Sleep
Effect of a rapid maxillary expansion on snoring and sleep in children: a pilot study Lilian Chrystiane Giannasi1, Israel Reis Santos1, Thays Almeida Alfaya2, Sandra Kalil Bussadori3, Fernando Studart Leita˜o-Filho1, Luis Vicente Franco de Oliveira1 1
Sleep Disorder Laboratory, University of Nove de Julho (UNINOVE), Sa˜o Jose´ dos Campos, SP, Brazil, Odontote´cnica, University Federal Fluminense, Nitero´i, RJ, Brazil, 3Rehabilitation Sciences Post Graduation Program, Nove de Julho University (UNINOVE), Sa˜o Paulo, SP, Brazil
2
Aim: The aim of this study was to assess the efficacy of the McNamara rapid palatal expansion device for the treatment of sleep disorders in children. Methods: The sample enrolled 12 children aged 4–11 years. Children with snoring and bruxism whose parents did not agree to tonsil surgery were included in the study. During the initial evaluation, a questionnaire addressing sleep was administered, and plaster models were made for the construction of the McNamara rapid maxillary expansion device. The expansion period was 7–15 days, and the McNamara device was removed after 6–8 months. The same questionnaire was administered again after 30 days of use of the orthopedic appliance. The data were analyzed using the McNemar test, with the level of significance set to 5% (P,0.05). Results: Significant improvements were found in tiredness upon waking (P50.002), mood (P50.008), lip seal (P50.031), drooling during sleep (P50.031), snoring (P50.001), and bruxism (P50.0062). Conclusion: The use of non-invasive methods, such as rapid maxillary expansion, can be an effective treatment for snoring and other undesirable sleep behaviors in children. Keywords: Sleep disorders, Child, Therapeutics
Introduction While orthodontic and craniofacial abnormalities are common among children with obstructive sleep apnea (OSA), these conditions have not received adequate attention from specialists in sleep disorders. Children with OSA may have enlarged tonsils, a narrow upper airway, maxillary/palate narrowing, some degree of mandibular retrognathism, crossbite, long face, oral breathing, dark circles under the eyes, tooth wear, lip incompetence, and a low-positioned tongue. Moreover, parents commonly report snoring, bruxism (grinding of one’s teeth), nightmares, body movements during sleep, and mood alterations upon waking.1–3 The prevalence of OSA in the pediatric population is as high as 5.7%.4 This condition can lead to behavioral, cognition, and learning disorders.5,6 A
Correspondence to: L. C. Giannasi, R. Esperanc¸a, 265, ap 31, Sa˜o Jose´ dos Campos-SP 12243-700, Brazil. Email: [email protected] ß W. S. Maney & Son Ltd 2014 DOI 10.1179/2151090314Y.0000000029
recent study reports that the prevalence of snoring and OSA in children with enlarged tonsils is 85 and 45%, respectively.7 Other sleep disorders in children include central hypoventilation syndrome, narcolepsy, hypersomnia, delayed sleep phase syndrome, periodic limb movements/restless leg syndrome, and sleep disorders due to psychiatric problems.1 Treatment should involve a multidisciplinary team and, depending on the symptoms, ranges from cognitive therapy1 to surgery.2,3,8,9 Studies have demonstrated a reduction in both snoring and OSA with the use of rapid maxillary expansion (RME).10–12 One study reports positive results with this type of therapy in children with OSA and the absence of enlarged tonsils.11 Another study found that the partial response to adenotonsillectomy in children may be correlated with craniofacial abnormalities, which are responsible for the maintenance of oral breathing.4,13 Moreover, the persistence of the oral breathing pattern can affect the outcome of orthodontic treatment.
CRANIOH: The Journal of Craniomandibular & Sleep Practice
2014
VOL.
000
NO.
000
1
Alfaya et al.
Effect of a rapid maxillary expansion on snoring and sleep
Figure 1 Modified sleep diary filled out by children’s parents.
In clinical practice, parents/guardians often prefer to avoid surgery, so they request non-invasive methods. Thus, the aim of the present pilot study was to evaluate the effect of RME for the treatment of snoring and clinical signs of sleep respiratory disorders in children with enlarged tonsils.
Methods Subjects The present pilot study was conducted with 14 children aged 4–11 years after receiving approval from the Human Research Ethics Committee of University Nove de Julho (Brazil). All parents signed a statement of informed consent. The inclusion criteria were anterior open bite, snoring, bruxism, and parents who opted for not performing tonsillectomy and treatment with topical medication. The exclusion criteria were neurological diseases and the use of drugs that could affect sleep or motor function.
Clinical evaluation All children were submitted to clinical medical and dental exams by a single otolaryngologist and a single dentist, who was a specialist in sleep disorders. The degree of tonsil hypertrophy was classified based on the method proposed by Brodsky:14 Grade 05tonsils 2
CRANIOH: The Journal of Craniomandibular & Sleep Practice
2014
within the tonsillar fossa with no airway obstruction; Grade 15tonsils slightly outside the tonsillar fossa with less than 25% obstruction of the airway; Grade 25tonsils obstructing 25–50% of the airway; Grade 35tonsils obstructing 50–75% of the airway; and Grade 45tonsils obstructing more than 75% of the airway. The oral breathing pattern was confirmed by a clinical evaluation and specific tests (mirror test and water test). The following aspects were also determined: long face, drooping eyes, dark circles around the eyes, thin upper lip, dry lips, hypotonic lips, inverted lower lip, narrow nostrils, high palate, type of molar class, inadequate lip seal, anterior open bite, and tooth wear suggestive of bruxism.
Sleep questionnaire Before therapy, the parents/guardians were instructed to keep a modified sleep diary (Fig. 1), with specific questions (yes/no responses) addressing signs of sleep disorder, such as tiredness upon waking, mood, nightmares, movements during sleep, lip seal, drooling, snoring, and bruxism. For statistical purposes, responses of ‘‘yes’’ received a score of 1 and responses of ‘‘no’’ received a score of 2. VOL .
000
NO .
000
Alfaya et al.
Figure 2 McNamara device.
RME Molds were made of the upper and lower arches, and plaster casts were sent to a specialized orthodontic laboratory for the fabrication of the McNamara rapid palatal expansion device (Fig. 2). All appliances were made by a single dental prosthesis technician. Placement of the appliances involved bonding to the teeth of the upper arch and occlusal adjustments before initiating the rapid expansion. The appliance was activated daily until achieving over-correction of the crossbite, with J turn during the day and/or J turn at night for 7–10 days. The expander remained in position for 6–8 months for the complete closure of the palatal suture before removal, to avoid relapse. The parents were instructed to fill out the sleep diary a second time after 30 days of usage of the appliance. The sample size was limited by the number of patients included during the data collection. The variables were expressed as mean6SD and proportions were used for categorical data. The McNemar’s test was used for matched paired comparisons, regarding the sleep questionnaire results for each patient before and after the intervention. SPSS Version 22.0 statistical software was used for data analysis (IBM, Chicago, IL, USA). The level of statistical significance was set at P,0.05 for all tests.
Results Twelve children (four girls and eight boys; mean age: 8.5 years) completed the entire protocol. The following was the distribution of molar relationships: class I (n52), class II (n59), and class III (n51). Regarding the tonsil classification, 8.3% (n51) exhibited Grade
Effect of a rapid maxillary expansion on snoring and sleep
2, 75.0% (n59) exhibited Grade 3, and 16.6% (n52) exhibited Grade 4. Table 1 displays the demographic data before treatment. Regarding type of molar class, nine children were Class II, 1 child was Cl and two children were Class III. The mean transverse expansion was 7.2 mm. The post-treatment evaluation of the sleep questionnaire revealed statistically significant improvements in tiredness upon waking (P50.002), mood (P50.008), lip seal (P50.031), drooling during sleep (P50.031), snoring (P50.001), and bruxism (P50.0062). Only two children continued to be tired upon waking; one child continued to be in a bad mood upon waking; one child continued snoring, and three children continued to exhibit bruxism. A reduction in the occurrence of nightmares was also reported, but this difference did not achieve statistical significance (Table 2).
Discussion The present findings demonstrate significant improvements in tiredness upon waking, mood, lip Table 2 Sleep problems assessed by questionnaire before and after 30 days of McNamara device usage
Tiredness upon waking Tired Not tired Mood Very angry Not angry Nightmares Frequently Absent Movements during sleeping Present Absent Lip seal Open mouth Closed mouth Drooling Present Absent Snoring Frequently Absent Bruxism Present Absent
Pre-treatment (n)
Post-treatment (n)
10 (83.3%) 2 (16.7%)
3 (25.0%) 9 (75.0%)
0.002*
11 (91.7%) 1 (8.3%)
1 (8.3%) 11 (91.7%)
0.008*
6 (50.0%) 6 (50.0%)
0 12 (100.0%)
0.250
7 (58.4%) 5 (41.6%)
1 (8.3%) 11 (91.7%)
0.250
9 (75.0%) 3 (25.0%)
2 (16.6%) 10 (83.4%)
0.031*
9 (75.0%) 3 (25.0%)
2 (16.6%) 10 (83.4%)
0.031*
12 (100.0%) 0
0 12 (100.0%)
0.001*
10 (83.4%) 2 (16.6%)
3 (25.0%) 9 (75.0%)
0.0062*
P-value
Table 1 Characteristics of the sample (n512) Gender
Age (years)
Final palatal expansion (mm)
Type of molar class
Four girls/eight boys
8.5860.7
7.4161.41
9 (Class II), 1 Class I, 2 Class III
Note: Class I5molar Class I; Class II5molar Class II; Class III5molar Class III.
CRANIOH: The Journal of Craniomandibular & Sleep Practice
2014
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000
NO .
000
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Alfaya et al.
Effect of a rapid maxillary expansion on snoring and sleep
seal, drooling during sleep, snoring, and bruxism after 30 days of use of the McNamara rapid palatal expansion device. Previous studies report the effects of RME on sleep disorders.10–12,15,16 While the studies cited mainly addressed the effect on OSA, the present investigation demonstrates the benefits of this method with regard to other symptoms that occur during sleep. RME is a non-invasive technique that achieves satisfactory results and should be employed when the bone structure is still in development.10,11 However, before any type of treatment, a detailed patient history should be taken, and a clinical exam should be carried out to determine the status of the hard palate and the size of both the tonsils and adenoids.17 The reduction in the symptoms of sleep disorders is related to the downward and forward movement of the maxillae caused by the RME, which leads to an increase in the nasal chambers and improved air flow.10 According to Buccheri et al., the orthopedic effect of such appliances on the tissues surrounding the maxillae leads to both an increase in nasopharyngeal space and an improvement in the position of the tongue.18 This broadening of the maxillary bone occurs through distraction osteogenesis, which is favored by the fact that this region is composed of compact bone laterally and fibrous tissue with collagen fibers, fibroblasts, and blood vessels centrally.19 Indeed, the present study evidenced improvements in a number of signs and symptoms resulting from the dynamics of RME, and a previous study reports that this method both raises the position of the tongue and widens the pharyngeal airways.20 Invasive methods have been reported for the treatment of sleep disorders.2,3,8,9 A previous study compared one group submitted to surgery followed by RME and another submitted to a protocol with the opposite sequence. The results of the clinical exam and polysomnography (sleep study) revealed improvements in the second group, in which two patients were successfully treated without the need for surgery. Moreover, the researchers highlight the need for subjective clinical scales for the determination of the treatment sequence.21 Nonetheless, surgery is widely employed in such cases,4,13 and few studies have been carried out on the efficacy of noninvasive methods.4,10,12,15,17 It should be stressed that invasive treatment subjects the patient to risks, and approximately 15% of patients continue to exhibit symptoms following surgery22 or experience the return of such problems in adulthood.23 Indeed, a retrospective study involving adolescents addressed the issue of recurrence, and the authors emphasize the importance of considering the possibility of 4
CRANIOH: The Journal of Craniomandibular & Sleep Practice
2014
recurrence, especially among patients submitted to surgery alone without RME.24
Conclusion Based on the present findings, the use of non-invasive methods, such as RME, can be an effective treatment for snoring and other undesirable sleep behaviors in children. Moreover, it is important to include a dentist on the multidisciplinary team for the treatment of sleep disorders.
Disclaimer Statements Contributors Giannasi and Santos conducted the research; Giannasi, Alfaya and Bussadori wrote the manuscript; Leita˜o-Filho and Oliveira revised the manuscript. Funding None. Conflicts of interest None. Ethics approval The present pilot study was conducted after receiving approval from the Human Research Ethics Committee of University Nove de Julho (Brazil).
References 1 Bellini B, Bruni O, Cescut A, de Martino S, Lucchese F, Guidetti V. Managing sleep disorders in children: which is the best strategy? Georgian Med News. 2011;(196–197):73–83. 2 DiFrancesco RC, Junqueira PA, Trezza PM, de Faria ME, Frizzarini R, Zerati FE. Improvement of bruxism after T & A surgery. Int J Pediatr Otorhinolaryngol. 2004;68(4):441–5. 3 Griffiths AL, Heggie A, Holman S, Robertson SP, White SM. Obstructive sleep apnea successfully treated by mandibular distraction osteogenesis in a rare skeletal dysplasia. J Craniofac Surg. 2013;24(2):508–10. 4 Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714–55. 5 Kotagal S, Chopra A. Pediatric sleep–wake disorders. Neurol Clin. 2012;30(4):1193–212. 6 Barnes ME, Gozal D, Molfese DL. Attention in children with obstructive sleep apnoea: an event-related potentials study. Sleep Med. 2012;13(4):368–77. 7 Dzieciolowska-Baran E, Dabrowski P, Gawlikowska-Sroka A, Poziomkowska-Gesicka I, Baran S. Snoring and sleep disorders in children with hypertrophy of lymphoid tissue in the throat. Respir Physiol Neurobiol. 2013;187(1):135–8. 8 Praud JP, Dorion D. Obstructive sleep disordered breathing in children: beyond adenotonsillectomy. Pediatr Pulmonol. 2008; 43(9):837–43. 9 Li HY, Lee LA. Sleep-disordered breathing in children. Chang Gung Med J. 2009;32(3):247–57. 10 Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27(4):761–6. 11 Villa MP, Malagola C, Pagani J, Montesano M, Rizzoli A, Guilleminault C, et al. Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 2007;8(2):128–34. 12 Villa MP, Rizzoli A, Miano S, Malagola C. Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up. Sleep Breath. 2011;15(2): 179–84. 13 Guilleminault C, Huang YS, Glamann C, Li K, Chan A. Adenotonsillectomy and obstructive sleep apnea in children: a
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prospective survey. Otolaryngol Head Neck Surg. 2007;136(2): 169–75. Brodsky L. Modern assessment of tonsils and adenoids. Pediatr Clin North Am. 1989;36(6):1551–69. Marino A, Ranieri R, Chiarotti F, Villa MP, Malagola C. Rapid maxillary expansion in children with Obstructive Sleep Apnoea Syndrome (OSAS). Eur J Paediatr Dent. 2012;13(1):57–63. Pirelli P, Saponara M, Attanasio G. Obstructive Sleep Apnoea Syndrome (OSAS) and rhino-tubaric disfunction in children: therapeutic effects of RME therapy. Prog Orthod. 2005;6(1):48–61. Villa MP, Miano S, Rizzoli A. Mandibular advancement devices are an alternative and valid treatment for pediatric obstructive sleep apnea syndrome. Sleep Breath. 2012;16(4):971–6. Buccheri A, Dilella G, Stella R. Rapid palatal expansion and pharyngeal space. Cephalometric evaluation. Prog Orthod. 2004;5(2):160–71. Melsen B. Histological analysis of the postnatal development of the nasal septum. Angle Orthod. 1977;47(2):83–96.
Effect of a rapid maxillary expansion on snoring and sleep
20 Iwasaki T, Saitoh I, Takemoto Y, Inada E, Kakuno E, Kanomi R, et al. Tongue posture improvement and pharyngeal airway enlargement as secondary effects of rapid maxillary expansion: a cone-beam computed tomography study. Am J Orthod Dentofacial Orthop. 2013;143(2):235–45. 21 Guilleminault C, Monteyrol PJ, Huynh NT, Pirelli P, Quo S, Li K. Adeno-tonsillectomy and rapid maxillary distraction in pre-pubertal children, a pilot study. Sleep Breath. 2011;15(2): 173–7. 22 Guilleminault C, Li KK, Khramtsov A, Pelayo R, Martinez S. Sleep disordered breathing: surgical outcomes in prepubertal children. Laryngoscope. 2004;114(1):132–7. 23 Tasker C, Crosby JH, Stradling JR. Evidence for persistence of upper airway narrowing during sleep, 12 years after adenotonsillectomy. Arch Dis Child. 2002;86(1):34–7. 24 Guilleminault C, Huang YS, Quo S, Monteyrol PJ, Lin CH. Teenage sleep-disordered breathing: recurrence of syndrome. Sleep Med. 2013;14(1):37–44.
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Effect of a rapid maxillary expansion on snoring and sleep in children: a pilot study Lilian Chrystiane Giannasi1, Israel Reis Santos1, Thays Almeida Alfaya2, Sandra Kalil Bussadori3, Fernando Studart Leita˜o-Filho1, Luis Vicente Franco de Oliveira1 1
Sleep Disorder Laboratory, University of Nove de Julho (UNINOVE), Sa˜o Jose´ dos Campos, SP, Brazil, Odontote´cnica, University Federal Fluminense, Nitero´i, RJ, Brazil, 3Rehabilitation Sciences Post Graduation Program, Nove de Julho University (UNINOVE), Sa˜o Paulo, SP, Brazil
2
Aim: The aim of this study was to assess the efficacy of the McNamara rapid palatal expansion device for the treatment of sleep disorders in children. Methods: The sample enrolled 12 children aged 4–11 years. Children with snoring and bruxism whose parents did not agree to tonsil surgery were included in the study. During the initial evaluation, a questionnaire addressing sleep was administered, and plaster models were made for the construction of the McNamara rapid maxillary expansion device. The expansion period was 7–15 days, and the McNamara device was removed after 6–8 months. The same questionnaire was administered again after 30 days of use of the orthopedic appliance. The data were analyzed using the McNemar test, with the level of significance set to 5% (P,0.05). Results: Significant improvements were found in tiredness upon waking (P50.002), mood (P50.008), lip seal (P50.031), drooling during sleep (P50.031), snoring (P50.001), and bruxism (P50.0062). Conclusion: The use of non-invasive methods, such as rapid maxillary expansion, can be an effective treatment for snoring and other undesirable sleep behaviors in children. Keywords: Sleep disorders, Child, Therapeutics
Introduction While orthodontic and craniofacial abnormalities are common among children with obstructive sleep apnea (OSA), these conditions have not received adequate attention from specialists in sleep disorders. Children with OSA may have enlarged tonsils, a narrow upper airway, maxillary/palate narrowing, some degree of mandibular retrognathism, crossbite, long face, oral breathing, dark circles under the eyes, tooth wear, lip incompetence, and a low-positioned tongue. Moreover, parents commonly report snoring, bruxism (grinding of one’s teeth), nightmares, body movements during sleep, and mood alterations upon waking.1–3 The prevalence of OSA in the pediatric population is as high as 5.7%.4 This condition can lead to behavioral, cognition, and learning disorders.5,6 A
Correspondence to: L. C. Giannasi, R. Esperanc¸a, 265, ap 31, Sa˜o Jose´ dos Campos-SP 12243-700, Brazil. Email: [email protected] ß W. S. Maney & Son Ltd 2014 DOI 10.1179/2151090314Y.0000000029
recent study reports that the prevalence of snoring and OSA in children with enlarged tonsils is 85 and 45%, respectively.7 Other sleep disorders in children include central hypoventilation syndrome, narcolepsy, hypersomnia, delayed sleep phase syndrome, periodic limb movements/restless leg syndrome, and sleep disorders due to psychiatric problems.1 Treatment should involve a multidisciplinary team and, depending on the symptoms, ranges from cognitive therapy1 to surgery.2,3,8,9 Studies have demonstrated a reduction in both snoring and OSA with the use of rapid maxillary expansion (RME).10–12 One study reports positive results with this type of therapy in children with OSA and the absence of enlarged tonsils.11 Another study found that the partial response to adenotonsillectomy in children may be correlated with craniofacial abnormalities, which are responsible for the maintenance of oral breathing.4,13 Moreover, the persistence of the oral breathing pattern can affect the outcome of orthodontic treatment.
CRANIOH: The Journal of Craniomandibular & Sleep Practice
2014
VOL.
000
NO.
000
1
Alfaya et al.
Effect of a rapid maxillary expansion on snoring and sleep
Figure 1 Modified sleep diary filled out by children’s parents.
In clinical practice, parents/guardians often prefer to avoid surgery, so they request non-invasive methods. Thus, the aim of the present pilot study was to evaluate the effect of RME for the treatment of snoring and clinical signs of sleep respiratory disorders in children with enlarged tonsils.
Methods Subjects The present pilot study was conducted with 14 children aged 4–11 years after receiving approval from the Human Research Ethics Committee of University Nove de Julho (Brazil). All parents signed a statement of informed consent. The inclusion criteria were anterior open bite, snoring, bruxism, and parents who opted for not performing tonsillectomy and treatment with topical medication. The exclusion criteria were neurological diseases and the use of drugs that could affect sleep or motor function.
Clinical evaluation All children were submitted to clinical medical and dental exams by a single otolaryngologist and a single dentist, who was a specialist in sleep disorders. The degree of tonsil hypertrophy was classified based on the method proposed by Brodsky:14 Grade 05tonsils 2
CRANIOH: The Journal of Craniomandibular & Sleep Practice
2014
within the tonsillar fossa with no airway obstruction; Grade 15tonsils slightly outside the tonsillar fossa with less than 25% obstruction of the airway; Grade 25tonsils obstructing 25–50% of the airway; Grade 35tonsils obstructing 50–75% of the airway; and Grade 45tonsils obstructing more than 75% of the airway. The oral breathing pattern was confirmed by a clinical evaluation and specific tests (mirror test and water test). The following aspects were also determined: long face, drooping eyes, dark circles around the eyes, thin upper lip, dry lips, hypotonic lips, inverted lower lip, narrow nostrils, high palate, type of molar class, inadequate lip seal, anterior open bite, and tooth wear suggestive of bruxism.
Sleep questionnaire Before therapy, the parents/guardians were instructed to keep a modified sleep diary (Fig. 1), with specific questions (yes/no responses) addressing signs of sleep disorder, such as tiredness upon waking, mood, nightmares, movements during sleep, lip seal, drooling, snoring, and bruxism. For statistical purposes, responses of ‘‘yes’’ received a score of 1 and responses of ‘‘no’’ received a score of 2. VOL .
000
NO .
000
Alfaya et al.
Figure 2 McNamara device.
RME Molds were made of the upper and lower arches, and plaster casts were sent to a specialized orthodontic laboratory for the fabrication of the McNamara rapid palatal expansion device (Fig. 2). All appliances were made by a single dental prosthesis technician. Placement of the appliances involved bonding to the teeth of the upper arch and occlusal adjustments before initiating the rapid expansion. The appliance was activated daily until achieving over-correction of the crossbite, with J turn during the day and/or J turn at night for 7–10 days. The expander remained in position for 6–8 months for the complete closure of the palatal suture before removal, to avoid relapse. The parents were instructed to fill out the sleep diary a second time after 30 days of usage of the appliance. The sample size was limited by the number of patients included during the data collection. The variables were expressed as mean6SD and proportions were used for categorical data. The McNemar’s test was used for matched paired comparisons, regarding the sleep questionnaire results for each patient before and after the intervention. SPSS Version 22.0 statistical software was used for data analysis (IBM, Chicago, IL, USA). The level of statistical significance was set at P,0.05 for all tests.
Results Twelve children (four girls and eight boys; mean age: 8.5 years) completed the entire protocol. The following was the distribution of molar relationships: class I (n52), class II (n59), and class III (n51). Regarding the tonsil classification, 8.3% (n51) exhibited Grade
Effect of a rapid maxillary expansion on snoring and sleep
2, 75.0% (n59) exhibited Grade 3, and 16.6% (n52) exhibited Grade 4. Table 1 displays the demographic data before treatment. Regarding type of molar class, nine children were Class II, 1 child was Cl and two children were Class III. The mean transverse expansion was 7.2 mm. The post-treatment evaluation of the sleep questionnaire revealed statistically significant improvements in tiredness upon waking (P50.002), mood (P50.008), lip seal (P50.031), drooling during sleep (P50.031), snoring (P50.001), and bruxism (P50.0062). Only two children continued to be tired upon waking; one child continued to be in a bad mood upon waking; one child continued snoring, and three children continued to exhibit bruxism. A reduction in the occurrence of nightmares was also reported, but this difference did not achieve statistical significance (Table 2).
Discussion The present findings demonstrate significant improvements in tiredness upon waking, mood, lip Table 2 Sleep problems assessed by questionnaire before and after 30 days of McNamara device usage
Tiredness upon waking Tired Not tired Mood Very angry Not angry Nightmares Frequently Absent Movements during sleeping Present Absent Lip seal Open mouth Closed mouth Drooling Present Absent Snoring Frequently Absent Bruxism Present Absent
Pre-treatment (n)
Post-treatment (n)
10 (83.3%) 2 (16.7%)
3 (25.0%) 9 (75.0%)
0.002*
11 (91.7%) 1 (8.3%)
1 (8.3%) 11 (91.7%)
0.008*
6 (50.0%) 6 (50.0%)
0 12 (100.0%)
0.250
7 (58.4%) 5 (41.6%)
1 (8.3%) 11 (91.7%)
0.250
9 (75.0%) 3 (25.0%)
2 (16.6%) 10 (83.4%)
0.031*
9 (75.0%) 3 (25.0%)
2 (16.6%) 10 (83.4%)
0.031*
12 (100.0%) 0
0 12 (100.0%)
0.001*
10 (83.4%) 2 (16.6%)
3 (25.0%) 9 (75.0%)
0.0062*
P-value
Table 1 Characteristics of the sample (n512) Gender
Age (years)
Final palatal expansion (mm)
Type of molar class
Four girls/eight boys
8.5860.7
7.4161.41
9 (Class II), 1 Class I, 2 Class III
Note: Class I5molar Class I; Class II5molar Class II; Class III5molar Class III.
CRANIOH: The Journal of Craniomandibular & Sleep Practice
2014
VOL .
000
NO .
000
3
Alfaya et al.
Effect of a rapid maxillary expansion on snoring and sleep
seal, drooling during sleep, snoring, and bruxism after 30 days of use of the McNamara rapid palatal expansion device. Previous studies report the effects of RME on sleep disorders.10–12,15,16 While the studies cited mainly addressed the effect on OSA, the present investigation demonstrates the benefits of this method with regard to other symptoms that occur during sleep. RME is a non-invasive technique that achieves satisfactory results and should be employed when the bone structure is still in development.10,11 However, before any type of treatment, a detailed patient history should be taken, and a clinical exam should be carried out to determine the status of the hard palate and the size of both the tonsils and adenoids.17 The reduction in the symptoms of sleep disorders is related to the downward and forward movement of the maxillae caused by the RME, which leads to an increase in the nasal chambers and improved air flow.10 According to Buccheri et al., the orthopedic effect of such appliances on the tissues surrounding the maxillae leads to both an increase in nasopharyngeal space and an improvement in the position of the tongue.18 This broadening of the maxillary bone occurs through distraction osteogenesis, which is favored by the fact that this region is composed of compact bone laterally and fibrous tissue with collagen fibers, fibroblasts, and blood vessels centrally.19 Indeed, the present study evidenced improvements in a number of signs and symptoms resulting from the dynamics of RME, and a previous study reports that this method both raises the position of the tongue and widens the pharyngeal airways.20 Invasive methods have been reported for the treatment of sleep disorders.2,3,8,9 A previous study compared one group submitted to surgery followed by RME and another submitted to a protocol with the opposite sequence. The results of the clinical exam and polysomnography (sleep study) revealed improvements in the second group, in which two patients were successfully treated without the need for surgery. Moreover, the researchers highlight the need for subjective clinical scales for the determination of the treatment sequence.21 Nonetheless, surgery is widely employed in such cases,4,13 and few studies have been carried out on the efficacy of noninvasive methods.4,10,12,15,17 It should be stressed that invasive treatment subjects the patient to risks, and approximately 15% of patients continue to exhibit symptoms following surgery22 or experience the return of such problems in adulthood.23 Indeed, a retrospective study involving adolescents addressed the issue of recurrence, and the authors emphasize the importance of considering the possibility of 4
CRANIOH: The Journal of Craniomandibular & Sleep Practice
2014
recurrence, especially among patients submitted to surgery alone without RME.24
Conclusion Based on the present findings, the use of non-invasive methods, such as RME, can be an effective treatment for snoring and other undesirable sleep behaviors in children. Moreover, it is important to include a dentist on the multidisciplinary team for the treatment of sleep disorders.
Disclaimer Statements Contributors Giannasi and Santos conducted the research; Giannasi, Alfaya and Bussadori wrote the manuscript; Leita˜o-Filho and Oliveira revised the manuscript. Funding None. Conflicts of interest None. Ethics approval The present pilot study was conducted after receiving approval from the Human Research Ethics Committee of University Nove de Julho (Brazil).
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