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The difference in expansion force with traditional maxillary expander vs mini-implant supported expander. (A, B) Traditional. (C, D) Implant assisted. Red arrows show vector at nasal floor. Yellow line delineates maxillary anatomy. 

The difference in expansion force with traditional maxillary expander vs mini-implant supported expander. (A, B) Traditional. (C, D) Implant assisted. Red arrows show vector at nasal floor. Yellow line delineates maxillary anatomy. 

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A narrow maxilla with high arched palate characterizes a phenotype of obstructive sleep apnea (OSA) patients that is associated with increased nasal resistance and posterior tongue displacement. Current maxillary expansion techniques for adults are designed to correct dentofacial deformity. We describe distraction osteogenesis maxillary expansion (...

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... Vinha et al. found a 56% AHI average reduction in SARPE patients, who underwent Le Fort I and mid-palatal osteotomies [16]. Recently, Liu et al. found an average 54% AHI reduction in 20 adults, non-obese patients subjected to maxillary distraction osteogenesis (DOME) with selective osteotomies, using a jackscrew associated with 4 to 6 mini-implants on the palate [33]. Similarly, Yoon et al. also found a significant reduction in the apnea index (17.65 + 19.30 to 8.17 + 8.47, p < 0.0001) and daytime somnolence (EES score 10.48 + 5.4 to 6.69 + 4.75), when analyzing 75 adults before and after a palatal expansion with a bone-borne expander [34]. ...
... We found a significant improvement on SpO 2 levels, but not on the minimal SpO 2 . Vinha et al. reported a statistical difference in the SpO 2 and oxygen desaturation index in SARPE patients [16,33]. Cistulli et al. found a statically Fig. 4 Boxplot comparing the AHI among the groups and timepoints significant difference in minimal SpO 2 , from 89 ± 1 to 91 ± 1 (p < 0.05), but the authors studied a mixed sample of surgical and non-surgical patients [29]. ...
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Introduction: Transverse maxillary deficiency is a high prevalent growth disorder within the adult population that may lead to serious health issues, such as detrimental malocclusions and higher risk of developing obstructive sleep apnea (OSA). Mini-implant assisted rapid palatal expansion (MARPE), as it expands the mid-face and augment the nasal and oral cavities dimensions, may reduce the airflow resistance and thus play an important role on OSA therapy in some patients. The main objective of the present trial is to assess MARPE effects on the sleep and quality of life of non-obese adult OSA patients with transverse maxillary deficiency. Methods: A total of 32 participants were divided into intervention and control groups. They underwent physical evaluation, Epworth Sleepiness Scale (EES) and Quebec Sleep Questionnaire (QSQ), cone-beam computed tomography (CBCT) and home sleep testing (HST) for OSA before MARPE (T1) and 6 months after the intervention (T2). Results: Questionnaires EES (daytime sleepiness) and QSQ (OSA-related quality of life) presented significant statistical differences between the groups. We also found clinical and statistical (p < 0.01) differences between the groups regarding the apnea/hypopnea index (AHI), as well as others HST parameters (mean oxygen saturation and snoring duration). Conclusion: In our sample, MARPE (without any auxiliary osteotomy) showed a good success rate (85%) and promoted important occlusal and respiratory benefits. We observed important daytime sleepiness and OSA-related quality of life improvement, as well as the AHI (65.3%), oxygen saturation and snoring duration.
... Alternatively, orthodontists can achieve palatal expansion in adult patients using miniscrew assisted rapid palatal expansion (MARPE). MARPE involves inserting miniscrew supported palatal expander to deliver orthopedic force directly to palatal shelves to separate the fused midpalatal suture (Liu et al., 2017). Before the midpalatal suture fuses, rapid palatal expansion with the expander resting on the dentition, can be delivered by an orthodontist to separate the palatal shelves. ...
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Dental sleep medicine is the field of dental practice that deals with the management of sleep-related breathing disorders, which includes obstructive sleep apnea (OSA) in adults and children. Depending on the developmental age of the patient and the cause of the apnea dental treatment options may vary. For adult patients, treatment modalities may include oral appliance therapy (OAT), orthognathic surgery and surgical or miniscrew supported palatal expansion. While for children, treatment may include non-surgical maxillary expansion and orthodontic functional appliances. Many physicians and dentists are unaware of the role dentistry, particularly orthodontics, may play in the interdisciplinary management of these disorders. This review article is an attempt to compile evidence-based relevant information on the role of orthodontists/sleep dentists in the screening, diagnosis, and management of sleep apnea. Oral sleep appliance mechanisms of action, selective efficacy, and the medical physiological outcomes are discussed. The purpose of this review is to provide a comprehensive understanding of how orthodontists and sleep physicians can work in tandem to maximize the benefits and minimize the side effects while treating patients with OSA.
... OSA shows particularly high prevalence in adult patients who are over 18 years of age. 14,15 The clinical concerns for other types of sleep-related breathing disorders such as insomnia, central disorders of hypersomnolence, circadian rhythm sleep-wake disorders, sleep-related movement disorders, parasomnias, should be referred to the physician or the primary care provider for a detailed assessment and management. A sleep medicine physician may be a preferred choice for such disorders. ...
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... MISMARPE can be used to coordinate the arches and correct the anterior maxillary constriction without dental repercussions, thus preventing relapse after removal of brackets. Liu et al. (2017), in a study of young adults with obstructive sleep apnea (OSA), used a technique and a device very similar to those presented here and observed a reduction in objective and subjective measurements of OSA. Vinha et al. (2020) also observed a reduction in OSA using the conventional surgically assisted rapid maxillary expansion (SARME) technique. ...
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The purpose of this study was to evaluate maxillary expansion, operative time and pain associated with a new minimally invasive surgical technique to treat maxillary hypoplasia in adult patients. Consecutive patients were included and prospectively analyzed. The technique consists in miniscrew-assisted rapid palatal expansion (MARPE), minimally invasive approach to maxillary osteotomies, latency period and activation period until the desired expansion. The parameters evaluated included operative time, treatment-related pain by the visual analog scale (VAS), and transverse maxillary expansion. The Shapiro–Wilk test was used to assess the normality of data distribution. A paired tt-test was used to compare the data between T0 (preoperative) and T1 (postoperative – end of activation). The significance level was set at 5%. Eleven patients were included. Mean operative time was 24.11 min minutes (14.4–32 min minutes) and overall postoperative VAS score was 2.81 (0–9). A comparative analysis showed significant increases in maxillary width at the skeletal, alveolar, and dental levels (p < 0.0001 for all), with a mean range of 1.8 (SD 0.3) mm to 4.7 (SD 0.5) mm. The present minimally invasive surgical MARPE (MISMARPE) technique appears to yield good skeletal outcomes with minimal trauma. It might have potential for clinical use, but larger comparative studies are needed to confirm the clinical relevance of the approach.
... People with maxillary transverse deficiency are prone to crowded dentition, narrow upper dental arches, high palatal arches, and posterior tooth crossbites [3,4]. This may result in a narrowed nasal cavity and cause an increase in nasal airflow resistance which may lead to a higher risk of developing obstructive sleep apnea syndrome (OSAS) [5][6][7]. OSAS is related to a number of systemic diseases such as myocardial infarction, arterial hypertension, and type 2 diabetes [8,9]. Therefore, it is necessary to pay special attention to the morphology and dynamics of the upper airway, as well as maxillary transverse deficiency. ...
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The use of the C-expander is an effective treatment modality for maxillary skeletal deficiencies which can cause ailments and significantly reduce life expectancy in late adolescents and young adults. However, the morphological and dynamic effects on the nasal airway have not been reported. The main goal of this study was to evaluate the nasal airway changes after the implementation of a C-expander. A sample of nine patients (8 females, 1 male, age range from 15 to 29 years) was included. The morphology parameters and nasal airway ventilation parameters of pretreatment and posttreatment were measured. All study data were normally distributed. A paired t-test was used to evaluate the changes before and after treatment. After expansion, the mean and standard deviation values of intercanine maxillary width (CMW) and intermolar maxillary width (MMW) increased from 35.75±2.48 mm and 54.20±3.17 mm to 37.87±2.26 mm (P<0.05) and 56.65±3.10 mm (P<0.05), respectively. The nasal cavity volume increased from 20320.00±3468.25 mm³ to 23134.70±3918.84 mm³ (P<0.05). The nasal pressure drop decreased from 36.34±3.99 Pa to 30.70±3.17 Pa (P<0.05), while the value of the maximum velocity decreased from 6.50±0.31 m/s to 5.85±0.37 m/s (P<0.05). Nasal resistance dropped remarkably from 0.16±0.14 Pa/ml/s to 0.08±0.06 Pa/ml/s (P<0.05). The use of C-expander can effectively broaden the area and volume of the nasal airway, having a positive effect in the reduction of nasal resistance and improvement of nasal airway ventilation. For patients suffering from maxillary width deficiency and respiratory disorders, a C-expander may be an alternative method to treat the disease.
... The device used in this study had: 6 anterior 3D axial springs; midline anterior/posterior 3-way screw; occlusal pads; retentive clasps, a labial bow and a screw-fin mechanism ( Figure 3). The patient was instructed to wear the device during the late afternoon, early evening and at nighttime (for approximate 12-16 h in total), but not during the daytime and not while eating, partly in line with the circadian rhythm of tooth eruption [6] , although this only occurs in children. Adjustments to the device were performed with 0.25 mm activation as required to optimize its efficacy. ...
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Background: Mandibular advancement devices (MADs) are used to treat mild to moderate obstructive sleep apnea (OSA), but there is a risk that the underlying condition can worsen in the long-term. Therefore, this case report is based on biomimetic oral appliance therapy as an alternative to MADs, which was found to be beneficial in the treatment of a case with severe OSA. Case summary: An overnight sleep study was undertaken in a 50-year-old male with excessive daytime sleepiness that lead to a diagnosis of severe OSA as the apnea-hypopnea index (AHI) was found to be 32.8/h. Since the patient was unable to comply with continuous positive airway pressure therapy and declined surgical intervention, treatment with a MAD was initiated. Approximately 10 years later, another sleep study was performed with no MAD in the mouth, which revealed an AHI of 67.9/h. In view of the deterioration in sleep quality, the patient sought alternative treatment and elected on biomimetic oral appliance therapy, using a mandibular repositioning nighttime appliance (mRNA appliance®, Vivos Therapeutics, Inc., United States). After 10 mo, another sleep study was performed with no device in the patient's mouth, which revealed an AHI of 11.8/h, a mean oxygen saturation of 94% and a mean oxygen desaturation index of 5.3% while sleeping. Finite-element analysis of the pre- and post-treatment study models of the upper jaw showed localized size increases of 15%-17% in the premolar regions and 15%-23% in the molar regions. Conclusion: In adults with severe OSA that are unable to accept continuous positive airway pressure or surgical treatment, biomimetic oral appliance therapy may be preferable over MADs since biomimetic oral appliance therapy may be able to prevent worsening of sleep parameters by remodeling the nasomaxillary complex. Long-term follow up studies are required to verify these novel findings.
... In such cases, the likely alternative for transverse correction is SARPE. Liu et al. 29 have introduced distraction osteogenesis maxillary expansion (DOME) tailored to adult patients with obstructive sleep apnoea, a narrow nasal floor, and a high arched palate, which is performed by placement of maxillary expanders supported by mini-implants along the midpalatal suture followed by Le Fort level I osteotomy. These authors have reported very good results 29 . ...
... Liu et al. 29 have introduced distraction osteogenesis maxillary expansion (DOME) tailored to adult patients with obstructive sleep apnoea, a narrow nasal floor, and a high arched palate, which is performed by placement of maxillary expanders supported by mini-implants along the midpalatal suture followed by Le Fort level I osteotomy. These authors have reported very good results 29 . ...
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This retrospective study was performed to evaluate nasomaxillary changes in 36 patients at an advanced stage of skeletal maturity who underwent miniscrew-assisted rapid palatal expansion (MARPE) or surgically assisted rapid palatal expansion (SARPE) with/without an alar base cinch. Cone beam computed tomography images taken before and after expansion were analysed. Changes in the width of the dental arch (D66S, D66I), maxillary base (MxMol), and nasal floor and nasal cavity in the molar and canine regions (NaFMol, NaFCan, NaCMol, NaCCan) were compared, as well as changes in the choanal aperture (CA) and nasal soft tissue (NW). The MARPE technique produced smaller dental changes (D66S; P = 0.025) and greater nasomaxillary expansion (MxMol, P = 0.010; NaCMol, P = 0.016; NaCCan, P = 0.017; NaFMol, P = 0.001; CA, P = 0.002) than both SARPE techniques. Changes in NW did not differ significantly between the groups (P = 0.200). MARPE uniformly increased the anterior and posterior widths of the nasal cavity. SARPE expanded the nasal cavity in a ‘V-shape’ pattern. Changes in the nasal cavity and choanal aperture related to the amount of dental arch expansion were greater for MARPE than for SARPE. All three approaches increased the width of the nasal soft tissue, although the cinch in SARPE limited this increase.
... Following a few days after surgery, the expander can be activated following a stabilization period. A DOME technique (Distraction Osteogenesis Maxillary Expansion), in which a custom-made expander supported by 4 to 6 boneborne mini-implants is placed, followed by a similar surgery as SARPE is proposed for a similar rationale (25). The expanded maxilla allows a sequential expansion of the nasal cavity as well as the nasal pharynx in a transverse dimension, thus enlarging the airway and in particular the airflow of the nasal cavity to improve OSA. ...
... Among wellknown factors related to bone structure is the relationship of OSA with growth deficiency or maxillomandibular positioning and a marked flexion of the skull base, among others [6][7][8][9]. However, the lack of transverse development of the maxillary arch is being described as one of the causal factors of OSA or one the factors that contribute to OSA [6,[10][11][12][13] both in terms of a direct impact and by the production of changes in the airways [14]. ...
... In addition to affecting occlusion, transverse maxillary deficiency may cause increased nose resistance to airflow [15] and posterior tongue dislocation facilitating pharyngeal collapse [16]. For adults, the treatment of transverse maxillary deficiency is surgically assisted rapid maxillary expansion (SARME) or distraction osteogenesis maxillary expansion (DOME) [11], which has proved to be effective for the reduction of OSA [10,17]. ...
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Purpose To assess the effects of transverse maxillomandibular distraction osteogenesis (TMDO) on the treatment of obstructive sleep apnea (OSA) and on the morphology of the pharynx. Methods A clinical trial was conducted with seven patients with OSA and with transverse maxillomandibular deficiency, two women and five men aged on average 41.16 ± 10.9 years on the day of surgery. All participants were submitted to computed tomography (CT) and full-night polysomnography (PSG) before and approximately 9 months after surgery. A 95% confidence interval was defined. Results The AHI and RDI of the participants were reduced by about 62% (from 27.65 ± 36.65 to 10.73 ± 11.78, p = 0.031 and from 41.21 ± 32.73 to 15.30 ± 13.87, p = 0.015, respectively). The airway showed a surprising mean reduction in volume of 10% (from 5.78 ± 2.53 to 4.71 ± 1.42, p = 0.437, for the upper pharynx; from 6.98 ± 2.23 to 6.23 ± 2.05, p = 0.437, for the lower pharynx; and from 12.76 ± 1.56 to 10.94 ± 2.42, p = 0.625, for the total pharynx). However, the site of the smallest area of the pharynx was considerably increased both in the anteroposterior and transverse direction and in its total area (from 0.88 ± 7.11 to 0.99 ± 0.39, p = 0.625; from 1.78 ± 0.81 to 2.05 ± 0.61, p = 0.812; and from 0.99 ± 0.74 to 1.40 ± 0.51, p = 0.180, respectively). Conclusion TMDO proved to be efficient in reducing or curing OSA, producing modifications of upper pharynx morphology with an increase of the smallest area of the pharynx.
... Patients with this phenotype tend struggle with both nasal obstruction and lack of intraoral volume for the tongue during sleep. Maxillary expansion directed at the nasal floor by way of distraction osteogenesis with maxillary expansion (distraction osteogenesis maxillary expansion [DOME]) has shown promise [55][56][57][58]. Minimally invasive osteotomies can be made at the LeFort I level via an intranasal incision. ...
Article
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Sleep surgery is part of a continuum of care for OSA that involves medical, pharmacologic, and behavioral therapy. Upper airway surgery for OSA can significantly improve stability by way of modulating the critical negative closing pressure. This is the same mechanism of action as PAP or oral appliance therapy (OAT). The updated surgical algorithm in this review adds precision in 3 areas: 1) patient selection, 2) identification of previously unaddressed anatomic phenotypes with associated treatment modality, and 3) improved techniques of previously established procedures. While the original Riley and Powell Phase 1 and 2 approach to sleep surgery has focused on individual surgical success rate, this algorithm strives for an overall treatment success with multi-modal and patient-centric treatments.