Innovations in Orthodontics: Skeletal Versus Dentoalveolar Expansion Utilizing Clear Aligners and TAD-Assisted Expanders.

Hypoplastic maxilla is a common skeletal anomaly that compromises function and esthetics. Beyond just a narrow-appearing smile, this abnormality presents significant restorative challenges in adult patients as it is often associated with crowding, compromised axial inclination of the teeth, lack of alveolar bone support, root proximity, and occlusal trauma.1 Recent research also confirms association of maxillary deficiency with nasal stenosis and a predisposition to compromised nasal airflow and pharyngeal collapse during sleep.2,3 Maxillary transverse skeletal deficiency is often but not always associated with posterior dental cross-bite. In most cases, maxillary posterior teeth are flared buccally and mandibular posterior teeth are excessively lingually inclined masking the underlying skeletal problem.4 Advances in 3D imaging in dentistry, namely ultra-low radiation cone-beam imaging technology, have significantly enhanced clinicians' ability to diagnose and subsequently treat a maxillary transverse deficiency.5.

Posterior Palatal Expansion via Subnasal Endoscopy (2PENN) for Maxillary Deficiency: A Pilot Study.

OBJECTIVE: Surgically assisted rapid palatal expansion (SARPE) addresses transverse maxillary deficiency, a known contributor to nasal obstruction. The purpose of this study was to assess the feasibility, preliminary outcomes, and safety of posterior palatal expansion via subnasal endoscopy (2PENN), a modified SARPE procedure, aimed at achieving anterior and posterior maxillary expansion. METHODS: This prospective case series included consecutive adult patients with findings of transverse maxillary deficiency that underwent the 2PENN procedure from 4/2021 to 4/2022. Patients completed pre- and post-operative clinical evaluations, Nasal Obstruction and Septoplasty Effectiveness (NOSE) questionnaires, and computed tomography (CT), with measures including expansion at the level of the posterior nasal spine (PNS), first maxillary inter-molar distance (IMD), and anterior nasal spine (ANS). RESULTS: The cohort (N = 20) was middle-aged (39 ± 11 years), predominantly male (80%), and overweight (BMI 28 ± 4 kg/m2 ). The majority (85%) of patients had sleep breathing issues, of which 10 (59%) had polysomnography-confirmed obstructive sleep apnea (OSA). Full anterior-posterior separation of the mid-palatal suture line was evident on all post-operative CT scans, with mean expansion at the PNS of 3.6 ± 1.3 mm, IMD of 6.1 ± 1.6 mm and ANS of 7.0 ± 1.6 mm (p < 0.001). Following surgery, mean NOSE scores improved from 57 ± 23 to 14 ± 13 (p < 0.001). One patient required maxillary antrostomy for post-operative sinusitis. CONCLUSION: 2PENN is an effective and safe technique for achieving both anterior and posterior maxillary expansion in patients with transverse maxillary deficiency. Further study is warranted to better understand the effect of 2PENN in patients with OSA, particularly as it relates to improving pharyngeal patency. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1970-1977, 2024.

The Association Between Transverse Maxillary Deficiency and Septal Deviation in Adults with Obstructive Sleep Apnea.

OBJECTIVES: Recent evidence suggests that environmental factors impact craniofacial development. Specifically, the height and width of the maxilla may impact the degree of septal deviation. We sought to determine the relationship between transverse maxillary deficiency and severity of septal deviation. METHODS: A prospective cohort of adult sleep surgery patients were evaluated by standardized CT imaging. Primary outcomes evaluated the relationship of a narrow, high-arched palate (the palatal height to width ratio) with the degree of septal deviation at the level of the 1st premolar and 1st molar. Secondary outcome evaluated the relationship of the palatal height-to-width ratio and nasal obstruction. Both adjusted and unadjusted linear regression were performed, including correction for multiple hypothesis testing. RESULTS: Ninety-three patients were included. On average, the cohort was middle aged (54.7 ± 12.7 years), obese (BMI 30.1 ± 4.5 kg/m2), predominantly male (74.2%), White (73.1%), and with severe obstructive sleep apnea (OSA) (AHI 30.0 ± 18.7 events/h). A moderate correlation was observed between both the relative and absolute inter-premolar palatal height and the degree of septal deviation at the inter-molar region. No significant correlation was observed between palatal dimensions and NOSE score. CONCLUSION: This study found that transverse maxillary deficiency is moderately associated with greater degree of septal deviation among a sample of OSA patients. This contributes to the concept that craniofacial development impacts the nasal airway, promoting a comprehensive evaluation of both endonasal and extranasal structures. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:2464-2470, 2024.

The role of craniofacial maldevelopment in the modern OSA epidemic: a scoping review.

OBJECTIVES: There is increasing recognition that environmental factors affect human craniofacial development and our risk for disease. A scoping review of the literature was performed looking at environmental influences on craniofacial development to better understand this relationship and investigate what further study is needed to determine how this relationship may impact obstructive sleep apnea. METHODS: A comprehensive literature search was performed using the Ovid Medline database from inception to May 2020 with relevance to craniofacial development in 5 clinically oriented variables: diet, secular change, breastfeeding/nonnutritive sucking habits, nasal obstruction/mouth breathing, and masticatory muscle function. The Oxford Centre for Evidence-Based Medicine Levels of Evidence was used to assess studies based on study design. RESULTS: We initially identified 18,196 articles, of which 260 studies were fully reviewed and 97 articles excluded. The remaining 163 articles were categorized as follows: secular change (n = 16), diet (n = 33), breastfeeding/nonnutritive sucking habits (n = 28), nasal obstruction/mouth breathing (n = 57), and masticatory muscle function (n = 35). Ninety-three percent of included studies reported a significant association between craniofacial morphology and environmental factors. The majority of studies were characterized as low-level-of-evidence studies, with 90% of studies being a level-of-evidence of 4 or 5. CONCLUSIONS: The studies in this review suggest that environmental factors are associated with changes in craniofacial development. However, most studies were heterogeneous and low-level studies, making strong conclusions about these relationships difficult. Future rigorous studies are needed to further our understanding of environmental influences on craniofacial development and obstructive sleep apnea risk. CITATION: Yu JL, Tangutur A, Thuler E, Evans M, Dedhia RC. The role of craniofacial maldevelopment in the modern OSA epidemic: a scoping review. J Clin Sleep Med. 2022;18(4):1187-1202.

American Academy of Periodontology Best Evidence Consensus Statement on Selected Oral Applications for Cone-Beam Computed Tomography.

BACKGROUND: The American Academy of Periodontology (AAP) recently embarked on a Best Evidence Consensus (BEC) model of scientific inquiry to address questions of clinical importance in periodontology for which there is insufficient evidence to arrive at a definitive conclusion. This review addresses oral indications for use of cone-beam computed tomography (CBCT). METHODS: To develop the BEC, the AAP convened a panel of experts with knowledge of CBCT and substantial experience in applying CBCT to a broad range of clinical scenarios that involve critical structures in the oral cavity. The panel examined a clinical scenario or treatment decision that would likely benefit from additional evidence and interpretation of evidence, performed a systematic review on the individual, debated the merits of published data and experiential information, developed a consensus report, and provided a clinical bottom line based on the best evidence available. RESULTS: This BEC addressed the potential value and limitations of CBCT relative to specific applications in the management of patients requiring or being considered for the following clinical therapies: 1) placement of dental implants; 2) interdisciplinary dentofacial therapy involving orthodontic tooth movement in the management of malocclusion with associated risk on the supporting periodontal tissues (namely, dentoalveolar bone); and 3) management of periodontitis. CONCLUSION: For each specific question addressed, there is a critical mass of evidence, but insufficient evidence to support broad conclusions or definitive clinical practice guidelines.

Expression profiling reveals heightened apoptosis and supports fiber size economy in the murine muscles of mastication.

Distinctions between craniofacial and axial muscles exist from the onset of development and throughout adulthood. The masticatory muscles are a specialized group of craniofacial muscles that retain embryonic fiber properties in the adult, suggesting that the developmental origin of these muscles may govern a pattern of expression that differs from limb muscles. To determine the extent of these differences, expression profiling of total RNA isolated from the masseter and tibialis anterior (TA) muscles of adult female mice was performed, which identified transcriptional changes in unanticipated functional classes of genes in addition to those attributable to fiber type. In particular, the masseters displayed a reduction of transcripts associated with contractile and cytoskeletal load-sensing and anabolic processes, and heightened expression of genes associated with stress. Associated with these observations was a significantly smaller fiber cross-sectional area in masseters, significantly elevated load-sensing signaling (phosphorylated focal adhesion kinase), and increased apoptotic index in masseters compared with TA muscles. Based on these results, we hypothesize that masticatory muscles may have a fundamentally different strategy for muscle design, compared with axial muscles. Specifically there are small diameter fibers that have an attenuated ability to hypertrophy, but an increased propensity to undergo apoptosis. These results may provide insight into the molecular basis for specific muscle-related pathologies associated with masticatory muscles.