SLEEP DISORDERED BREATHING RISK IN SURGICAL AND EARLY CLASS II CORRECTION ORTHODONTIC POPULATIONS

Orthodontics, through the movement of the facial skeleton and the dentition, may alter the risk of Sleep Disordered Breathing (SDB). Accordingly, understanding the prevalence of SDB in patients who might undergo treatment is critical. Methods: 140 patients who were referred for orthognathic surgery consultation were screened with two validated sleep questionnaires to assess their risk for SDB. Physical, dental and radiographic exams were completed. Two patients who had completed a randomized clinical trial comparing the efficacy of single-phase vs. two phase class II correction orthodontic treatment over 20 years ago were recalled. These participants underwent clinical exams and completed sleep questionnaires to assess their risk for SDB. Results: In the surgery population, there was no difference in gender (P=1.0), median age (P=0.10), ethnicity(P=0.43), or skeletal class (P=0.24) between good and poor sleepers. Similarly, there was no difference in genders (P=0.210), median age (P=0.41), ethnicity(P=0.89), or skeletal class (P=0.96) between good and poor daily functioners. Overbite was the only statistically significant variable to have a relationship to both sleep quality (P=0.04) and daily function (P=0.02). The odds of having poor sleep quality were 1.17 times more likely with each millimeter decrease in overbite (95%CI: 1.0; 1.22). The odds of having poor daily function were 1.13 times greater with each mm decrease in overbite (95%CI: 1.02; 1.24). Lastly, the prevalence of poor sleep quality was nearly double that of the general population (63% vs 31%), suggesting an increased risk. In our case study, patient A, who underwent early treatment with a functional appliance, was at high risk according to sleep questionnaires, and had physician diagnosed sleep apnea and undergoes active treatment. Patient B, who received a single phase of treatment, was at low risk for SDB but had TMD comorbidities. The occlusion of both subjects was stable, remaining Class I with under 3mm of crowding in both cases. Conclusions: The prevalence of risk for SDB is higher in a orthognathic-surgical population y. Severe skeletal disharmonies may modify other traditional risk factors such as age, sex, and skeletal class. Two case studies from a previous randomized trial of orthopedic treatment included the appearance of both SDB and TMD as related comorbidities at an ultra long-term follow-up.Master of Scienc

Aesthetic Outcome of Maxillomandibular Advancement Surgery for the Treatment of Obstructive Sleep Apnea

Introduction: Obstructive sleep apnea (OSA) is a common sleep disorder in which complete or partial airway obstruction causes disruptive sleep and excessive daytime sleepiness. Highly successful treatment outcomes for OSA utilizing maxillomandibular advancement (MMA) surgery have been reported. However, due to the large degree of surgical advancement that is performed, concerns may exist regarding the final aesthetic result. Objectives: To evaluate facial profile changes in patients treated for OSA with MMA surgery utilizing panels of oral and maxillofacial surgeons (OMFS), orthodontists (ORTHO) and laypeople (LAY). Methods: This was a retrospective cohort analysis. Pre- and post-treatment silhouettes of patients who underwent MMA surgery for OSA (n=22) were generated from patient profile photographs. The silhouettes were shown in random order to a panel of judges consisting of OMFS (n=48), ORTHO (n=58), and LAY (n=70). The judges were asked to assess patient silhouettes on a visual analogue scale (VAS) based on attractiveness, paying particular attention to facial balance. Results: Post-surgical silhouette ratings were significantly more positive, or neutral, in 21 of 22 patients when compared to pre-surgical ratings. The mean increase in aesthetic score post-surgically was found to be 1.9 for all groups combined, 2.1 for OMFS and ORTHO, and 1.6 for LAY. There was a significant difference in the way that OMFS and ORTHO rated silhouettes as compared to LAY for 12 of 22 patients (p \u3c 0.05). Mean aesthetic score change was not significant between OMFS and ORTHO ratings for any of the 22 patients. Conclusions: In general, MMA surgery for the treatment of OSA does not have a negative impact on facial aesthetics. All groups of evaluators felt that post-surgical aesthetic changes were positive in the vast majority of patients. OMFS and ORTHO reported a higher positive post-surgical change than LAY

The Relationship of Parent-Reported Symptoms of Sleep-Disordered Breathing with the Presence of Malocclusion and Craniofacial Disharmony in Pediatric Orthodontic Patients

Introduction: Sleep-disordered breathing (SDB) is a term for breathing difficulties occurring during sleep and encompasses frequent loud snoring to Obstructive Sleep Apnea (OSA). SDB in children has been linked to daytime sleepiness, poor school performance, hyperactivity, cardiovascular complications, impaired overall growth, development of malocclusion, and craniofacial disharmony. The American Academy of Pediatrics and the American Association of Orthodontists (AAO) urge more studies to educate about etiology, symptoms, and sequelae of SDB. Therefore, this study proposed to investigate the association between symptoms of SDB and malocclusion and craniofacial disharmony in children. Methods: The Pediatric Sleep Questionnaire (PSQ) was used to obtain cross-sectional data from a sample of parents attending their child’s appointment at Nova Southeastern University’s Orthodontic Clinic. Additional questionnaire items included literature-supported SDB-related sociodemographic and clinical history information. Specific variables of malocclusion and craniofacial disharmony were analyzed using the child’s photos and casts. Univariate, bivariate, and multivariable logistic regression analyses were used to assess the specific aims. Results: Of 147 participants, sixteen children (10.9%) were at risk for SDB. Significant bivariate associations were found between risk for SDB and tonsilloadenoidectomy (p = 0.015) and allergies (p = 0.041). The final model indicated children with a tonsilloadenoidectomy were 83.6% less likely to be at risk for SDB (adjusted odds ratio [AOR] = 0.164, 95% confidence interval [CI] 0.034, 0.795). Ten children (6.8%) were at risk for snoring. The final model for snoring risk indicated that children who qualified for free/reduced lunch were 4.5 times more likely to be at risk for snoring (AOR=4.533, 95% CI 1.037-19.806) while children with a deep/narrow palate were 84.8% less likely to be at risk for snoring (AOR=0.152, 95% CI 0.033, 0.693). Conclusions: Though no significant associations were found between the children’s dentofacial measurements and the parent responses on the PSQ, a history of tonsilloadenoidectomy produced a significant association with risk of SDB. Additionally, significant associations with snoring risk were found with qualification for free/reduced lunch and palatal measurements. Our findings suggest that orthodontists are at unique position to screen for SDB and snoring. Our study proposes the PSQ, with additional SDB-related medical history questions and dentofacial measurements, for orthodontists to use as a screening tool

Craniofacial morphology and dental characteristics in children and adolescents with sleep disorders: a systematic review

PURPOSE: To systematically evaluate the available evidence regarding craniofacial morphology and dental characteristics in children and adolescents with sleep disorders. METHODS: A systematic electronic literature search was conducted on May 3, 2022. The Cochrane Library, MEDLINE (PubMed), Embase, CINAHL, Web of Science and Dentistry and Oral Sciences Source were accessed. Hand searching of reference lists and study inclusions were established. Data extraction and quality assessment were carried out for each included study. Significant findings of each study were reported. RESULTS: A total of 18,615 papers were identified, and 4 additional studies with manual searching. Fifty-two papers were included. Obstructive sleep apnea (OSA) was found to be associated with increased lower anterior facial height in 18/47 studies, mandibular retrusion in 16/47 studies, narrow maxilla in 9/47 studies, steep mandibular plane angle in 8/47 studies, cross bite in 8/47 studies, deep palatal height in 6/47 studies, inferior hyoid bone position in 5/47 studies, overjet in 4/47 studies, and longer or larger soft palate in 6/47 studies. Sleep bruxism (SB) was found to be associated with increased incisal overjet in 3/5 studies. CONCLUSION: Within the limitations of the studies included, the most common craniofacial morphologies found in association with OSA children were increased lower anterior facial height, mandibular retrusion, narrow maxilla and steep mandibular plane angle, while the most common dental characteristics found in association with OSA children were cross bite, deep palatal height, overjet and longer or larger soft palate

Orthodontic Management of Adult Sleep Apnea: Clinical Case Reports

Obstructive sleep apnea (OSA) is a serious public health problem that has important impacts on the quality and life expectancy of affected individuals. It is characterized by repetitive upper airway collapse during sleep. OSA requires a multidisciplinary plan of treatment. There is increasing interest in the role of the orthodontist both in screening for adult obstructive sleep apnea and its management. Dental appliances and orthognathic surgery are two strategies that are currently used in the treatment of sleep apnea. This chapter focuses on the orthodontic management of sleep apnea in adults through three clinical cases with varying degrees of severity of sleep apnea. It provides a background on OSA treatment approaches and discusses the potential risks and benefits of each

Robin Sequence:Clinical implications and functional outcomes following (non-) surgical management

Robin Sequence (RS) is a congenital craniofacial abnormality characterized by mandibular hypoplasia, glossoptosis, and varying degrees of upper airway obstruction. The interaction between the various etiological causes, the great variability in clinical expression, and the lack of a uniform definition continuously pose challenges to clinicians. The aim of this thesis is to gain another step towards a better understanding of this complex and challenging condition by focusing on the clinical characteristics and functional outcomes regarding airway, feeding, swallowing, and growth in patients with RS. In this way, we attempt to add valuable information to the current knowledge of RS and therefore contribute to an improved quality of care for these patients

Clinical Implications of Treacher Collins Syndrome

__Abstract__ Treacher Collins syndrome (OMIM 154500) is a rare congenital craniofacial condition.1 The incidence of Treacher Collins syndrome is nowadays estimated at 1 in 50,000.2-3 Based on this, every year approximately 4-5 patients are born with this syndrome in the Netherlands. Treacher Collins syndrome has several eponyms, for example it is also known as Franceschetti-Zwahlen-Klein syndrome or Berry syndrome. George Andreas Berry in 1889 first described an abortive form with colobomata of the lower eyelids. In 1900 Treacher Collins presented two similar cases and described their features (Figure 1).4 Forty-four years later in 1944 Franceschetti and Zwahlen and later Franceschetti and Klein published a review with phenotypic features and designated it “mandibulofacial dysostosis”.5 In addition, later on Fazen described in 1967 10 affected persons in four generations.1 Nowadays “Treacher Collins syndrome” (TCS) is the most used eponym for this congenital craniofacial syndrome

Acromegaly

Acromegaly is an acquired disorder related to excessive production of growth hormone (GH) and characterized by progressive somatic disfigurement (mainly involving the face and extremities) and systemic manifestations. The prevalence is estimated at 1:140,000–250,000. It is most often diagnosed in middle-aged adults (average age 40 years, men and women equally affected). Due to insidious onset and slow progression, acromegaly is often diagnosed four to more than ten years after its onset. The main clinical features are broadened extremities (hands and feet), widened thickened and stubby fingers, and thickened soft tissue. The facial aspect is characteristic and includes a widened and thickened nose, prominent cheekbones, forehead bulges, thick lips and marked facial lines. The forehead and overlying skin is thickened, sometimes leading to frontal bossing. There is a tendency towards mandibular overgrowth with prognathism, maxillary widening, tooth separation and jaw malocclusion. The disease also has rheumatologic, cardiovascular, respiratory and metabolic consequences which determine its prognosis. In the majority of cases, acromegaly is related to a pituitary adenoma, either purely GH-secreting (60%) or mixed. In very rare cases, acromegaly is due to ectopic secretion of growth-hormone-releasing hormone (GHRH) responsible for pituitary hyperplasia. The clinical diagnosis is confirmed biochemically by an increased serum GH concentration following an oral glucose tolerance test (OGTT) and by detection of increased levels of insulin-like growth factor-I (IGF-I). Assessment of tumor volume and extension is based on imaging studies. Echocardiography and sleep apnea testing are used to determine the clinical impact of acromegaly. Treatment is aimed at correcting (or preventing) tumor compression by excising the disease-causing lesion, and at reducing GH and IGF-I levels to normal values. Transsphenoidal surgery is often the first-line treatment. When surgery fails to correct GH/IGF-I hypersecretion, medical treatment with somatostatin analogs and/or radiotherapy can be used. The GH antagonist (pegvisomant) is used in patients that are resistant to somatostatin analogs. Adequate hormonal disease control is achieved in most cases, allowing a life expectancy similar to that of the general population. However, even if patients are cured or well-controlled, sequelae (joint pain, deformities and altered quality of life) often remain

Impact of facial conformation on canine health: Brachycephalic Obstructive Airway Syndrome

The domestic dog may be the most morphologically diverse terrestrial mammalian species known to man; pedigree dogs are artificially selected for extreme aesthetics dictated by formal Breed Standards, and breed-related disorders linked to conformation are ubiquitous and diverse. Brachycephaly–foreshortening of the facial skeleton–is a discrete mutation that has been selected for in many popular dog breeds e.g. the Bulldog, Pug, and French Bulldog. A chronic, debilitating respiratory syndrome, whereby soft tissue blocks the airways, predominantly affects dogs with this conformation, and thus is labelled Brachycephalic Obstructive Airway Syndrome (BOAS). Despite the name of the syndrome, scientific evidence quantitatively linking brachycephaly with BOAS is lacking, but it could aid efforts to select for healthier conformations. Here we show, in (1) an exploratory study of 700 dogs of diverse breeds and conformations, and (2) a confirmatory study of 154 brachycephalic dogs, that BOAS risk increases sharply in a non-linear manner as relative muzzle length shortens. BOAS only occurred in dogs whose muzzles comprised less than half their cranial lengths. Thicker neck girths also increased BOAS risk in both populations: a risk factor for human sleep apnoea and not previously realised in dogs; and obesity was found to further increase BOAS risk. This study provides evidence that breeding for brachycephaly leads to an increased risk of BOAS in dogs, with risk increasing as the morphology becomes more exaggerated. As such, dog breeders and buyers should be aware of this risk when selecting dogs, and breeding organisations should actively discourage exaggeration of this high-risk conformation in breed standards and the show ring

Obstructive sleep apnoea in adults

Obstructive sleep apnoea (OSA) is characterised by repetitive closure of the upper airway, repetitive oxygen desaturations and sleep fragmentation. The prevalence of adult OSA is increasing because of a worldwide increase in obesity and the ageing of populations. OSA presents with a variety of symptoms the most prominent of which are snoring and daytime tiredness. Interestingly though, a significant proportion of OSA sufferers report little or no daytime symptoms. OSA has been associated with an increased risk of cardiovascular disease, cognitive abnormalities and mental health problems. Randomised controlled trial evidence is awaited to confirm a causal relationship between OSA and these various disorders. The gold standard diagnostic investigation for OSA is overnight laboratory-based polysomnography (sleep study), however, ambulatory models of care incorporating screening questionnaires and home sleep studies have been recently evaluated and are now being incorporated into routine clinical practice. Patients with OSA are very often obese and exhibit a range of comorbidities, such as hypertension, depression and diabetes. Management, therefore, needs to be based on a multidisciplinary and holistic approach which includes lifestyle modifications. Continuous positive airway pressure (CPAP) is the first-line therapy for severe OSA. Oral appliances should be considered in patients with mild or moderate disease, or in those unable to tolerate CPAP. New, minimally invasive surgical techniques are currently being developed to achieve better patient outcomes and reduce surgical morbidity. Successful longterm management of OSA requires careful patient education, enlistment of the family’s support and the adoption of self-management and patient goal-setting principles.Australian National Health and Medical Research Counci