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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 (DOME) tailored to adult patients with OSA with narrow nasal floor and high arched palate without soft tissue redundancy. DOME is performed with placement of maxillary expanders secured by mini-implants along the midpalatal suture. This minimizes the maxillary osteotomies necessary to re-create sutural separation for reliable expansion at the nasal floor and palatal vault. We report the safety and efficacy profile of the first 20 patients at Stanford who underwent DOME.
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Clinical Techniques and Technology
Distraction Osteogenesis Maxillary
Expansion (DOME) for Adult Obstructive
Sleep Apnea Patients with High Arched
Head and Neck Surgery
2017, Vol. 157(2) 345–348
ÓAmerican Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2017
Reprints and permission:
DOI: 10.1177/0194599817707168
Stanley Yung-Chuan Liu, MD, DDS
Christian Guilleminault, MD, DBiol
, Leh-Kiong Huon, MD
and Audrey Yoon, DDS
No sponsorships or competing interests have been disclosed for this article.
A narrow maxilla with high arched palate characterizes a phe-
notype of obstructive sleep apnea (OSA) patients that is asso-
ciated 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 (DOME)
tailored to adult patients with OSA with narrow nasal floor
and high arched palate without soft tissue redundancy. DOME
is performed with placement of maxillary expanders secured
by mini-implants along the midpalatal suture. This minimizes
the maxillary osteotomies necessary to re-create sutural
separation for reliable expansion at the nasal floor and palatal
vault. We report the safety and efficacy profile of the first 20
patients at Stanford who underwent DOME.
obstructive sleep apnea, nasal obstruction, high arched
palate, maxillary expansion, distraction osteogenesis, mini-
implant assisted rapid maxillary expander, bone-borne maxil-
lary expander, rapid palatal expander
Received October 26, 2016; revised March 21, 2017; accepted April 7,
Anarrow maxilla with high arched palate charac-
terizes a phenotype of patients with obstructive sleep
apnea (OSA).
This is associated with increased
nasal airflow resistance and posterior displacement of the
Guilleminault et al
reported a 10.9-fold increase in
odds of OSA with this phenotype (Figure 1).
In pediatric OSA, maxillary expansion has been reported
with successful long-term results.
Systematic review also
reports that adults after maxillary expansion show improve-
ment in the apnea-hypopnea index (AHI) and subjective
daytime sleepiness.
Maxillary expansion can be performed noninvasively via
dental expanders prior to midpalatal suture fusion around
age 15 years. Until now, adult maxilla also has been
expanded with dental expanders in conjunction with surgery
to re-create maxillary sutures (Lefort osteotomy and midpa-
latal osteotomy).
This technical note addresses 2 shortcomings with cur-
rent techniques described for adult maxillary expansion, par-
ticularly in adults with OSA and narrow palate.
1. Current techniques are described for the correction
of dentofacial deformity. Most patients with OSA
have normal occlusion but may still present with
high arched palate and narrow nasal floor.
2. Dental expanders exert force at the maxillary
molars. This does not reliably expand the nasal
floor along the midpalatal region, which is perti-
nent for patients with OSA (Figure 2A,B).
We describe the safety and efficacy of distraction osteo-
genesis maxillary expansion (DOME) for 20 patients at
Stanford that addresses these shortcomings and where we
convert the palatal vault from an arched to domed
Division of Sleep Surgery, Department of Otolaryngology–Head & Neck
Surgery, Stanford University School of Medicine, Stanford, California, USA
Stanford University Sleep Medicine Division, Stanford Outpatient Medical
Center, Redwood City, California, USA
Department of Otolaryngology–Head & Neck Surgery, Cathay General
Hospital, Taipei, Taiwan
School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
Section of Pediatric Dentistry, Division of Growth and Development,
UCLA School of Dentistry, Los Angeles, California, USA
This article was presented at the 2016 AAO-HNSF Annual Meeting and
OTO EXPO; September 18-21, 2016; San Diego, California.
Corresponding Author:
Audrey Yoon, DDS, Section of Pediatric Dentistry, UCLA School of
Dentistry, 10833 Le Conte Ave, CHS 20-137, Los Angeles, CA 90095,
Materials and Methods
From September 2014 to April 2016, a prospective cohort
study was conducted of 20 subjects (4 women and 16 men)
who underwent DOME after evaluation by Stanford Sleep
Medicine (C.G.) and Sleep Surgery (S.Y.-C.L., A.Y.).
Standard surgical consent was obtained for all subjects. This
study was approved by the Institutional Review Board of
Stanford University (protocol 36385, IRB 6208).
Subjects’ mean age was 31.7 66.5 years. Patients who
underwent DOME were uniformly (1) intolerant of continuous
positive airway pressure (CPAP) or oral appliance therapy, (2)
showed narrow palatal roof (measuring from 0.8-3 cm), (3)
had no palatine or lingual tonsillar hypertrophy, and (4) were
Mallampati class 4 (70%) or 3 (30%). All underwent pre- and
post-DOME polysomnography (PSG) at Stanford. Outcome
measures obtained include the Epworth Sleepiness Scale
(ESS), Nose Obstruction Symptom Evaluation (NOSE), rhino-
manometry, and computed tomography (CT) measurements of
the nasal floor (Table 1). Paired ttests were used for statistical
analysis with significance set at P\.05.
DOME—Description of Techniques
Step 1. Placement of maxillary expander with mini-implants
(orthodontist). The maxillary expander is custom-fabricated
to fit the narrow palatal vault. Four to 6 mini-implants are
placed along the midpalatal suture and into the maxillary
bone. The orthodontist places the implant and expander in
the office under local anesthesia.
Step 2. Maxillary osteotomy (surgeon). Two small incisions are
made 1 cm above the maxillary mucogingival junction bilat-
erally. Lefort level I osteotomies are made. A vertical inci-
sion is made between the maxillary incisor roots. A
piezoelectric saw is used to deepen the primordial groove of
the midpalatal suture. Thin straight osteotomes are used to
wedge open the midpalatal suture. A diastema (gap between
the maxillary incisors) is seen immediately as the suture
Figure 1. Adult patient with obstructive sleep apnea (OSA) with
maxillary morphology significant for a narrow nasal floor and high
arched palate.
Figure 2. 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.
346 Otolaryngology–Head and Neck Surgery 157(2)
opens (see Movie 1 in the online version of the article). The
expander is then turned to ensure symmetric and easy separa-
tion of the maxilla bilaterally, until a 1-mm diastema is seen
(see Movie 2 in the online version of the article).
Step 3. Expansion (patient). Patients turn the expander daily
(opens by 0.25 mm). Eight to 10 mm of expansion at the
nasal floor can be achieved within a month (Figure 3).
Step 4. Reestablish normal occlusion (orthodontist). Orthodontic
treatment to close the gap between maxillary incisors is ini-
tiated after completion of expansion (usually 1 month after
DOME surgery).
Separation of the midpalatal suture and subsequent maxillary
and nasal floor expansion were successfully achieved in all
subjects. Significant reductions in ESS, NOSE, AHI, oxygen
desaturation index (ODI), and nasal airflow resistance were
seen. Increase of the nasal floor width at the levels of the naso-
palatine nerve and first molar palatal roots was also significant
(Table 1).
Sinus infection, oronasal fistula, loss of incisor teeth, and
malunion did not occur. Minor asymmetric maxillary expan-
sion occurred in 3 subjects but was within the range of
orthodontic correction. Resolution of V
paresthesia in the
Table 1. Demographic, Subjective, and Objective Parameters before and after Distraction Osteogenesis Maxillary Expansion (DOME)
Characteristic Before, Mean 6SD After, Mean 6SD Paired tTest, PValue
BMI 26.8 65.0 26.4 65.5 0.44
ESS 12.3 64.1 7.8 64.8 \0.001
NOSE 11.7 65.3 3.85 63.23 \0.001
AHI 30.9 627.1 14.2 69.3 \0.01
ODI 23.0 628.4 8.7 66.9 0.07
Reff Insp (left) 1.4 60.4 1.0 60.5 \0.001
Reff Insp (right) 1.4 60.4 0.9 60.3 \0.001
Nasal floor width—anterior, mm 22.7 64.58 27.4 64.7 \0.001
Nasal floor width—posterior, mm 27.9 64.3 32.1 64.8 \0.001
AHI, apnea-hypopnea index; BMI, body mass index; ESS, Epworth Sleepiness Scale; NOSE, Nose Obstruction Symptom Evaluation; ODI, oxygen desaturation
index; Reff Insp, effective resistance inspiration.
Anterior nasal floor width measured at the level of nasopalatine nerve; posterior nasal floor width measured at the level of maxillary first molar palatal root.
Figure 3. A 24-year-old woman with obstructive sleep apnea who underwent distraction osteogenesis maxillary expansion. (A-C) Nasal
floor width, palatal width, and occlusion at baseline. (D-F) One month after expansion. (G-I) Nine months after treatment (apnea-hypopnea
index from 12.2 to 3.8 events/h).
Liu et al 347
anterior maxilla ranged from 1 to 6 months. Three patients
exhibited transient decrease of perfusion to the maxillary
incisor with darker color change to the dentition. This
resolved over the course of orthodontic treatment. Class I
occlusion was achieved in all patients after expansion, with
no esthetic or functional compromise.
We designed DOME to achieve maxillary expansion for
adult patients with OSA exhibiting high arched palate and
nasal obstruction. A similar phenotype in children has been
well addressed with maxillary expansion.
Existing adult maxillary expansion techniques, however, are
directed mainly for treating dentofacial deformity. Frequent
called SARPE (surgery-assisted rapid palatal expansion), it has
the shortcoming of using dental expanders that require invasive
osteotomy, including pterygoid plate fracture that carries signifi-
cant bleeding risk. Furthermore, forces exerted at the dentition
do not reliably lead to expansion of bone at the midpalatal junc-
tion, leading to a relapse rate as high as 64%.
With mini-implants, DOME negates the need to perform
pterygoid disjunction. Furthermore, the force is exerted at
the height of palatal vault and nasal floor. It is readily
applied to patients with normal, albeit narrow, jaw occlusal
relationship. Results need to be interpreted with the fact that
expanders remain in place for at least 8 months after dis-
traction osteogenesis, and we do not have data on long-term
relapse at this time.
DOME is conceived to widen the maxilla of adult patients
with OSA with high arched palate and normal occlusion. It
requires minimal maxillary osteotomies to reliably expand
the adult maxilla. The reduction in objective and subjective
measures of OSA in this patient phenotype requires long-
term follow-up to establish DOME as a form of ‘‘skeletal’’
palate surgery.
Author Contributions
Stanley Yung-Chuan Liu, original conception, design, analysis
and drafting the work, total clinical treatment and writing the
manuscript; Christian Guilleminault, data analysis, interpretation
of data, revising the work; Leh-Kiong Huon, acquisition of data
and revising the work; Audrey Yoon, original conception, design,
analysis and drafting the work, total clinical treatment and review-
ing the manuscript.
Competing interests: None.
Sponsorships: None.
Funding source: None.
Supplemental Material
Additional supporting information is available in the online version
of the article.
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348 Otolaryngology–Head and Neck Surgery 157(2)
... Distraction osteogenesis maxillary expansion (DOME) was developed as a patient-specific surgical-orthodontic protocol for reliable, consistent, and effective maxillary expansion without the uncertainty and adverse effects of mini-implant-assisted rapid palatal expansion (MARPE) or surgically assisted rapid palatal expansion (SARPE) [5]. DOME combines a miniimplant-assisted palatal expander and minimally invasive maxillary osteotomy and has been shown to significantly reduce nasal obstruction and severity of OSA [6]. ...
... Conventional DOME surgical technique includes limited LeFort I osteotomy that may or may not require fracture of the pterygoid plates. A full description of the surgical and expansion procedures is well documented elsewhere [5,6,12]. The expander screw is turned up to 2 mm of maxillary separation to validate the successful MARPE placement and DOME procedure at the end of the procedure (Fig. 1B). ...
... For patients with nasal obstruction and a high-arched palate and maxillary transverse hypoplasia, intranasal surgery as septoplasty, inferior turbinate reduction, and nasal vale stabilization tend to fail in improving obstructive symptoms [22]. DOME has shown to be an effective procedure for patients with this particular anatomic phenotype [5]. We previously demonstrated the effect of DOME on nasal breathing using validated internal nasal valve measures suggesting proof of its efficacy [20]. ...
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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.
... For the participants of this study, the levels of nasal obstruction were reduced and, consequently, breathing was facilitated. Liu et al., 28 Abdelwahab et al. 31 and Yoon et al. 30 28 and ...
... For the participants of this study, the levels of nasal obstruction were reduced and, consequently, breathing was facilitated. Liu et al., 28 Abdelwahab et al. 31 and Yoon et al. 30 28 and ...
Introduction The aim of this systematic review and meta-analysis was to evaluate the effects of maxillary expansion on adults with obstructive sleep apnoea (OSA). Methods Electronic searches up to July 2021 in eight electronic databases were conducted. Study selection, data extraction, risk of bias evaluation using ROBINS-I, quality of evidence assessment using GRADE and meta-analyses were performed. Results The electronic searches yielded 1,007 studies. Following the application of the eligibility criteria, 15 articles were fully read and five studies were included. The studies evaluated the effects of surgically assisted rapid maxillary expansion in adults with OSA. The meta-analysis demonstrated an improvement in Apnoea-Hypopnea Index (AHI) (MD = -9.91, CI = -14.57 to -5.25), Oxygen Desaturation Index (ODI) (MD = -7.95, CI = -12.23 to -3.67), and Epworth Sleepiness Scale (ESS) (MD = -4.40, CI = -6.39 to -2.40). ROBINS-I indicated serious, no information and critical risk of bias for the included studies. The quality of the evidence was very low. Conclusion The findings herein suggest that maxillary expansion could improve OSA in adults in the short term.
... PA: You have devoted many articles to the surgical treatment of OSA, of which I am only referencing the most recent ones 15,18,19,21,[108][109][110][111][112][113][114][116][117][118]123,124,133,154,155,173,186 . What are the short-and long-term results and current indications of these various procedures? ...
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Philippe Amat: The relationship between sleep medicine and orthodontics is a subject of constant interest for our disciplines, as shown by the programmes of their respective congresses and the many publications devoted to them over the last thirty years. We would like this interview to provide our readers with a summary of some of the key elements of this relationship and to shed light on the many facets of your important contributions to the creation and development of “sleep medicine” as a new field of medicine throughout the world.
... Nevertheless, there is a noticeable subjective improvement in nasal breathing associated with the enlargement of the nasal valve. This procedure has been used since 1938 and has become widely accepted as an effective and safe technique for maxillary expansion with minor complications [54,55]. Vinha et al. published an article about the SARME technique for the treatment of OSA in adult patients with good results regarding OSA symptoms, such as decreased rates of respiratory disturbances, desaturation, microarousal, and reduced daytime sleepiness [52]. ...
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Obstructive sleep apnea (OSA) is a chronic, sleep-related breathing disorder. It is characterized by a nocturnal periodic decrease or complete stop in airflow due to partial or total collapse of the oropharyngeal tract. Surgical treatment of OSA is constantly evolving and improving, especially with the implementation of new technologies, and this is needed because of the very heterogeneous reasons for OSA due to the multiple sites of potential airway obstruction. Moreover, all of these surgical methods have advantages and disadvantages; hence, patients should be approached individually, and surgical therapies should be chosen carefully. Furthermore, while it is well-established that oromaxillofacial surgery (OMFS) provides various surgical modalities for treating OSA both in adults and children, a new aspect is emerging regarding the possibility that some of the surgeries from the OMFS domain are also causing OSA. The latest studies are suggesting that surgical treatment in the head and neck region for causes other than OSA could possibly have a major impact on the emergence of newly developed OSA, and this issue is still very scarcely mentioned in the literature. Both oncology, traumatology, and orthognathic surgeries could be potential risk factors for developing OSA. This is an important subject, and this review will focus on both the possibilities of OMFS treatments for OSA and on the OMFS treatments for other causes that could possibly be triggering OSA.
... The introduction of tunneling technique [1] limits the nasolabial changes, whereas the minimally invasive surgical and miniscrew-assisted rapid palatal expansion (MISMARPE) approach avoids the need for pterygoid plate disjunction. However, the already proposed mini-invasive surgery techniques use multiple small incisions or a long horizontal vestibular incision of the maxilla and perform osteotomies that involve the piriform aperture [2][3][4]. ...
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Surgically assisted rapid palatal expansion (SARPE) has two main shortcomings: possibility of bleeding due to pterygoid plate disjunction and nasolabial changes due to the full thickness vestibular incision of the maxilla. The introduction of tunneling technique limits the nasolabial changes, whereas the minimally invasive surgical and miniscrew-assisted rapid palatal expansion (MISMARPE) approach avoids the need for pterygoid plate disjunction. However, the already proposed mini-invasive surgery techniques use multiple small incisions or a long horizontal vestibular incision of the maxilla and perform osteotomies that involve the piriform aperture. Our technique combines surgery, performed with only one vestibular vertical mucosal incision, with a specific type of miniscrew-assisted rapid palatal expansion (MARPE) device called Maxillary Skeletal Expander (MSE) for treatment of maxillary transverse deficiency in adult patients. Maxillary osteotomies don’t involve the piriform rim.
Obstructive sleep apnea (OSA) is a prevalent condition that affects people of all ages. Surgical management has improved with growing understanding of OSA pathophysiology, new methods of airway phenotyping and precision in operative techniques. The classic Stanford phased approach serves as a foundation for the updated algorithm, which places surgery on a continuum with medical and dental care. The last 40 years have seen a burgeoning of effort focused on individual surgical or dental procedural success rates. What lies ahead should be a focus on improving overall treatment success, usually achievable only with multimodal interventions. The goal of treatment success for the OSA patient will foster collaboration across disciplines.
Upper airway (UA) collapsibility is one of the key factors that determine the severity of obstructive sleep apnea (OSA). Interventions for OSA are aimed at reducing UA collapsibility, but selecting the optimal alternative intervention for patients who fail CPAP is challenging because currently no validated method predicts how anatomical changes affect UA collapsibility. The gold standard objective measure of UA collapsibility is the pharyngeal critical pressure (Pcrit). A systematic literature review and meta-analysis were performed to identify the anatomical factors with the strongest correlation with Pcrit. A search using the PRISMA methodology was performed on PubMed for English language scientific papers that correlated Pcrit to anatomic variables and OSA severity as measured by the apnea-hypopnea index (AHI). A total of 29 papers that matched eligibility criteria were included in the quantitative synthesis. The meta-analysis suggested that AHI has only a moderate correlation with Pcrit (estimated Pearson correlation coefficient r = 0.46). The meta-analysis identified four key anatomical variables associated with UA collapsibility, namely hyoid position (r = 0.53), tongue volume (r = 0.51), pharyngeal length (r = 0.50), and waist circumference (r = 0.49). In the future, biomechanical models that quantify the relative importance of these anatomical factors in determining UA collapsibility may help identify the optimal intervention for each patient. Many anatomical and structural factors such as airspace cross-sectional areas, epiglottic collapse, and palatal prolapse have inadequate data and require further research.
Background: Maxillomandibular advancement (MMA) remains one of the most effective surgeries for the treatment of obstructive sleep apnea (OSA), but it can be difficult to manage nasal and midfacial esthetics for patients requiring significant maxillary advancement. Objective: To evaluate changes in the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) after the modified MMA approach. Methods: This prospective study was conducted on subjects undergoing MMA at a tertiary referral center from September 2020 to August 2021. Nasal function, cosmesis, and sleepiness were assessed perioperatively with the SCHNOS, visual analog scale for nasal function and cosmesis, and Epworth sleepiness scale (ESS). Objective polysomnography data were also investigated. Results: Thirty-one subjects met inclusion criteria. After MMA, SCHNOS-O (obstruction domain) improved from 44.38 ± 26.21 to 19.03 ± -4.75 (p < 0.001). The SCHNOS-C (cosmesis domain) improved significantly from 13.95 ± 19.32 to 5.27 ± 8.93 (p = 0.029). Specific items evaluating self-esteem, nasal straightness, and symmetry showed significant improvement (p = 0.006, 0.025, 0.044). The ESS also improved from 9.41 ± 6.11 to 3.26 ± 3.03 (p < 0.001), and it correlated with nasal obstruction scores. Conclusion: In this study, patients' perception of nasal obstruction and appearance improved after applying the nasal modifications to MMA described for OSA.
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L’alternance veille-sommeil est un des cycles circadiens fondamentaux ubiquitaire dans le règne animal. Chez l’homme, le sommeil correspond à une succession de cycles (lent et paradoxal) qui ont de nombreuses fonctions bénéfiques sur le plan physiologique et comportemental (e.g. Urrila et al., 2017). Les troubles du sommeil sont des facteurs de risque de nombreuses pathologies telles que le cancer, le diabète, la susceptibilité aux maladies infectieuses et les troubles cognitifs (e.g. Prather et al., 2015). La classification internationale des pathologies du sommeil distingue six grandes catégories de pathologies, parmi lesquelles on trouve les troubles respiratoires du sommeil (AASM, 2014). Ils sont généralement divisés en syndrome d’apnées-hypopnées obstructives du sommeil (SAHOS), syndrome d’apnées centrales, syndrome d’hypoventilation obstructive, ronchopathie primaire et syndrome de résistance des voies aériennes supérieures. Les troubles respiratoires obstructifs du sommeil (TROS) sont souvent l’objet d’une prise en charge pluridisciplinaire impliquant somnologue, ORL, chirurgien maxillo-facial et chirurgien-dentiste. L’orthodontiste, en sa qualité de spécialiste de la croissance et du développement cranio- facial, a un rôle important à jouer au sein de ces équipes pluridisciplinaires, tout particulièrement dans la prise en charge des cas pédiatriques.
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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). 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. 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. 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. Copyright © 2015 Elsevier B.V. All rights reserved.
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The purpose of this article is to present further longitudinal data for short-term and long-term stability, following up our previous article in the surgery literature with a larger sample and 2 years of stability data. Data from 38 patients enrolled in this prospective study were collected before treatment, at maximum expansion, at removal of the expander 6 months later, before any second surgical phase, at the end of orthodontic treatment, and at the 2-year follow-up, by using posteroanterior cephalograms and dental casts. With surgically assisted rapid palatal expansion (SARPE), the mean maximum expansion at the first molar was 7.60 ± 1.57 mm, and the mean relapse was 1.83 ± 1.83 mm (24%). Modest relapse after completion of treatment was not statistically significant for all teeth except for the maxillary first molar (0.99 ± 1.1 mm). A significant relationship (P < 0.0001) was observed between the amount of relapse after SARPE and the posttreatment observation. At maximum, a skeletal expansion of 3.58 ± 1.63 mm was obtained, and this was stable. Skeletal changes with SARPE were modest but stable. Relapse in dental expansion was almost totally attributed to lingual movement of the posterior teeth; 64% of the patients had more than 2 mm of dental changes. Phase 2 surgery did not affect dental relapse.
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Obstructive sleep apnea syndrome (OSAS) was diagnosed in157 subjects based on clinical symptoms, physical evaluation, cephalometric x-ray films, and polysomnography. These index cases identified 844 living first-degree relatives. Mailings were sent to 792 (94%). The mailing consisted of two identical questionnaires, one for the family member of the index case and one to be given to a friend (not a relative) of approximately the same age. In response, we received 531 (63%) questionnaires from relatives and 198 (25%) questionnaires from age-matched nonrelated friends, which were used as a control group. A more extensive investigation was performed on first-degree relatives of the index group living in the San Francisco Bay Area or vicinity. Two hundred seventy-nine relatives (100%) were identified. One hundred sixty-six subjects (59%) as well as 69 age-matched friends (ie, 41% of the 166 relatives and 25% of the potential total group) agreed to participate in further studies. These subjects had interviews, clinical investigations, and nonattended ambulatory monitoring. Cephalometric x-ray films could be obtained on only 22 of 166 participating relatives and 6 of 69 friends. Body mass index was not a differentiating measure between relatives and friends. Odds ratios (ORs) were calculated from the questionnaiare data. The report of tiredness, fatigue, and sleepiness did not distinguish family members from friends. The OR, however, progressively increases when there is a positive history of near nightly loud snoring (OR = 1.78; 95% confidence interval [CI] 1.25-2.54) or a positive history of daytime sleepiness in conjunction with near nightly loud snoring (OR = 3.11; 95% CI = 1.94-4.99). The investigation in the Bay Area indicated that, when first-degree relatives were compared with friends, the complaint of daytime tiredness, sleepiness, or both with the presence of a high and narrow(ogival) hard palate sharply differentiated between friends and relatives (OR = 10.9, 95, CI = 5.31-22.5). An Epworth Sleepiness Scale score of 9 or greater with the presence of another symptom associated with OSAS, and a respiratory disturbance index greater than 5 (number of apneas and hypopneas per hour of sleep > 5) gave an OR of 45.6 (95% CI = 18.8-11.0). Disproportionate craniofacial anatomy was common in familial groups with OSAS. Craniofacial familial features can be a strong indicator of risk for the development of OSAS.
Objective This study sought to systematically review the international literature for articles evaluating maxillary expansion and maxillomandibular expansion as treatments for obstructive sleep apnea (OSA) in adults and to perform a meta-analysis. Data Sources Nine databases (including MEDLINE/PubMed). Review Methods Searches were performed through January 8, 2016. The PRISMA statement was followed. Results Eight adult studies (39 patients) reported polysomnography and/or sleepiness outcomes. Six studies reported outcomes for maxillary expansion (36 patients), and the apnea-hypopnea index (AHI) decreased from a mean (M) ± standard deviation (SD) of 24.3±27.5 [95% CI 15.3, 33.3] to 9.9±13.7 [95% CI 5.4, 14.4] events/hr (relative reduction: 59.3%). Maxillary expansion improved lowest oxygen saturation (LSAT) from a M±SD of 84.3±8.1% [95% CI 81.7, 87.0] to 86.9±5.6% [95% CI 85.1, 88.7]. Maxillomandibular expansion was reported in two studies (3 patients) and AHI decreased from a M±SD of 47.53±29.81 [95% CI -26.5 to 121.5] to 10.7±3.2 [95% CI 2.8, 18.6] events/hr (relative reduction: 77.5%). Maxillomandibular expansion improved LSAT from a M±SD of 76.7±14.5% [95% CI 40.7, 112.7] to 89.3±3.1 [95% CI 81.6, 97]. Conclusion The current literature demonstrates that maxillary expansion can improve and maxillomandibular expansion can possibly improve AHI and LSAT in adults; however, given the paucity of studies, these remain open for additional research efforts.
The relationship between maxillary constriction and the etiology of obstructive sleep apnea (OSA) is not clear. This prospective case-control study compared maxillary morphology in 94 dentate subjects (47 OSA and 47 control subjects), using upright lateral cephalograms and study models. Each subject had height, weight, and neck circumference measurements recorded and underwent an orthodontic examination. An upright lateral cephalogram and dental impressions were obtained. All data were analyzed using the SPSS statistical package applying nonparametric tests at the 5% level of significance. Male and female subjects were examined separately, and statistically significant differences were found between the cephalometric measurements for OSA and the control subjects. The palatal angle was more obtuse in male OSA subjects (P < .05). The PNS-posterior pharyngeal wall was shorter (P < .05) and the soft palate longer in female OSA subjects (P < .05). Minimum palatal airway widths were significantly reduced in both male (P < .01) and female (P < .001) subjects. In the comparison of study model measurements, palatal heights in OSA subjects were greater (P < .05). Thus, maxillary morphological differences do exist between OSA and control subjects, supporting their role as a etiological factor.