its capability to manipulate periodontal tissues. This concept is certainly not new, but the use of aligners in certain clinical conditions can be considered as being innovative when a multidisciplinary treatment is necessary. Moreover, aligners enable to plan 3D tooth movements, root placement, staging, and range of dental movements, alongside the improvement of oral hygiene. Thus, aligners can be suitable for the treatment of periodontal issues. In this article, the authors present two clinical cases with different periodontal issues: one with superficial periodontal problems and the other with a deep one. Both cases were successfully treated with aligners, highlighting how this invisible and comfortable tool can simplify the management of complex adult treatments. CONCLUSION: Digital workflow is the key for success in the aligner technique. The possibility to design a virtual plan of treatment and to transfer it in the real clinical world represents a way to limit errors and to reduce the time of orthodontic therapy.

Fluorinated Agents Effects on Orthodontic Alloys: A Descriptive In Vitro Study.

Fluoride-based mouthwashes and gels are preventive measures in countering demineralization and caries but, modifying environmental acidity, can reduce the wet corrosion resistance of orthodontic alloys. To evaluate chemical stability, in vitro experiments were conducted on stainless steel and nickel-titanium wires, weighed before and after immersion in household fluorinated mouthwashes and gels, measuring weight variations and elution of metal ions from acid corrosion phenomena. Elution samples were analyzed by inductively coupled plasma mass spectrometry, detecting residual ion concentration, while surface changes were analyzed under scanning electron microscopy. Results showed stainless steel wires do not undergo significant erosion when exposed to most fluorinated mouthwashes but, at prolonged exposure, alloys elute gradually greater amounts of metals and Ni-Ti wires become more sensitive to some mouthwashes. Ions' elution varies considerably, especially for Ni-Ti wires, if exposed to household fluorinated gels, for which significant negative values were obtained. Changes, affecting wires' outer layer, negatively act on shiny appearance and luster, reducing corrosion resistance. Although examined orthodontic wires showed good chemical stability and low toxicity, surface corrosion from exposure to fluorinated agents was observed. Home use must be accompanied by clinician prescription and, for household dental gels, must follow manufacturers' recommendations, ensuring prophylactic action without damaging alloys surfaces.

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.

Cone beam CT evaluation of skeletal and nasomaxillary complex volume changes after rapid maxillary expansion in OSA children.

OBJECTIVE: The first objective of this study was to evaluate skeletal changes and changes in dimensions and volume of the upper airways before and after rapid maxillary expansion (RME) therapy in children with obstructive sleep apnoea (OSA), by Cone Beam computed tomography (CBCT). The second objective was to evaluate if RME therapy could improve both the patency of the nasal airways and the Obstructive Sleep Apnoea Syndrome (OSAS). METHODS: 19 children with OSA and malocclusion took CBCT scans with a Dentascan and 3D reconstruction program before (T0) and 4 months after (T1) RME. Patients underwent an ENT visit with auditory and respiratory tests, including a daytime sleepiness questionnaire, a 19-channel polysomnography, and an orthognatodontic examination before orthodontic therapy (T0), after 2 months (T1) with the device still on, and 4 months after the end of the orthodontic treatment (T2). RESULTS: In all cases opening of the mid-palatal suture was demonstrated. Nasal osseous width, volume of the total upper airways, nasal cavity and nasopharynx and oropharynx increased significantly (P, .001). The increased W-ANS, W-mid and WPNS were closed linked to the enlarged midpalatal suture (P, .001). The increased WPNS were closed linked to the enlarged pterygoid processes (P, .001). The increased V-NC and V-NPA was closely linked to the enlarged W-PNS (P, .001) as well as VOPA and consequently to the enlarged midpalatal suture and pterygoid processes. CONCLUSION: RME treatment had a positive effect on children affected by chronic snoring and OSA, causing an increase in volume of the nasal cavity and nasopharynx, with expansion of the nasal osseous width and maxillary width. Enlarged nasal width at the PNS plane contributed to the increase in nasopharynx volume. Enlarged maxillary width showed a direct correlation to increased airways volume, bringing a functional improvement. The results show that the RME therapy can restore and improve a normal nasal airflow with disappearance of obstructive sleep breathing disorder.

In Vitro Evaluation of Structural Factors Favouring Bacterial Adhesion on Orthodontic Adhesive Resins.

Bacterial adhesion to the surface of orthodontic materials is an important step in the formation and proliferation of plaque bacteria, which is responsible for enamel demineralization and periodontium pathologies. With the intent of investigating if adhesive resins used for bracket bonding are prone to bacteria colonization, the surface roughness of these materials has been analyzed, combining information with a novel methodology to observe the internal structures of orthodontic composites. Scanning electron microscopy, combined with focus ion bean micromachining and stylus profilometry analyses, were performed to evaluate the compositional factors that can influence specific pivotal properties facilitating the adhesion of bacteria to the surface, such as surface roughness and robustness of three orthodontic adhesive composite resins. To confirm these findings, contact angle measurements and bacteria incubation on resin slide have been performed, evaluating similarities and differences in the final achievement. In particular, the morphological features that determine an increase in the resins surface wettability and influence the bacterial adhesion are the subject of speculation. Finally, the focused ion beam technique has been proposed as a valuable tool to combine information coming from surface roughness with specific the internal structures of the polymers.

Objective and subjective long term outcome of maxillomandibular advancement in obstructive sleep apnea.

STUDY OBJECTIVES: To evaluate the objective and subjective long-term outcome of maxillomandibular advancement (MMA) in Far-East Asian patients with moderate to severe obstructive sleep apnea (OSA). METHODS: This is a long-term follow-up study to evaluate the treatment outcome of MMA in OSA patients by objective polysomnography (PSG) and subjective questionnaires (Pittsburgh Sleep Quality Index-PSQI, Insomnia Severity Index-ISI, Beck Anxiety Inventory-BAI, Beck Depression Inventory-BDI, Epworth Sleepiness scale-ESS, and Short Form-36 Quality of Life-SF-36). Evaluation was done before surgery and we followed these patients one and two years after surgery. We also assessed the neurocognitive function by Continuous performance test (CPT) and Wisconsin Card Sorting Test (WCST) before and after MMA. RESULTS: A total of 82 patients with OSA (female = 19) were enrolled and 53 participants (75.7% men, age 35.66 ± 11.66 years [mean ± SD], BMI = 24.80 ± 3.29) completed the two-year follow-up. The apnea-hypopnea index (AHI) decreased from a mean of 34.78 ± 26.01 to 3.61 ± 2.79 and 7.43 ± 6.70 events/hour (p = 0.007) at the first and second year evaluation. There was significant improvement in PSG (especially respiratory profile), questionnaires (PSQI and ISI total score), and neurocognitive testing (attention and executive function) after MMA. Meanwhile, no major complication such as avascular necrosis of bonny segments, facial nerve injury, blindness or compromise of airway was found after surgery. CONCLUSIONS: MMA is a clinically effective treatment for patients with moderate-to-severe OSA as demonstrated by significant long-term decrease in AHI and improvement in neurocognitive testing.

Skeletal changes after rapid maxillary expansion in children with obstructive sleep apnea evaluated by low-dose multi-slice computed tomography.

OBJECTIVE: The objective of this study was to evaluate the skeletal effects of rapid maxillary expansion (RME) therapy performed using teeth as anchors, in obstructive sleep apnea (OSA) children, by low-dose computed tomography (CT) of the midpalatal suture opening, maxillary base width, nasal cavities width, first molar angulation and, unlike most studies in the literature, on the pterygoid processes distance. METHODS: Fourteen children (mean age 8.68 years) with OSA presenting a malocclusion characterized by upper-jaw contraction had 16-Multislice CT (MSCT) scans taken before (T0) and after (T1) RME. All exams were performed using a rigid protocol to ensure reproducibility of image collection over time, with a 16-row MSCT scanner equipped with a Dentascan reconstruction program. Scanning parameters were as follows: scout view in the anteroposterior (AP) and laterolateral (LL); 1.25-mm slice thickness with 0.6-mm collimation from the dentoalveolar and basal areas of the maxilla up to the nasal cavity, parallel to the palatal plane; 80 kV, 100 mA with an 11.25-mm table speed/rotation, rotation time 0.6 s. Matrix size was 512 × 512. RESULTS: Opening of the midpalatal suture was demonstrated in all cases. The results showed statistically significant T0 to T1 increments in all treated cases and clear imaging findings. CONCLUSION: Use of three-dimensional (3D)-CT for follow-up studies requires a very rigid protocol to maintain reproducible positions in the scanner over time. The images confirm the real remodeling of craniofacial structure. However, to be valid such an imaging approach needs great attention to reproducibility of anatomic images over time. The changes in volume of the UA, even with a rigid protocol, cannot be affirmed with 3D-CT. There is a need to improve the definition of markers using this imaging approach when performing longitudinal studies; currently this issue is unresolved.

Rapid maxillary expansion for pediatric obstructive sleep apnea: A systematic review and meta-analysis.

OBJECTIVES/HYPOTHESIS: To perform a systematic review with meta-analysis for sleep study outcomes in children who have undergone rapid maxillary expansion (RME) as treatment for obstructive sleep apnea (OSA). DATA SOURCES: PubMed/MEDLINE and eight additional databases. REVIEW METHODS: Three authors independently and systematically reviewed the international literature through February 21, 2016. RESULTS: Seventeen studies reported outcomes for 314 children (7.6 ± 2.0 years old) with high-arched and/or narrow hard palates (transverse maxillary deficiency) and OSA. Data were analyzed based on follow-up duration: ≤3 years (314 patients) and >3 years (52 patients). For ≤3-year follow-up, the pre- and post-RME apnea-hypopnea index (AHI) decreased from a mean ± standard deviation (M ± SD) of 8.9 ± 7.0/hr to 2.7 ± 3.3/hr (70% reduction). The cure rate (AHI <1/hr) for 90 patients for whom it could be calculated was 25.6%. Random effects modeling for AHI standardized mean difference (SMD) is -1.54 (large effect). Lowest oxygen saturation (LSAT) improved from 87.0 ± 9.1% to 96.0 ± 2.7%. Random effects modeling for LSAT SMD is 1.74 (large effect). AHI improved more in children with previous adenotonsillectomy or small tonsils (73-95% reduction) than in children with large tonsils (61% reduction). For >3-year follow-up (range = 6.5-12 years), the AHI was reduced from an M ± SD of 7.1 ± 5.7/hr to 1.5 ± 1.8/hr (79% reduction). CONCLUSIONS: Improvement in AHI and lowest oxygen saturation has consistently been seen in children undergoing RME, especially in the short term (<3-year follow-up). Randomized trials and more studies reporting long-term data (≥3-year follow-up) would help determine the effect of growth and spontaneous resolution of OSA. Laryngoscope, 2016 Laryngoscope, 127:1712-1719, 2017.

Obstructive Sleep Apnoea Syndrome (OSAS) and rhino-tubaric disfunction in children: therapeutic effects of RME therapy.

The aim of the study was to evaluate if RME (Rapid Maxillary Expansion) therapy could improve both the patency of the nasal airways and the Obstructive Sleep Apnoea Syndrome (OSAS). 42 children with a case history of oral breathing, snoring and night time apnoeas were studied. Selection criteria were: no adenotonsillar hypertrophy, Body Mass Index (BMI) below 24 and a malocclusion characterised by a narrow upper jaw, determined by postero-anterior cephalometric evaluation. Patients underwent an ENT visit with auditory and respiratory tests including daytime a sleepiness questionnaire, a 19-channel polysomnography, and an orthognatodontic examination; finally the patient underwent X-rays investigations. All the investigations were carried out before orthodontic therapy (T0), after one month (T1) with the device still on, and 4 months after the end of the orthodontic treatment which lasted for about 6-12 months (T2). All the changes induced by RME on the upper jaw and nasal septum were analysed by postero-anterior cephalometric evaluation in T0, T1 and T2. In all treated cases, the authors obtained an opening of the midpalatal suture; this was confirmed both by intraoral occlusal X-rays and postero-anterior cephalograms. The results reported by the 42 patients studied show that the R.M.E. therapy widens the nasal fossa and releases the septum thus restoring a normal nasal airflow with disappearance of obstructive sleep disordered breathing. Changing the anatomic structure, RME brought a significant functional improvement. Therefore the orthodontist can play an important role in the interdisciplinary treatment of OSAS patients.

Rapid maxillary expansion (RME) for pediatric obstructive sleep apnea: a 12-year follow-up.

OBJECTIVE: The objective of this study was to prospectively evaluate the long-term efficacy of rapid maxillary expansion (RME) in a group of children with obstructive sleep apnea (OSA). MATERIAL AND METHOD: Thirty-one children diagnosed with OSA were involved in the study. These children had isolated maxillary narrowing and absence of enlarged adenotonsils at baseline. Twenty-three individuals (73% of the initial group) were followed up annually over a mean of 12 years after the completion of orthodontic treatment at a mean age of 8.68 years. Eight children dropped out over time due to either moving out of the area (n = 6) or refusal to submit to regular follow-up (n = 2). Subjects underwent clinical reevaluation over time and repeat polysomnography (PSG) in the late teenage years or in their early 20s. During the follow-up period, eight children dropped out and 23 individuals (including 10 girls) underwent a final clinical investigation with PSG (mean age of 20.9 years). The final evaluation also included computerized tomographic (CT) imaging that was compared with pre- and post-initial treatment findings. RESULTS: Yearly clinical evaluations, including orthodontic and otolaryngological examinations and questionnaire scores, were consistently normal over time, and PSG findings remained normal at the 12-year follow-up period. The stability and maintenance of the expansion over time was demonstrated by the maxillary base width and the distance of the pterygoid processes measured using CT imaging. CONCLUSION: A subgroup of OSA children with isolated maxillary narrowing initially and followed up into adulthood present stable, long-term results post RME treatment for pediatric OSA.

Rapid maxillary expansion in children with obstructive sleep apnea syndrome.

OBJECTIVE: To evaluate the effect of rapid maxillary expansion on children with nasal breathing and obstructive sleep apnea syndrome. METHOD: Recruitment of children with maxillary contraction, without of adenoid hypertrophy, with a body mass index < 24 kg/m2, with obstructive sleep apnea syndrome demonstrated by polysomnography, and whose parents signed informed consent. Otolaryngologic and orthognathic-odontologic evaluation with clinical evaluation, anterior rhinometry and nasal fibroscopy, panoramic radiographs, anteroposterior and laterolateral telecephalometry were performed at entry and follow-up. INTERVENTION: Rapid maxillary expansion (ie, active phase of treatment) was performed for 10 to 20 days; maintenance of device (for consolidation) and orthodontic treatment on teeth lasted 6 to 12 months. RESULTS: 31 children (19 boys), mean age 8.7 years, participated in the study. The mean apnea-hypopnea index was 12.2 events per hour. At the 4-month follow-up, the anterior rhinometry was normal, and all children had an apnea-hypopnea index < 1 event per hour. The mean cross-sectional expansion of the maxilla was 4.32 +/- 0.7 mm. There was a mean increase of the pyriform opening of 1.3 +/- 0.3 mm. CONCLUSION: Rapid maxillary expansion may be a useful approach in dealing with abnormal breathing during sleep.

Orthodontics and obstructive sleep apnea in children.

Children who suffer from respiratory problems and obstructive sleep apnea (OSA) commonly exhibit disturbances of craniofacial morphology. A significant number have nasal obstruction associated with a narrow maxilla; maxillary constriction may increase nasal resistance and alter the tongue posture, leading to narrowing of the retroglossal airway and OSA. Sixty children with a case history of oral breathing, snoring, and night time apneas were studied. An orthognathodontic investigation was performed using radiographs that included not only the usual examinations (posteroanterior cephalographs and intraoral radiographs) but also computed tomographic scans. This article discusses the materials and methods and the results of this study.