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Mandibular Advancement Devices

  • Maria Pia VillaEmail author
  • Silvia Miano
Chapter
Part of the Respiratory Medicine book series (RM)

Abstract

Orthodontic and craniofacial abnormalities associated with pediatric sleep-disordered breathing (SDB) are, despite their impact on public health, widely ignored: a narrow upper airway with maxillary constriction and/or some degree of mandibular retrusion is a common phenotype of pediatric obstructive sleep apnea syndrome (OSAS). In such cases, children are typically described as having a narrow, long face. Several anatomical and functional mechanisms may lead to OSAS in children and in adults, one being a smaller upper airway, which predisposes subjects to airway collapse during sleep in all age groups.

Many studies based on cephalometrics indicate that children without congenital craniofacial anomalies may display subtle craniofacial morphometric features associated with SDB. Children with OSAS may have retrognathic mandibles and increased posterior facial height associated with severe tonsillar hypertrophy. Zucconi et al. described several craniofacial abnormalities pointing to a hyperdivergent skeletal growth pattern in children with OSAS, such as increased craniomandibular, intermaxillary, goniac, and mandibular plane angles. Whether this skeletal conformation is genetically determined or influenced by the early onset of habitual snoring has yet to be assessed. Many investigators suggest that these craniofacial changes may be mild and reversible after adenotonsillectomy (AT). It has recently been suggested that children with habitual snoring and OSAS have a special craniofacial morphology with a persistent abnormal mandibular development and malocclusion that may involve the jaws as well as the skeletal structures of the respiratory dynamics, thereby resulting in mandibular retroposition and leading to OSAS. Moreover, mandibular retroposition is also associated with posterior displacement of the tongue base, which further narrows the upper airway, predisposing it to collapse during sleep. Another common abnormality in patients with OSAS is a high-arched (ogival) palate, which results in posterior tongue displacement forcing the lateral palatine processes to expand over the abnormally placed tongue.

Orthodontic treatment by means of oral devices is considered to represent a potential or supplementary treatment in children presenting with OSAS. Although the use of oral appliances has received relatively little attention in the literature, interest in this approach is growing rapidly. Oral appliances may improve upper airway patency during sleep by enlarging the upper airway and/or by decreasing upper airway collapsibility, thereby improving upper airway muscle tone.

The treatment options available for growing children are rapid maxillary expansion, mandibular retropositioning, and a modified monobloc (MM).

Rapid maxillary expansion (RME), which is a dentofacial orthopedic treatment procedure routinely used in young patients with constricted maxillary arches, is considered to be an effective treatment for OSAS in children.

Keywords

Obstructive Sleep Apnea Syndrome Orthodontic Treatment Oral Appliance Rapid Maxillary Expansion Adenotonsillar Hypertrophy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Guilleminault C, Partinen M, Praud JP, et al. Morphometric facial changes and obstructive sleep apnea in adolescents. J Pediatr. 1989;114:997–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Guilleminault C, Li KK, Khramtsov A, et al. Sleep disordered breathing: surgical outcomes in prepubertal children. Laryngoscope. 2004;114:132–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Tasker C, Crosby JH, Stradling JR. Evidence for persistence of upper airway narrowing during sleep, 12 years after adenotonsillectomy. Arch Dis Child. 2002;86:34–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Mitchell RB, Kelly J. Outcome of adenotonsillectomy for severe obstructive sleep apnea in children. Int J Pediatr Otorhinolaryngol. 2004;68:1375–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Arens R, Marcus CL. Pathophysiology of upper airway obstruction: a developmental perspective. Sleep. 2004;27:997–1019.PubMedGoogle Scholar
  6. 6.
    Dayyat E, Kheirandish-Gozal L, Gozal D. Childhood obstructive sleep apnea: one or two distinct disease entities? Sleep Med Clin. 2007;2:433–44.PubMedCrossRefGoogle Scholar
  7. 7.
    Kulnis R, Nelson S, Strohl K, et al. Cephalometric assessment of snoring and nonsnoring children. Chest. 2000;118:596–603.PubMedCrossRefGoogle Scholar
  8. 8.
    Shintani T, Asakura K, Kataura A. Adenotonsillar hypertrophy and skeletal morphology of children with obstructive sleep apnea syndrome. Acta Otolaryngol Suppl. 1996;523:222–4.PubMedGoogle Scholar
  9. 9.
    Shintani T, Asakura K, Kataura A. Evaluation of the role of adenotonsillar hypertrophy and facial morphology in children with obstructive sleep apnea. ORL J Otorhinolaryngol Relat Spec. 1997;59:286–91.PubMedCrossRefGoogle Scholar
  10. 10.
    Kawashima S, Niikuni N, Chia-hung L, et al. Cephalometric comparisons of craniofacial and upper airway structures in young children with obstructive sleep apnea syndrome. Ear Nose Throat J. 2000; 79(499–502):505–6.Google Scholar
  11. 11.
    Agren K, Nordlander B, Linder-Aronsson S, et al. Children with nocturnal upper airway obstruction: postoperative orthodontic and respiratory improvement. Acta Otolaryngol. 1998;118:581–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Kawashima S, Peltomäki T, Sakata H, et al. Craniofacial morphology in preschool children with sleep-related breathing disorder and hypertrophy of tonsils. Acta Paediatr. 2002;91:71–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Zucconi M, Caprioglio A, Calori G, et al. Craniofacial modifications in children with habitual snoring and obstructive sleep apnoea: a case-control study. Eur Respir J. 1999;13:411–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Zonato AI, Martinho FL, Bittencourt LR, et al. Head and neck physical examination: comparison between nonapneic and obstructive sleep apnea patients. Laryngoscope. 2005;115:1030–4.PubMedCrossRefGoogle Scholar
  15. 15.
    Fransson AM, Tegelberg A, Svenson BA, et al. Influence of mandibular protruding device on airway passages and dentofacial characteristics in obstructive sleep apnea and snoring. Am J Orthod Dentofacial Orthop. 2002;122:371–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Harvold EP, Tomer BS, Vargevik K, et al. Primate experiments on oral respiration. Am J Orthod. 1981;79:359–72.PubMedCrossRefGoogle Scholar
  17. 17.
    Villa MP, Malagola C, Pagani J, et al. Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12 months follow-up. Sleep Med. 2007;8: 128–34.PubMedCrossRefGoogle Scholar
  18. 18.
    Jamieson A, Guilleminault C, Partinen M, et al. Obstructive sleep apneic patients have craniomandibular abnormalities. Sleep. 1986;9:469–77.PubMedGoogle Scholar
  19. 19.
    Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27:761–6.PubMedGoogle Scholar
  20. 20.
    Cistulli PA, Palmisano RG, Poole MD. Treatment of obstructive sleep apnea syndrome by rapid maxillary expansion. Sleep. 1998;21:831–5.PubMedGoogle Scholar
  21. 21.
    Ferguson KA, Cartwright R, Rogers R, et al. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29:244–62.PubMedGoogle Scholar
  22. 22.
    Ramires T, Maia R, Barone JR. Nasal cavity changes and the respiratory standard after maxillary expansion. Braz J Otorinolaringol. 2008;74:763–9.CrossRefGoogle Scholar
  23. 23.
    Monini S, Malagola C, Villa MP, et al. Rapid maxillary expansion for the treatment of nasal obstruction in children younger than 12 years. Arch Otolaryngol Head Neck Surg. 2009;135:22–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Doruk C, Bicakci AA, Basciftci FA, et al. A comparison of the effects of rapid maxillary expansion and fan-type rapid maxillary expansion on dentofacial structures. Angle Orthod. 2004;74:184–94.PubMedGoogle Scholar
  25. 25.
    Doruk C, Sökücü O, Sezer H, et al. Evaluation of nasal airway resistance during rapid maxillary expansion using acoustic rhinometry. Eur J Orthod. 2004;26: 397–401.PubMedCrossRefGoogle Scholar
  26. 26.
    Ceroni Compadretti G, Tasca I, Alessandri-Bonetti G, et al. Acoustic rhinometric measurements in children undergoing rapid maxillary expansion. Int J Pediatr Otorhinolaryngo. 2006;70:27–34.CrossRefGoogle Scholar
  27. 27.
    Chung CH, Font B. Skeletal and dental changes in the sagittal, vertical, and transverse dimensions after rapid palatal expansion. Am J Orthod Dentofacial Orthop. 2004;126:569–75.PubMedCrossRefGoogle Scholar
  28. 28.
    Bicakci AA, Agar U, Sökücü O, et al. Nasal airway changes due to rapid maxillary expansion timing. Angle Orthod. 2005;75:1–6.PubMedGoogle Scholar
  29. 29.
    Chrcanovic BR, Custódio AL. Orthodontic or surgically assisted rapid maxillary expansion. Oral Maxillofac Surg. 2009;13:123–37.PubMedCrossRefGoogle Scholar
  30. 30.
    Kiliç N, Oktay H. Effects of rapid maxillary expansion on nasal breathing and some naso-respiratory and breathing problems in growing children: a literature review. Int J Pediatr Otorhinolaryngol. 2008;72: 1595–601.PubMedCrossRefGoogle Scholar
  31. 31.
    Ölmez H, Akin E, Karaçay S. Multitomographic evaluation of the dental effects of two different rapid palatal expansion appliances. Eur J Orthod. 2007;29:379–85.PubMedCrossRefGoogle Scholar
  32. 32.
    American Sleep Disorders Association. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. Sleep. 1995;18:511–3.Google Scholar
  33. 33.
    Kushida CA, Morgenthaler TI, Littner MR, et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: An Update for 2005. Sleep. 2006;29:240–3.PubMedGoogle Scholar
  34. 34.
    Carvalho FR, Lentini-Oliveira D, Machado MA, et al. Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children. Cochrane Database Syst Rev. 2007;18:CD005520.Google Scholar
  35. 35.
    Villa MP, Bernkopf E, Pagani J, et al. Randomized controlled study of an oral jaw-positioning appliance for the treatment of obstructive sleep apnea in children with malocclusion. Am J Respir Crit Care Med. 2002;165:123–7.PubMedGoogle Scholar
  36. 36.
    Marino A, Malagnino I, Ranieri R, et al. Craniofacial morphology in preschool children with obstructive sleep apnoea syndrome. Eur J Paediatr Dent. 2009;10:181–4.PubMedGoogle Scholar
  37. 37.
    Guimarães KC, Drager LF, Genta PR, et al. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2009;179:962–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Villa MP, Bertarini A, Pagani J, et al. Terapia Miofunzionale in bambini con ostruzione delle alte vie respiratorie (Myofunctional therapy in children with upper airway obstruction). Ital J Pediatr. 2001;27:229–36.Google Scholar
  39. 39.
    Villa MP, Brunetti L, Bruni O, et al. Guidelines for the diagnosis of childhood obstructive sleep apnea. Minerva Pediatr. 2004;56:239–53.PubMedGoogle Scholar
  40. 40.
    Miano S, Rizzoli A, Evangelisti M, et al. NREM sleep instability changes following rapid maxillary expansion in children with obstructive apnea sleep syndrome. Sleep Med. 2009;10:471–8.PubMedCrossRefGoogle Scholar
  41. 41.
    Guilleminault C, Huang YS, Glamann C, et al. Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey. Otolaryngol Head Neck Surg. 2007;136:169–75.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Department of Pediatrics, S. Andrew HospitalUniversity of Rome, “La Sapienza”RomeItaly

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