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

Abstract

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.

Keywords: breastfeeding; craniofacial development; diet; mandible; masticatory muscles; maxilla; nasal obstruction.

Figure 1. Sagittal profiles of 3-dimensional reconstructed CT imaging.

(A) Preindustrial and (B) modern human skull with history of nasal obstruction and mouth breathing. Features to note are a lengthening of the face as well as posterior rotation of the mandible in the modern skull that may be attributed to modern environmental influences. CT = computed tomography.

Figure 2. Coronal cross-sectional CT imaging.

(A) Preindustrial and (B) modern human skull showing a narrowing of the bony nasal and oral cavity width in the modern human skull. CT = computed tomography.

Figure 3. Proposed interaction of environmental influences leading to craniofacial maldevelopment and ultimate pathology.

Figure 4. Flow diagram for study selection.

NNSH = nonnutritive sucking habits.

Figure 5. Study design considerations in evaluation of environmental influences and craniofacial development.

CSA = cross-sectional area, CT = computed tomography, MRI = magnetic resonance imaging, NNSH = nonnutritive sucking habits, US = ultrasound.