Mini-implant assisted rapid palatal expansion (MARPE) effects on adult obstructive sleep apnea (OSA) and quality of life: a multi-center prospective controlled trial

Interdisciplinary Role of Orthodontist in Screening and Managing Obstructive Sleep Apnea in Children and Adults

Obstructive sleep apnea (OSA) can affect children and adults, and, if left untreated, could have a major impact on the general and overall well-being of the patient. Dental health care providers and orthodontists have an interdisciplinary role in screening patients at risk for OSA and make a referral to establish a definitive diagnosis by a sleep physician. The gold standard of diagnostic testing is polysomnography. The adeno-tonsillar hypertrophy is the primary cause of sleep apnea in children; therefore, adeno-tonsillectomy must be the first line of treatment. Post adeno-tonsillectomy, if there is residual OSA due to underlying skeletal discrepancy, the patient may be referred to an orthodontist for appropriate management. Currently the evidence in the literature for prophylactic growth modification in children to prevent OSA is weak. In adults, the gold standard for managing OSA is Positive Airway Pressure (PAP) therapy; however, adherence to this treatment is rather low. The oral appliance (OA) therapy is an alternate for PAP intolerant patients and for mild to moderate OSA patients. The OA therapy has to be administered by a qualified dentist or orthodontist after careful examination of dental and periodontal health as well as any pre-existing joint conditions. The OA therapy could cause OA-associated malocclusion and patients have to be made aware of prior to initiating treatment. In patients with severe OSA, surgical maxilla-mandibular advancement (MMA) is highly effective.

Does Miniscrew-Assisted Rapid Palatal Expansion Influence Upper Airway in Adult Patients? A Scoping Review

(1) Objective: This scoping review evaluates the effects of miniscrew-assisted rapid palatal expansion (MARPE) on different regions of the upper airway in adult patients and investigates various methods of measurement. (2) Methods: The search encompassed Pubmed, Cochrane Library, Scopus and Web of Science. This review was conducted following the PRISMA_ScR guidelines, and the inclusion criteria for examined studies were chosen in accordance with the PICOS framework. (3) Results: Seven studies were included in this review, comprising four retrospective studies, one prospective and two case reports. All studies involved the use of Cone Beam Computed Tomography (CBCT) for measurements of the areas of interest. The percentage of increase in the volume of the nasal cavity varied between 31% and 9.9%, depending on the study. Volumetric variations in the nasopharynx were reported as increases between T0 (before expansion) and T1 (immediately after expansion) of 6.4%, 20.7% and 14.1%. All studies considered T0 before expansion and T1 immediately after expansion. Only one study evaluated remote follow-up to assess if the results were maintained after one year. (4) Conclusions: MARPE appears to lead to a statistically significant increase in the upper airway, especially in the nasal cavity and nasopharynx immediately after expansion. However, further prospective and retrospective trails with long-term controls are required to verify the effects of MARPE on the upper airway.

Controversies in Sleep Apnea

This chapter discusses controversies in diagnosis and management of obstructive sleep apnea (OSA), with particular focus on surgical management to improve quality of life. Though OSA is a complex disorder that affects millions of people worldwide, its management remains controversial among clinicians. Gaps in understanding its pathophysiology, long-term health consequences, diagnostic methods, and treatment strategies exist. While continuous positive airway pressure (CPAP) therapy is considered the gold standard for moderate to severe obstructive sleep apnea (OSA), its adherence rate is often low, and its efficacy in improving outcomes beyond symptom reduction and quality of life improvement is uncertain. As such, surgical intervention may be an alternative for specific patient populations. Additionally, the type of surgical intervention may depend on individual patient needs, anatomic features, as well as preferences.

Evolution, current status, and future trends of maxillary skeletal expansion: a bibliometric analysis

OBJECTIVES

The study aims to conduct a bibliometric analysis on maxillary skeletal expansion to elucidate the evolution and current status and predict future research hotspots and trends.

MATERIAL AND METHODS

A search was conducted in the Web of Science Core Collection at the University of Hong Kong's electronic library using the query "(TS = maxillary expansion) AND (TS = skeletal expansion)." The resulting literature data were imported into CiteSpace 6.2.R4 and VOS viewer software to analyze authorship, countries, institutions, keywords, etc. RESULTS: A total of 923 articles were analyzed. The research in this field has shown a steady growth, with a significant increase since 2019. The USA and Italy have played prominent roles in contributing to the publication volume and strengthening collaborative exchanges. Clustering labels provide directions for in-depth analysis of the literature.

CONCLUSIONS

(1) MARPE (miniscrew-assisted rapid palatal expansion) and SARME (surgically assisted rapid maxillary expansion) have gained widespread attention and become research hotspots due to their applicability in adults whose growth and development have ceased, while still producing favorable skeletal effects. (2) In addition to widening the maxillary arch, maxillary expansion techniques have shown significant effects on increasing nasal cavity width and volume. However, there is still controversy regarding whether they can effectively improve the deviated nasal septum. (3) Maxillary skeletal expansion techniques have been shown to increase upper airway volume and improve breathing, making them potentially valuable in the treatment of obstructive sleep apnea (OSA).

CLINICAL RELEVANCE

This study can provide cutting-edge clinical recommendations for healthcare professionals to better formulate clinical strategies.

The short- and long-term changes of upper airway and alar in nongrowing patients treated with Mini-Implant Assisted Rapid Palatal Expansion (MARPE): a systematic review and meta-analysis

OBJECTIVE

This study aims to assess the short- and long-term changes in the upper airway and alar width after mini-implant -assisted rapid palatal expansion (MARPE) in nongrowing patients.

METHODS

Five electronic databases (PubMed, Scopus, Embase, Web of Science, and Cochrane Library) were searched up to 2 August, 2023 based on the PICOS principles. The main outcomes were classified into three groups: 1) nasal cavity changes, 2) upper airway changes and 3) alar changes. The mean difference (MD) and 95% confidence intervals (CI) were used to assess these changes. Heterogeneity tests, subgroup analyses, sensitivity analyses, and publication bias were also analyzed.

RESULT

Overall, 22 articles were included for data analysis. Nasal cavity width (WMD: 2.05 mm; 95% CI: 1.10, 3.00) and nasal floor width (WMD: 2.13 mm; 95% CI: 1.16, 3.11) increased significantly. While palatopharyngeal volume (WMD: 0.29 cm3, 95% CI: -0.44, 1.01), glossopharyngeal volume (WMD: 0.30 cm3, 95% CI: -0.29, 0.89) and hypopharyngeal volume (WMD: -0.90 cm3; 95% CI: -1.86, 0.06) remained unchanged, nasal cavity volume (WMD: 1.24 cm3, 95% CI: 0.68, 1.81), nasopharyngeal volume (MD: 0.75 cm3, 95% CI: 0.44, 1.06), oropharyngeal volume (WMD: 0.61 cm3, 95% CI: 0.35, 0.87), and total volume of the upper airway (WMD: 1.67 cm3, 95% CI: 0.68, 2.66) increased significantly. Alar width (WMD: 1.47 mm; 95% CI: 0.40, 2.55) and alar base width (WMD: 1.54 mm; 95% CI: 1.21, 1.87) also increased.

CONCLUSION

MARPE can increase nasal cavity width, nasal cavity volume, nasopharyngeal volume and oropharyngeal volume for nongrowing patients, but has no significant effect on hypopharyngeal volume. In addition, the alar width also increased. However, the studies included in this meta-analysis were mainly retrospective, nonrandomized and small in number, so the findings should be interpreted with caution and high-quality RCTs need to be studied.

Near-Infrared Light-Controlled MicroRNA-21-Loaded Upconversion Nanoparticles to Promote Bone Formation in the Midpalatal Suture

Rapid maxillary expansion (RME) is a common therapy for maxillary transverse deficiency. However, relapses after RME usually occur because of insufficient bone formation. MicroRNA-21 (miR-21) was reported as an important post-transcriptional modulator for osteogenesis. Herein, a photocontrolled miR-21 (PC-miR-21)-loaded nanosystem using upconversion nanoparticles (UCNPs) modified with poly(ether imide) (PEI), i.e., UCNPs@PEI@PC-miR-21, was constructed to promote bone formation in the midpalatal suture. UCNPs@PEI was constructed as the light transducer and delivery carrier. The UCNPs@PEI@PC-miR-21 nanocomplexes have good aqueous dispersibility and biocompatibility. The in vitro cell experiment suggested that UCNPs@PEI could protect PC-miR-21 from biodegradation and release PC-miR-21 into the cytoplasm under near-infrared light (NIR) irradiation. Furthermore, UCNPs@PEI@PC-miR-21 upregulated the expression of the osteogenic key markers, ALP, RUNX2, and COL1A1, at the levels of both genes and proteins. Besides, the results of the in vivo RME mice models further corroborated that photocontrollable UCNPs@PEI@PC-miR-21 accelerated bone formation with upregulating osteogenic markers of ALP, RUNX2, and osteoprotegerin and inducing fewer osteoclasts formation. In conclusion, UCNPs@PEI@PC-miR-21 nanoparticles with a NIR light could facilitate the remote and precise delivery of exogenous miR-21 to the midpalatal suture to promote bone formation during RME. This work represents a cutting-edge approach of gene therapy to promote osteogenesis in the midpalatal suture during RME and provides a frontier scientific basis for later clinical treatment.

Immediate dentoskeletal and periodontal effects of miniscrew-assisted rapid palatal expansion: Comparison between young vs middle-aged adults

INTRODUCTION

This study aimed to compare the dentoskeletal and periodontal changes after miniscrew-assisted rapid palatal expansion (MARPE) in patients aged 18-29 and 30-45 years.

METHODS

The sample comprised 28 subjects with transverse maxillary discrepancy successfully treated with MARPE. The young adult (YA) group comprised 14 subjects (mean age, 22.8 years; 3 male, 11 female). The middle adult (MA) group comprised 14 subjects (mean age, 36.8 years; 6 male, 8 female). All patients were treated with a 4-miniscrew MARPE expander. The activation protocol was one quarter turn twice a day until the midline diastema opening, followed by one quarter turn a day until overcorrection. Cone-beam computed tomography (CBCT) scans taken before and immediately after the expansion was analyzed using OnDemand3D Dental software. Using CBCT coronal images, transversal dentoskeletal and periodontal variables were measured in the preexpansion and postexpansion. Intergroup comparisons of expansion changes were performed using t and Mann-Whitney tests (P <0.05).

RESULTS

Groups were compatible at preexpansion for most CBCT measurements. A success rate of midpalatal suture opening of 100% and 81% was observed for YA and MA groups, respectively. No intergroup differences were found for the maxillary and dental arch widths increases. The buccal tip of anchorage teeth was observed similarly in both groups. The buccal bone thickness of posterior teeth decreased, and the palatal bone thickness increased after expansion with no difference between groups.

CONCLUSIONS

After MARPE, the MA group showed similar dentoskeletal and periodontal changes compared to the YA group.

Global trends and hotspots on childhood obstructive sleep apnea: a 10-year bibliometric analysis

Background

Obstructive sleep apnea (OSA) is children's most common sleep-related breathing disorder. It may develop a wide range of severe complications if not diagnosed promptly and treated effectively. However, Childhood OSA has not specifically been analyzed using a bibliometric approach.

Methods

We respectively collected the research results of childhood OSA from 2013 to 2022 through Web of Science and PubMed. Vosviewer, CiteSpace, and bibliometric online analysis platforms were used for visualizing and analyzing the literature. The MeSH terms were bi-clustered using the Bibliographic Item co-occurrence Matrix Builder (BICOMB) and graph clustering toolkit (gCLUTO) to identify the hotspots.

Results

4022 publications were finally identified on childhood OSA from 2013 to 2022. The United States has the largest number of publications (1902), accounting for 47.29%. University of Cincinnati is the most productive organization (196), followed by the University of Pennsylvania (151). The most prolific journal was the International Journal of Pediatric Otorhinolaryngology, with 311 documents published. In comparison, Pediatrics is the most cited journal (6936). Gozal D ranked highest among all authors in publication (192). Burst detection shows continuous positive airway pressure, Robin sequence, and nocturnal oximetry are recent keywords of great interest to researchers. Five hotspots were identified by co-word biclustering.

Conclusion

Research over the past ten years has been fruitful, establishing the foundation for childhood OSA. Clusters (0-4) of high-frequency Major Mesh topics have attracted extensive attention. Evaluation and treatment methods of childhood OSA remain major focuses. We believe this article will provide other researchers with new directions and may contribute to a future breakthrough in this field.

Retrospective Analysis of Real-World Data for the Treatment of Obstructive Sleep Apnea with Slow Maxillary Expansion Using a Unique Expansion Dental Appliance (DNA)

In addition to mandibular advancement devices, dental expansion appliances are an important clinical approach for achieving an increased intra-oral space that promotes airflow and lessens the frequency or severity of apneic events in patients diagnosed with obstructive sleep apnea (OSA). It has been thought that dental expansion in adults must be preceded by oral surgery; however, in this paper, we examine the results of a new technique for slow maxillary expansion without any surgical procedures. The palatal expansion device, DNA (Daytime-Nighttime Appliance), was reviewed in this retrospective study, particularly regarding its effects on measurements of transpalatal width, airway volume, and apnea-hypopnea indices (AHI) as well as its common modalities and complications. The DNA effectively reduced AHI by 46% (p = 0.00001) and significantly increased both airway volume and transpalatal width (p < 0.00001). After DNA treatment, 80% of patients showed some improvement in AHI scores with 28% of patients having their OSA symptoms completely resolved. Compared to the use of mandibular appliances, this approach is intended to create a sustained improvement in airway management that can reduce or eliminate dependence on continuous positive airway pressure (CPAP) or other OSA treatment devices.

Three-Dimensional Evaluation Effects of Microimplant-Assisted Rapid Palatal Expansion on the Upper Airway Volume: A Systematic Review and Meta-Analysis

Microimplant-assisted rapid palatal expansion is increasingly used clinically; however, the effect on the upper airway volume in patients with maxillary transverse deficiency has not been thoroughly evaluated yet. The following electronic databases were searched up to August 2022: Medline via Ovid, Scopus, Embase, Web of Science, Cochrane Library, Google Scholar, and ProQuest. The reference lists of related articles were also reviewed by manual search. The Revised Cochrane Risk of Bias Tool for randomized trials (ROB2) and the Risk of Bias in non-randomized Studies of Interventions (ROBINS-I) tool were used to evaluate the risks of bias of the included studies. The mean differences (MD) and 95% confidence intervals (CI) of changes in nasal cavity and upper airway volume were analyzed using a random-effects model, and subgroup and sensitivity analyses were also performed. Two reviewers independently completed the process of screening studies, extracting data, and assessing the quality of studies. In total, twenty-one studies met the inclusion criteria. After assessing the full texts, only thirteen studies were included, with nine studies selected for quantitative synthesis. Oropharynx volume increased significantly after immediate expansion (WMD: 3156.84; 95% CI: 83.63, 6230.06); however, there was no significant change in nasal volume (WMD: 2527.23; 95% CI: -92.53, 5147.00) and nasopharynx volume (WMD: 1138.29; 95% CI: -52.04, 2328.61). After retention a period, significant increases were found in nasal volume (WMD: 3646.27; 95% CI: 1082.77, 6209.77) and nasopharynx volume (WMD: 1021.10; 95% CI: 597.11, 1445.08). However, there was no significant change after retention in oropharynx volume (WMD: 789.26; 95% CI: -171.25, 1749.76), palatopharynx volume (WMD: 795.13; 95% CI: -583.97, 2174.22), glossopharynx volume (WMD: 184.50; 95% CI: -1745.97, 2114.96), and hypopharynx volume (WMD: 39.85; 95% CI: -809.77, 889.46). MARPE appears to be linked with long-term increases in nasal and nasopharyngeal volume. However, high-quality clinical trials are required to further verify the effects of MARPE treatment on the upper airway.

Obstructive sleep apnea: a review for the orthodontist

INTRODUCTION

Obstructive sleep apnea (OSA) affects an important part of the population and is characterized by recurrent total or partial obstruction of the upper airway (UA) during sleep, negatively affecting the quality of life of patients in the short and long terms, and constituting an important public health problem for the society. The field of expertise of orthodontists is closely related to the UA, placing them in a strategic position to diagnose air passage failures and intervene when necessary. Orthodontists, as health professionals, must know how to recognize respiratory problems and manage them appropriately, when indicated.

OBJECTIVE

Thus, this paper aims to review and critically evaluate the related literature, to provide orthodontists with updated knowledge on the diagnosis and therapy related to OSA. Science and technology are constantly evolving; thus, the literature was also reviewed considering new technologies available in consumer-targeted applications and devices for the diagnosis, monitoring, and treatment of sleep-disordered breathing.

Dimensional changes of upper airway after slow vs rapid miniscrew-supported maxillary expansion in adolescents: a cone-beam computed tomography study

BACKGROUND

To date, the effects of different activation rates of miniscrew-supported expanders on the airway have not been compared. Hence, the purpose of this retrospective study was to evaluate and compare the effects of slow and rapid miniscrew-supported maxillary expansion on the upper airway dimensions using cone-beam computed tomography (CBCT).

METHODS

Data of 20 patients (Age 12 to 16 years old) treated using miniscrew-supported expanders at the Faculty of Dentistry, Alexandria University was collected. The patients were equally divided into two groups according to the activation protocol; slow maxillary expansion (SME): activation once every other day, and rapid maxillary expansion (RME): activation twice daily. CBCT scans obtained pre-expansion and 5 months post-expansion were used to evaluate the changes in the upper airway dimensions. Comparisons between the two time points within each group were done using paired samples t-test. SME and RME groups were compared using independent samples t-test. Significance level was set at p < 0.05.

RESULTS

Both groups showed a significant increase in anterior, middle, and posterior nasal cavity width. SME resulted in significantly greater increase of the anterior nasal cavity width than RME (Mean difference between the groups, 2.64 mm; 95% CI, 0.83, 4.45; p = 0.007). The dimensions of the retropalatal and retroglossal airways did not change significantly in either group. Both groups resulted in a significant increase of maxillary width, palatal width, and inter-molar width. RME showed a significantly larger increase of inter-molar width than SME (Mean difference between the groups, - 2.44 mm; 95% CI, - 3.88, - 1.00; p = 0.002).

CONCLUSIONS

The use of either a slow or rapid activation protocol is effective in expanding the nasomaxillary complex, with greater expansion achieved in the anterior section of the nasal cavity using the slow rate. However, the expander design employed in the current study does not affect the dimensions of the retropalatal or retroglossal airways.