A roadmap of craniofacial growth modification for children with sleep-disordered breathing: a multidisciplinary proposal

Abstract

Craniofacial modification by orthodontic techniques is increasingly incorporated into the multidisciplinary management of sleep-disordered breathing in children and adolescents. With increasing application of orthodontics to this clinical population it is important for healthcare providers, families, and patients to understand the wide range of available treatments. Orthodontists can guide craniofacial growth depending on age; therefore, it is important to work with other providers for a team-based approach to sleep-disordered breathing. From infancy to adulthood the dentition and craniofacial complex change with growth patterns that can be intercepted and targeted at critical time points. This article proposes a clinical guideline for application of multidisciplinary care with emphasis on dentofacial interventions that target variable growth patterns. We also highlight how these guidelines serve as a roadmap for the key questions that will influence future research directions. Ultimately the appropriate application of these orthodontic techniques will not only provide an important therapeutic option for children and adolescents with symptomatic sleep-disordered breathing but may help also mitigate or prevent its onset.

Keywords: craniofacial growth modification roadmap; growth modification; growth modification protocol; pediatric obstructive sleep apnea; rapid palatal expansion; sleep; sleep apnea; sleep-disordered breathing in children.

Graphical Abstract

Figure 1.

Maxillary (palatal) expansion protocol for OSA. Pink zone (up to 8 years: removable expander or slow/semi-rapid maxillary expander)—toddlers and preschoolers usually up to age 8 have malleable mid-palatal sutures, and can benefit from a removable maxillary expander or slow fixed maxillary expander; orthodontic appliances that have a jackscrew that is manually turned as part of a retainer appliance or a fixed appliance with slow release of force on the palate to widen the transverse. Yellow zone (6–15 years old: RPE)—children with a maturing mid-palatal suture can benefit from a conventional rapid maxillary expander, which is an orthodontic appliance that is cemented to the first molars, and sometimes first premolars with a jackscrew to manually expand the maxillary arch. Green zone (10–35 years old: MARPE)—late adolescents and young adults with a mature mid-palatal suture and airway issues can benefit from mini-implant/mini-screw assisted maxillary expander (MARPE) that is anchored into the palate with mini-implants and turned manually to split the mid-palatal suture. Blue zone (18 years old + to aging adult: surgical expansion or DOME)—adults with mature mid-palatal sutures and OSA can benefit from the mini-screw assisted maxillary expander in conjunction with surgery aka, distraction osteogenesis maxillary expansion (DOME) surgical procedure to expand maxilla.