Brief  Bio:  Rose  D.  Sheats� D.M.D.,  M.P.H.  � Diplomate  – American  Board  of  Orthodontics� University  of  North  Carolina  Graduate  Orthodontic  Program  Director  (retired  2013)

� American  Academy  of  Dental  Sleep  Medicine� Board  of  Directors� Associate  editor  – Journal  of  Dental  Sleep  Medicine

Rose  D.  Sheats,  DMD,  MPHUniversity  of  North  Carolina  (Retired)

Chapel  Hill,  NC

Topics� Impact  of  positive  airway  pressure  to  manage  sleep  disordered  breathing  (SDB)  on  craniofacial  growth

� Orthodontic  procedures  to  manage  pediatric  SDB� Rapid  maxillary   expansion� Mandibular   advancement   devices  

� Controversy  regarding  orthodontic  premolar  extractions  and  development  of  SDB

Positive  Airway  Pressure  (PAP)and  Craniofacial  GrowthCase  reports  and  small  case  series  of  CPAP  suggest  adverse  impact  on  craniofacial  growth  in  children

BaroneCM  et  al.  (1994).  Cleft  Palate  Craniofac J  31(1):  74-­‐77.FaurouxB  et  al. (2005).  Intensive  Care  Med  31(7):965-­‐9.

16  yr 11  mos maleBiPap x  10  yrs• Medical  history:    

Achondroplasia• Age  6  yr:    

adenotonsillectomyfor  OSA

• BiPAP initiated  for  residual   OSA

• Pressure   increased  over  time  until  titrated  to  max  of  28  cm  H2O  (age  16  yrs)

• Severe  maxillary  retrusion

Positive  Airway  Pressure  (PAP)  and  Pediatric  Craniofacial  Growth� 2014:  SD  Roberts,  University  of  Washington  orthodontic  residency  thesis

� N  =  100  children,  Seattle  Children’s  Hospital  Craniofacial  Center  and  Sleep  Disorders  Center

� nPAP >  2.5  yrs� Compliant(>20   hrs/week,   >  6  mos):  n  =    50,  mean  age  =  10.4  yrs

� Non-­‐compliant:   n  =  50,  mean   age   =  8.5  yrs

Roberts SD et al. (2016). J Clin Sleep Med 12 (4): 469-475.

PAP  and  Craniofacial  Growth  &  DevelopmentNon-­‐compliant  PAP Compliant  PAP

T1 (dark), T2 (light)Roberts SD et al.(2016). J Clin Sleep Med 12(4): 469-475.

Positive  Airway  Pressure  and  Pediatric  Craniofacial  Growth:  Summary� SDB  children  compliant  with  PAP  demonstrate  impaired  craniofacial  growth,  notably  deficient  maxillary  development

� Sleep  physicians  who  prescribe  PAP  are  encouraged  to  collaborate  with  orthodontists  to  monitor  growth  and  development� Discuss  alternative  treatment  options� Have  frank  discussions  about  jaw  surgery  in  future

RME  &  Pediatric  Obstructive  Sleep  Apnea   (OSA)• 31  children  (8.7  yr)  with  OSA  and  crossbite

• AHI*  Pre-­‐tx =  12.2  (severe)

• Rapid  maxillary  expansion  for  3  weeks

• At  4  months:  AHI  <  1  (normal)  in  100%  of  patients

• No  long-­‐term  outcomes

*Apnea-­‐hypopnea   index

Pirelli P, et al. (2004). Sleep 27(4):761-6, Fig 2.

Maxillary  AnatomyMidpalatal Suture   Maxillary   Bone

Bartleby.com: Gray 's Anatomy, Plates 160 and 190. Licensed under Public Domain via Wikimedia Commons -

https://commons.wikimedia.org/wiki/File:Gray160.png#/media/File:Gray160.png

RME  Effect  on  Airway

Ribeiro A (2012). Angle Orthod82 :458, Fig 6.

Nasopharynx Oropharynx

• Nasal cavity: Increase in width of lower third of nasal cavity• Nasopharynx: No change in volume, cross-sectional area, or AP width• Oropharynx: Increase in all dimensions

RME:  Airway  and  O2� N  =  22,  mean  age  =    8.3  ± 0.9  years� Baseline  and  12  mos post-­‐expansion  (at  removal  of  expander):� CBCT� PSG

� Baseline  to  follow-­‐up:  increase  in  airway  volume  and  SpO2   (90.7%  to  96.1%)  and  decrease  in  AHI  (5.8  to  1.6)  (p<.001)

� Total  airway  volume  was  not  correlated  with  SpO2 or  AHI  values

Fastuca R et al. (2015). Angle Orthod.85:955-61

RME  and  Pediatric  OSA  Studies� 2016  meta-­‐analysis  identified  5  studies:

� Pirelli  et  al.,  NRS  2004  (Italy)� Villa  et  al.,  NRS  2007  (Italy)� Guilleminault et  al.,  RCT  2011  (US)� Marino  et  al.,  RCT  2012  (Italy)� Pirelli  et  al.,  NRS  2012  (Italy)

Huynh  NT  et  al.  (2016).  Sleep  Med  Rev  25:  84-­‐94.

RME  and  Pediatric  SDB  Studies� 5  studies:

� N  =  88  patients� Age range:  6-­‐13  yrs� Presenceof  posteriorcrossbite� Primary outcome:    AHI  scores pre-­‐ and  post-­‐tx� Follow-­‐up:  6-­‐18  mos

RME  and  Pediatric  SDB  Studies

All  studies  demonstrated  improvement  in  AHI  with  RME  treatment

From  Fig  3:  Huynh  NT  et  al.  (2016).  Sleep  Med  Rev  25:  84-­‐94.

Malocclusion  Prevalence  and  Pediatric  SDB� Two  specific  malocclusion  traits  thought  to  be  associated  with  pediatric  SDB� Mandibular   retrognathia� Maxillary   constriction

� Early  orthodontic  treatment  has  demonstrated  improvement  in  OSA

� Is  prevalence  of  maxillary  constriction  and  mandibular  retrognathia higher  in  pediatric  SDB  patients?

Pliska  B  et  al.  (2017).J  Dent  Sleep  Med  4(2):  41-­‐44.� Cohort  of  children  consecutively  referred  to  sleep  center  for  SDB

� N  =  90   (5-­‐10  yrs old;  mean  age  =  6.8  yrs)� Otolaryngology  to  assess  airway� Orthodontics  to  identify  need  for  early  treatment� Parent  report  of  SDB  signs  and  symptoms

Findings  (Total  Sample  =  90)n  (%)

Age  in  yr (SD) 6.8  (1.29)Female 46  (51%)Parent  report

Witnessed  apneas 42  (47%)Mouthbreathing 42  (47%)Bruxism 22  (24%)

Class  II  Canines  (n=63) 20  (32%)Overjet  >  7  mm(n=63) 3  (5%)Anterior  crossbite 5  (6%)Posterior  crossbite 14  (16%)

� In  pediatric   SDB   sample,  prevalence   of   mandibular  retrognathia and  maxillary  constriction   similar  to  that  of  a  typical   orthodontic  population   of   6-­‐9  year  olds

� Referral   to  orthodontist   for  early   treatment   may   not   be  beneficial   for  majority   of  pediatric   SDB  patients  evaluated   in  regional   sleep  center  

Data derived from Pliska B (2017). J Dent Sleep Med 4(2): 41-44, Table 1.

Study  Limitations� SDB  not  confirmed  by  PSG� Criteria  for  early  orthodontic  treatment  may  have  been  too  restrictive:� OJ  >  7  mm� Presence  of  posterior  crossbite

BimaxillaryExpansion  (BE)  for  SDB� Retrospective  study  (2001-­‐2011)� N=45  children  (age:  3-­‐14  yrs)� Inclusion  criteria:

� PSG  confirmed  OSA  pre-­‐BE� Treated  with  maxillary  and  mandibular  expansion� Complete  records  (including  lateral  cephs  and  PSGs)� No  other  co-­‐therapy� Post-­‐BE  PSG  (3-­‐6  mos)

� Exclusion  criteria:� Previous  adenotonsillectomy� Syndromic  craniofacial  anomalies

Quo  SD  et  al.  (2017).  Sleep  Medicine  30:  45-­‐51.

Bimaxillary ExpansionMaxilla:  Skeletal  Expansion  (Rapid  maxillary  expansion)

Mandible:Dentoalveolar Expansion

Quo SD et al. (2017). Sleep Medicine 30 : 45-51 (left: Fig 3; right: Fig 2).

Bimaxillary ExpansionAHI Mild  OSA

AHI  <  5  (n=12)

Moderate5  <  AHI  <  10  

(n=17)

SevereAHI  >  10  (n=16)

Pre-­‐BE 2.9 7.1 22.0Post-­‐BE 6.1 6.1 10.3p-­‐value 0.03 0.25 0.001

• AHI increased in 15/45 patients• No cephalometric findings associated with BE response• Favorable BE response significantly associated with OSA

severity• OSA was not eliminated in any case

Data derived from Quo 2017 and presented as median values (Min – Max AHI)

Quo SD et al. (2017). Sleep Medicine 30 : 45-51.

RME  and  Vomer� Beware  of  intervening  with  rapid  maxillary  expansion  in  children  <  8  yrs old

� Anecdotal  reports  of  nasal  distortion

� Caused  by  “vomer drop”?� 10-­‐20  lbs force

Fig  14-­‐11  B  &  C.    Proffit WR.  Contemporary  Orthodontics.  St.  Louis,  Mo:  Elsevier/Mosby,  2013.    

VomerAnatomy� Paired  bone  in  utero� Fuses  prior  to  birth� Articulates  with  crest  of  maxilla  and  crest  of  palatine  bone

Gray's  Anatomy  plates.   (2015,  April   13).  Wikimedia  Commons,  the  free  media  repository.Retrieved   02:46,  October  20,  2015  from  

https://commons.wikimedia.org/w/index.php?title=Gray%27s_Anatomy_plates&oldid=156953426.

VomerAnatomy

Gray's  Anatomy   plates.   (2015,   Apr il   13).  Wikimedia   Commons,   the   free  media   repository.

Retr ieved   02:46,   October   20,   2015  from  https://commons.wikimed ia.org/w/in dex.p hp? tit le=

Gray%27s_Anatomy_plates&oldid=15 6953426 .

"Vomer"   by  Anatomist90   -­‐ Own   work.  Licensed   under   CC  BY-­‐SA   3.0  via   Commons  

https://commons.wikimed ia.org/wik i/File:Vomer .jpg#/media/File:Vomer .jpg

� Rapid  maxillary  expansion  in  children  <  8  yrs may  lead  to  drop  in  vomer,  causing  nasal  deformities

� No  studies  have  examined  behavior  of  vomer  or  nose  during  maxillary  expansionProffit WR.  Contemporary  Orthodontics.

St.  Louis,  Mo:  Elsevier/Mosby,  2013.  Fig  07-­‐08

RME  and  Vomer  “Drop”

RME  for  Pediatric  SDB:  Summary� Physician   colleagues   need   to   be  educated   on  limitations  

of  RME� RME   is  promising  tool  in  select   orthodontic   cases   but  

insufficient   data   exist   to  recommend   its  use  more  generally   at   this  time   as  a  treatment   option  for  pediatric  sleep   disordered  breathing

� Research   efforts   are  underway   to  investigate   this  treatment   modality   in  young  children

� Slow  expansion   in  management   of   pediatric   SDB   has  not  been   described   to  date

Mandibular  Advancement  DevicesMethods� “Quasi-­‐randomized”   controlled  

clinical  trial� N=32,  mean  age:  7.2  yrs� Treatment:  Mono-­‐bloc  

removable  mandibular  advancement   device  to  correct  Class  II  malocclusion  x  6  mo(n=19)

� Controls:   no  tx (n=13)� Daytime  and  nighttime  symptom  

questionnaires   in  all  subjects� Pre-­‐ and   post-­‐PSG   in  treated  

children  only

Results

Villa MP et al. (2002). Am J Respir CritCare Med 165 (1):123-7.

• 9 dropouts (5 tx/4 control)• AHI significantly improved from

7.1 to 2.6 (p<.001) in tx group• Questionnaire results suggest

decrease in symptoms in treated group

Mandibular  Advancement  Devices  (MAD)2002-­‐2013:  systematic  review  of  MAD  for  pediatric  SDB� Only  4  (of   1759)  studies  met  criteria  for  inclusion

� Randomized   or  non-­‐randomized,   prospective   or  retrospective   clinical   trials

� Children  and   adolescents   (<  16  yrs)� Dx =  SDB,  Treated   with  MAD� Treatment   and  control   groups  or  pre-­‐ and  post-­‐treatment   outcomes   (AHI)

� Available   evidence   is  scarce  and   of  poor  quality

Nazarali N  et  al.  (2015).  EurJ  Orthod 37:618-­‐26.

Mandibular  Advancement  Devices  (MAD)� 2016  Cochrane  Review:  

� 686  trials  initially   identified� one  met   inclusion  criteria   (RCT  or  quasi-­‐RCT,  with  control   group)  – Villa  et  al.  (2002)  Am  J  RespirCritCare  Med

� Small  sample  (N=23),  low  quality  of  evidence� Suggests  promise  of  oral  appliance  therapy  for  pediatric  SDB,  but  evidence  is  thus  far  lacking  to  demonstrate  effectiveness

Fernando R Carvalho et al. Cochrane Database of Systematic Reviews 2016, Issue 10. Art. No.: CD005520. DOI: 10.1002/14651858.CD005520.pub3.

Mandibular  Advancement  Devices:  Summary� Currently  insufficient  research  to  judge  feasibility  and  effectiveness  of  oral  appliance  therapy  (OAT)  for  pediatric  OSA

� Practical  considerations  have  limited  use  of  OAT  in  children

� Long-­‐term  outcomes  have  not  been  assessed� Respiratory� Behavioral� Cognitive� Cardiovascular  

To  Extract  or  Not  to  Extract?� Zhang  J,  Chen  G,  Li  W,  Xu  T,  Gao  X.  Upper  Airway  Changes  after  Orthodontic  

Extraction  Treatment  in  Adults:  A  Preliminary  Study  using  Cone  Beam  Computed  Tomography.  Cray  J,  ed. PLOS  ONE.  2015;10(11):e0143233.  doi:10.1371/journal.pone.0143233.

� Germec-­‐Cakan D,  TanerT,  Akan  S.  Uvulo-­‐glossopharyngeal  dimensions  in  non-­‐extraction,  extraction  with  minimum  anchorage,  and  extraction  with  maximum  anchorage.  EurJ  Orthod 2011  Oct;33(5):515-­‐20.  Epub 2010  Nov  30.  PubMed  PMID:  21118911.

� Valiathan M,  El  H,  Hans  MG,  PalomoMJ.  Effects  of  extraction  versus  non-­‐extraction  treatment  on  oropharyngeal  airway  volume.  Angle  Orthod 2010  Nov;80(6):1068-­‐74.  PubMed  PMID:  20677956.

� Chen  Y,  Hong  L,  Wang  C,  Zhang  S,  Cao  C,  Wei  F,  Lv F,  Zhang  F,  and  Liu  D.  Effect  of  large  incisor  retraction  on  upper  airway  morphology  in  adult  bimaxillary protrusion  patients.  Angle  Orthod 2012;  82:  964-­‐970.

� Wang  Q;  Jia P;  Anderson  N;  Wang  L;  Lin  J.  Changes  of  pharyngeal  airway  size  and  hyoid  bone  position  following  orthodontic  treatment  of  Class  I  bimaxillaryprotrusion.  Angle  Orthod 2012;82:115–121.

Ortho  Extractions  and  “Tongue  Space”� Studies  conflict  with  regard  to  association  between  extractions  and  posterior   airway  dimensions

� Poor  correlation  between  posterior   airway  dimensions  and  SDB

Airway  Volume  and  AHINo  significant  relationship  between  airway  size  and  treatment  efficacy  with  either  mandibular  advancement  device  or  tongue  stabilizing  device

Sutherland  K  (2011).  Sleep 34:469-­‐477.  Fig  6

Missing  Link� Assessment  of  airway  size  after  treatment  not  most  useful  outcome

� Need  data  on  association  between  premolar  extractions  and  SDB  confirmed  by  PSG

Premolar  Extractions  &  OSA� Review  of  electronic  medical  and  dental  health  records  of  HealthPartners  in  MN

� N=5,584� Cases:  50%   (2,792)  -­‐ missing  one  premolar/quadrant� Controls:  50%  -­‐ no  missing  premolars� Matched   1:1  on  age,  gender,   BMI   categories   (normal,  overweight,   obese,   unknown)

� Age  groups:  40-­‐49  yrs,  50-­‐59  yrs,  60-­‐70  yrs� Outcome:    prevalence  of  OSA  (confirmed  by  PSG)

Larsen  AJ  et  al.  (2016).  J  ClinSleep  Med  11(12):  1443-­‐1448.

Premolar  Extractions  &  OSAAssumptions:� If  missing  one  premolar/quadrant  and  no  more  than  one  other  missing  tooth  (except  for  3rd molars)  àorthodontic  treatment

� Likelihood  of  being  referred  for  PSG  to  rule  out  OSA  same  in  both  case  and  contol groups

Larsen  AJ  et  al.  (2016).  J  ClinSleep  Med  11(12):  1443-­‐1448.

Premolar  Extractions  &  OSA:  Results%

Female 35%Age Group

40-­‐49  yrs50-­‐59  yrs60-­‐70  yrs

43%40%17%

BMI  category  (kg/m2)<  2525  -­‐ <3030+Unknown  

26%26%23%25%

� Prevalence  of  OSA� Controls:  9.56%� Cases:  10.71%

� Prevalence  of  OSA  not  significantly  different  between  groups  (OR  =  1.14,  p  =  .144)

Larsen AJ et al. (2016). J Clin Sleep Med 11(12): 1443-1448.)

Due to 1:1 matching, subject characteristics identical between Cases and Controls

Premolar  Extractions  &  OSA:  Conclusion

Extraction  of  premolars  is  not  a  risk  factor  in  development  of  OSA

Conclusions� Orthodontic  treatment  modalities  have  been  described  to  manage  pediatric  SDB

� Much  research  is  still  needed  to  clarify� Appropriate   procedures� Optimal   age� Outcomes:   Cognitive,   behavioral,   cardiovascular,   effect  on  airway   and   craniofacial   growth  and   development

� Treatment  protocols  need  to  be  established

AAO  Donated  Orthodontic  Services  (DOS)  Program

All   that  is  missing   is  You!

• Introduced  in  2009,  the  DOS  program  provides  access  to  care  for  children  in  need.    Access  to  quality   orthodontic  care  is  missing   in  many   children’s  lives.    The  AAO   DOS   program  mission   is  to  serve  indigent  children  without  insurance  coverage  or  that  do  not  qualify   for  other  assistance  in  their  state  of  residence.    

• The  program   has  expanded  and  offers  care  to  children  nationwide  in  addition  to  the    recognized  state  programs  in  Illinois,   Indiana,   Kansas,   Michigan,   New  Jersey,  North  Carolina,  Rhode  Island,   Tennessee,  Texas  and  Virginia.    

• In  order  to  expand  further,  we  need  you  to  help  us  by  volunteering  to  serve  as  a   provider  orthodontist  or  help  identify  orthodontists  willing  to  lead  efforts  to  establish  a   DOS   chapter  in  your  state.    

• Stop  by  the  DOS   booth  here  in  San  Diego  to  learn  more  about  the  program  or  contact  Ann  Sebaugh   at  asebaugh@aaortho.org with  questions.    

The  AAO  Foundation,  the  charitable  arm  of  the American  Association  of  

Orthodontists,  provides  support  to  orthodontic  education  programs  and  orthodontic  research

If  Your  Passion  is  Orthodontics…

Then  pledge,  or  increase  your  pledge,  to  the  AAO  Foundation

Ensure  the  future  of  orthodontics

� As  a   practicing  orthodontic  specialist,  you  are  passionate  about  every   aspect  of  your  professional  life.  From  day-­‐to-­‐day  clinical   experience   to  community  relations   to  keeping  abreast  of  the  latest  in  innovative   treatment  options,  orthodontics  is  your  life.

� Qualified   teachers,   scholars  and  researchers   have   been  the  backbone  of  our  specialty.    The  AAOF  is   committed  to  promoting  education  for  our  profession  and  ensuring  the  continuance  of  our  specialty.

� You  can  help  to  improve  the  picture  for  orthodontics  today  by  pledging  or  renewing  your  pledge  to  the  AAOF.  

� There  is   no  better  way  to  communicate  your  professional  dedication  while  ensuring  the  ongoing  vitality  of  our  specialty.

� To  contribute  or  discuss  giving  options,  please   call   Mr.  Robert  W.  Hazel  at  800-­‐424-­‐2841,  ext.  246  at  the  AAOF  offices  in  St.  Louis.    

� Share  the  passion  and  give  back  to  the  profession  that  has  given  so  much  to  you.