Changes in airway patency and sleep-breathing in healthy skeletal Class II children undergoing functional Activator therapy

Introduction: Several studies agree that an abnormal maxilla-mandible relationship correlates better as an Obstructive Sleep Apnea (OSA) predictor, rather than obesity. One of the orthodontic therapies recommended for this kind of craniofacial deformity is to advance the mandible forward with an orthodontic activator, therefore, the aim of this study is to determine if healthy children that use this appliance experience a widening of the upper airway as well as an improvement in their sleep-breathing patterns. Materials and methods: 39 healthy children, 20 for activator group (10 boys and 10 girls, 4 mean age 10.9 + 0.9; BMI 16.2 + 1.4), 19 for control group (13 boys and 6 girls, mean age 5 9.8 + 1.4; BMI 17.6 + 2.1) participated in this study. They were required to submit 2 lateral cephalometric radiographs both at initial and final stages of evaluation, and finally three athome sleep-breathing monitoring results for the activator group and one for the control group. Results: After radiographic evaluation, it was found that children in the activator group experienced an increase in all measured variables. After evaluation with the sleep monitor, an improvement of sleep-breathing was found in children from the activator group (p<0.05). Conclusion: The activator not only provides a harmonious occlusion and proper development of the mandible, but it also helps improve the quality of sleep–breathing through widening of the upper airway and reducing the number of disordered breathing events in children that undergo this therapy.

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  • 1. Gottlieb DJ, Chase C, Vezina RM, Heeren TC, Corwin MJ, Auerbach SH, Weese–Mayer DE, Lesko SM. Sleep–disordered breathing symptoms are associated with poorer cognitive function in 5–year–old children. J Pediatr. 2004; 145(4):458–64.
  • 2. Stone RS, Spiegel JH. Prevalence of obstructive sleep disturbance in children with failure to thrive. J Otolaryngol Head Neck Surg. 2009; 38(5):573–79.
  • 3. Dayyat E, Kheirandish–Gozal L, Sans Capdevila O, Maarafeya MMA, Gozal D. Obstructive sleep apnea in children: relative contributions of body mass index and adenotonsillar hypertrophy. Chest. 2009; 136(1):137–44.
  • 4. Zhong Z, Tang Z, Gao X, Zeng XL. A comparison study of upper airway among different skeletal craniofacial patterns in non–snoring Chinese children. Angle Orthod. 2010; 80(2):267–74. 5. Yoshiike N, Miyoshi M. Epidemilogical aspects of overweight and obesity in Japan-International comparisons. Nihon Rinsho. 2013;71 (2):207-16.
  • 6. Tanaka H, Kokubo Y. Epidemiology of Obesity in Japan. JMAJ 48(1): 34–41, 2005
  • 7. Endo A, Mataki S, Kurosaki N. Cephalometric evaluation of craniofacial and upper airway structure in Japanese patients with obstructive sleep apnea. J Med Dent Sci. 2003; 50:109–20.
  • 8. Trenouth MJ, Timms DJ. Relationship of the functional oropharynx to craniofacial morphology. Angle Orthod. 1999; 69(5):419–23.
  • 9. Okubo M, Suzuki M, Horiuchi A, Okabe S, Ikeda K, Higano S, Mitani H, Hida W, Kobayashi T, Sugawara J. Morphologic analyses of mandible and upper airway soft tissue by mri of patients with Obstructive Sleep Apnea Hypopnea Syndrome. Sleep, 2006; 29 (7):909–15.
  • 10. Subramani Y, Singh M, Wong J, Kushida CA, Malhotra A, Chung F. Understanding phenotypes of obstructive sleep apnea: applications in anesthesia, surgery, and perioperative medicine. Anesth Analg. 2017; 124(1):179–91.
  • 11. Brouillette RT, Fernbach SK, Hunt SE. Obstructive sleep apnea in infants and children. J Pediatr. 1982; 100:31–40.
  • 12. Teculescu DB, Caillier I, Perrin P, Rebstock E, Rauch A. Snoring in French pre–school children. Pediatr Pulmonol. 1992; 13:239–44.
  • 13. Suen JS, Arnold JE Brooks LJ. Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg. 1995; 121:525–30.
  • 14. Villa MP, Bernkopt E, Pagani, Broia V, Montesano M, Ronchetti R. Randomized Controlled Study of an Oral Jaw–Positioning Appliance for the Treatment of Obstructive Sleep Apnea in Children with Malocclusion. Am J Respir Crit Care Med. 2002; 165(1):123–27.
  • 15. Schütz TC, Dominguez GC, Hallinan MP, Cunha TC, Tufik S. Class II correction improves nocturnal breathing in adolescents. Angle Orthod. 2011; 81(2):222–28.
  • 16. Restrepo C, Santamaria A, Peláez S, Tapias A. Oropharyngeal airway dimensions after treatment with functional appliances in class ll retrognathic children. J Oral Rehabil. 2011; 38(8):588-94.
  • 17. Ozbek MM, Memikoglu TU, Göhen H, Lowe AA, Baspinar E. Oropharyngeal airway dimensions and functional orthopedic treatment in skeletal Class II cases. Angle Orthod. 1998; 68(4): 327-36.
  • 18. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991; 14(6): 540–45.
  • 19. Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep–disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med. 2000; 1(1):21–32.
  • 20. Iwamoto T, Takata Y, Kitamura N, Hasebe D, Kobayashi T, Saito C. Prognostic predictors on the efficacy of oral appliance therapy for obstructive sleep apnea syndrome. Open J Stomatology. 2012; 2(3):201–21.
  • 21. Trenouth MJ. A comparison of Twin Block, Andresen and Removable appliances in the treatment of Class II Division I malocclusion. Funct Orthod. 1992; 9:26–31.
  • 22. Pancherz H. The effects, limitations, and long–term dentofacial adaptations to treatment with the Herbst appliance. Semin Orthod. 1997; 3(4):232–43. . 23. Trenouth MJ, Mew J. A cephalometric evaluation of the Biobloc technique using matched normative data. J Orofac Orthop. 2001; 62:466–75.
  • 24. Yassei S, Tabatabaei Z, Ghafurirfard R. Stability of pharyngeal airway dimensions, tongue and hyoid changes after treatment with a functional appliance. IJO. 2012; 23(1):9–15.
  • 25. Liu Y, Zeng X, Fu M, Huang X, Lowe AA. Effects of a mandibular repositioner on obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 2000; 118(3):248–56.
  • 26. Isono S, Tanaka A, Tagaito Y, Sho Y, Nishino T. Pharyngeal potency in response to advancement of the mandible in obese anesthetized persons. Anesthesiology. 1997; 87: 1055–62
  • 27. Horihata A, Ueda H, Koh M, Watanabe G, Tanne K. Enhanced increase in pharyngeal airway size in Japanese class II children following a 1–year treatment with an activator appliance. Int J Orthod Milwaukee. 2013; 24(4):35–40.
  • 28. Tsuiki S, Lowe AA, Almeida FR, Fleetham JA. Effects of an anteriorly titrated mandibular position on awake airway and obstructive sleep apnea severity. Am J Orthod Dentofacial Orthop. 2004; 125:548–55
  • 29. Poon KH, Chay SH, Choing K. Airway and craniofacial changes with mandibular advancement device in Chinese with obstructive sleep Apnoea. Ann Acad Med Singapore. 2008; 37(8):637–44.
  • 30. Shepard JW, Tawley SE. Localization of upper airway collapse during sleep in patients with obstructive sleep apnea. Am Rev Respir Dis. 1985; 132:211–15.
  • 31. Mills, JR. The effect of functional appliances in the skeletal pattern. Br J Orthod. 1991; 18(4):267–75.
  • 32. Santamaría–Villegas A, Manrique–Hernández R, Álvarez–Varela E, Restrepo–Serna C. Effect of removable functional appliances on mandibular length in patients with class II with retrognathism: systematic review and meta–analysis. BMC Oral Health. 2017; 17:52.
  • 33. Koretsi V, Zymperdikas VF, Papageorgiou SN, Papadopoulos MS. Treatment effects of removable functional appliances in patients with Class II malocclusion: a systematic review and meta–analysis. Eur J Ortho. 2015; 37(4):418–34
  • 34. Shayeb ME, Topfer LA, Stafinski T, Pawluk L, Menon D. Diagnostic accuracy of level 3 portable sleep tests versus level 1 polysomnography for sleep–disordered breathing: a systematic review and meta–analysis. CMAJ. 2014; 186(1):25–51.
  • 35. Hosoya H, Kawanabe H, Fukui K. A case of polysomnographic changes using a Twin–Block appliance in a child with maxillary protrusion. J of Dental Sleep Med. 2016; 3(2):71–72.
  • 36. Medina CC, Ueda H, Matsumura Y, Iwai k, Sumi K, Tanimoto K. A case of sleep–breathing changes achieved using the Andresen activator in a child with maxillary protrusion. J of Dental Sleep Med. 2017; 4(3):71–75.