Efficacy of a Pre-Fabricated Myofunctional Appliance for the Treatment of Mild to Moderate Pediatric Obstructive Sleep Apnea: A Preliminary Report

Orofacial Myofunctional Therapy for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis

OBJECTIVE

Orofacial myofunctional therapy (OMT) is an alternative form of treatment of obstructive sleep apnea (OSA), that incorporates various exercises to optimize tongue placement and increase oropharyngeal tone. The objective of this systematic review and meta-analysis is to determine the efficacy of OMT in OSA patients.

DATA SOURCES

PubMed/Medline, EMBASE, Cochrane, Web of Science.

REVIEW METHODS

Using PRISMA guidelines, a directed search strategy was performed for randomized control trials (RCTs) published prior to March 24, 2023, featuring 10+ patients with OSA undergoing mono-therapeutic OMT. The primary outcome of interest was apnea-hypopnea index (AHI). Secondary outcomes included subjective sleepiness, sleep-related quality-of-life, and snoring frequency.

RESULTS

Of the 1244 abstracts that were identified, 7 RCTs involving 310 patients met inclusion criteria. Adult OMT patients had a statistically significant improvement in AHI (MD -10.2; 95% CI, -15.6, -4.8, p < 0.05), subjective sleepiness (Epworth Sleepiness Scale; MD -5.66; 95% CI, -6.82, -4.5, p < 0.05), sleep-related quality-of-life (Pittsburgh Sleep Quality Index; MD -3.00; 95% CI, -4.52, -1.49, p < 0.05), and minimum oxygen saturation (MD 2.71; 95% CI, 0.23, 5.18, p < 0.05) when compared with sham OMT or no therapy. Within the single RCT featuring pediatric OMT patients, patients had poor compliance (<50%) and did not show any improvements in AHI, minimum oxygen saturation, or snoring frequency.

CONCLUSION

OMT may provide a reasonable alternative for OSA patients who cannot tolerate CPAP or other more established treatment options. OMT benefits appear limited in children due to poor compliance. More studies are required to evaluate compliance and the long-term effects of OMT on OSA outcomes.

LEVEL OF EVIDENCE

1 Laryngoscope, 134:480-495, 2024.

Mandibular Advancement Appliances in Pediatric Obstructive Sleep Apnea: An Umbrella Review

Introduction  Obstructive sleep apnea (OSA) is defined as intermittent partial or complete collapse of the upper airway during sleep. It is a common condition in childhood, with an incidence ranging from 1.2% to 5.7%, and it can harm several aspects of children's life, such as cognitive, metabolic and cardiovascular functions, among others. There are treatment options, such as adenotonsillectomy, myofunctional therapy, mandibular advancement appliances (MAAs), rapid maxillary expansion, and positive airway pressure devices, but there is still doubt about which method is more suitable for the treatment of OSA in children. Objective  To analyze the effectiveness of MAAs in the treatment of pediatric OSA. Materials and Methods  The search was conducted in August 2021 in different electronic databases, such as PubMed, EBSCO (Dentistry & Oral Sciences Source), LILACS, Ovid, SciELO, Web of Science, EMBASE BIREME, BBO BIREME, and the Cochrane Library. Results  Only three systematic reviews and two meta-analyses were included in the present study. All studies showed improvement in the score on the apnea-hypopnea index after using MAAs in the treatment of pediatric OSA. Conclusion  Although more randomized studies are needed, based on the present umbrella review, MAAs must be considered part of the multidisciplinary treatment for pediatric OSA.

A non-randomized concurrent controlled trial of myofunctional treatment in the mixed dentition children with functional mouth breathing assessed by cephalometric radiographs and study models

OBJECTIVES

This study aimed to examine the clinical effects of myofunctional treatment on children with functional mouth breathing by cephalometric radiographs and study models.

METHODS

A total of 224 children (6-10 years old; 114 males and 110 females; SNA°: 82.24 ± 1.67°; ANB°: 2.79 ± 0.80°, 28° < SN-GoGn° < 37°) formed three groups: MB-M group (mouth breathers with myofunctional treatment,n = 75); MB-N group (mouth breathers with no treatment,n = 70); NB group (nasal breathers with no treatment, n = 79). A blind evaluation of cephalometric radiographs and study models was conducted at T1(pre-study) and T2 (post-study), respectively.

RESULTS

Two hundred four children (MB-M:66, MB-N:68, NB:70) completed the present study. At T1, MB-M and MB-N groups, compared to their NB counterpart, had greater anterior lower facial height(P < 0.01) and overjet(P < 0.001) but shorter overbite and maxillary canines width (P < 0.001). At T2, the MB-N group exhibited a higher ANB angle, anterior lower facial height, and overjet, but shorter overbite and maxillary canines width (P < 0.001). From T1 to T2, the anterior lower facial height increased, overbite and the maxillary canines width further decreased in the MB-N group (P < 0.001). However, in the MB-M group, the incisors were retracted, overbite increased (P < 0.001), anterior lower facial height increased insignificantly (P > 0.05), and maxillary canines width increased slightly (P < 0.05). In the NB and MB-M groups, the mandible showed a normal tendency to grow forward, whereas, in the MB-N group, the mandible showed a tendency to grow downward (P < 0.001).

CONCLUSIONS

Mouth breathers demonstrated increased anterior facial height and overjet but reduced overbite and maxillary arch width, which improved significantly following myofunctional treatment.

TRIAL REGISTRATION

TCTR: TCTR20220401001 . Registered 1stApril 2022-Retrospectively registered.

Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review

INTRODUCTION

Obstructive sleep apnea syndrome is a common condition in childhood and if left untreated can result in many health problems. An accurate diagnosis of the etiology is crucial for obstructive sleep apnea treatment success. Functional orthodontic appliances that stimulate mandibular growth by forward mandibular positioning are an alternative therapeutic option in growing patients.

OBJECTIVE

To perform a literature review about the effects of functional orthodontic appliances used to correct the mandibular deficiency in obstructive sleep apnea treatment.

METHODS

The literature search was conducted in June 2020 using Cochrane Library; PubMed, EBSCO (Dentistry & Oral Sciences Source), LILACS Ovid; SciELO Web of Science; EMBASE Bireme and BBO Bireme electronic databases. The search included papers published in English, until June 2020, whose methodology referred to the types and effects of functional orthopedic appliances on obstructive sleep apnea treatment in children.

RESULTS

The search strategy identified thirteen articles; only four articles were randomized clinical studies. All studies using the oral appliances or functional orthopedic appliances for obstructive sleep apnea in children resulted in improvements in the apnea-hypopnea index score. The cephalometric (2D) and tomographic (3D) evaluations revealed enlargement of the upper airway and increase in the upper airspace, improving the respiratory function in the short term.

CONCLUSION

Functional appliances may be an alternative treatment for obstructive sleep apnea, but it cannot be concluded that they are effective in treating pediatric obstructive sleep apnea. There are significant deficiencies in the existing evidence, mainly due to absence of control groups, small sample sizes, lack of randomization and no long-term results.

Effect of surgical intervention for mild childhood obstructive sleep apnoea on attention and behavioural outcomes: A randomized controlled study

BACKGROUND AND OBJECTIVE

We evaluated inattention and behavioural outcomes following surgery versus watchful waiting (WW) in school-aged children with mild obstructive sleep apnoea (OSA).

METHODS

A prospective randomized controlled study was performed in pre-pubertal children aged 6-11 years with polysomnography (PSG)-confirmed mild OSA. They were assigned randomly to early surgical intervention (ES) or WW. The surgical intervention consisting of tonsillectomy with or without adenoidectomy and turbinate reduction was carried out within 4-6 weeks after randomization. Both groups underwent PSG, attention and behavioural assessment and review by an otorhinolaryngologist at baseline and 9-month follow-up. The primary outcome was omission T score from Conners' continuous performance test (CPT). Secondary outcomes were parent-reported behaviours, quality of life, symptoms and PSG parameters.

RESULTS

A total of 114 participants were randomized. Data of 35 subjects from the ES and 36 from the WW group were available for final analysis. No significant treatment effect could be found in all CPT parameters and behavioural outcomes. Nevertheless, significantly greater reductions were seen in PSG parameters (obstructive apnoea-hypopnoea index [-1.4 ± 2.0 cf. +0.3 ± 4.1/h, p = 0.038] and arousal index [-1.3 ± 4.4 cf. +1.4 ± 4.5/h, p = 0.013]) and OSA-18 total symptom score (-17.3 ± 19.7 cf. -3.6 ± 14.1, p = 0.001) in the ES group. Subjects who underwent surgery also had significantly greater weight gain (+3.3 ± 2.1 cf. +2.2 ± 1.5 kg, p = 0.014) and increase in systolic blood pressure (+5.1 ± 12.4 cf. -1.2 ± 8.7 mm Hg, p = 0.016).

CONCLUSION

Despite improvements in PSG parameters and parent-reported symptoms, surgical treatment did not lead to parallel improvements in objective attention measures in school-aged children with mild OSA.

Effect of myofunctional therapy on children with obstructive sleep apnea: a meta-analysis

OBJECTIVE

To systematically review the current literature for articles describing the effect of myofunctional therapy on pediatric obstructive sleep apnea (OSA) and to perform a meta-analysis on the sleep study data.

METHODS

Three authors (A.B., K.K. and M.C.) independently searched from inception through April 20, 2020 in PubMed/MEDLINE, Scopus, Embase, Google Scholar and The Cochrane Library. Mean difference (MD), standard deviations and 95% confidence intervals were combined in the meta-analysis for apnea-hypopnea index (AHI), mean oxygen saturations, and lowest oxygen saturations (nadir O2).

RESULTS

10 studies with 241 patients met study criteria and were further analyzed. The AHI reduced from 4.32 (5.2) to 2.48 (4.0) events/hr, a 43% reduction. Random effects modeling demonstrated a mean difference in AHI of -1.54 (95% CI -2.24,-0.85)/hr, z-score is 4.36 (p < 0.0001). Mean oxygen saturation increased by 0.37 (95% CI 0.06,0.69) percent, z-score is 2.32 (p = 0.02). There was no significant increase in nadir O2.

CONCLUSIONS

Despite heterogeneity in exercises, myofunctional therapy decreased AHI by 43% in children, and increased mean oxygen saturations in children with mild to moderate OSA and can serve as an adjunct OSA treatment.

[The contribution of orofacial myofunctional reeducation to the treatment of obstructive sleep apnoea syndrome (OSA): a systematic review of the literature]

Obstructive sleep apnoea syndrome (OSA) is a widespread and under-diagnosed condition, making it a major public health and safety problem. Orofacial myofunctional reeducation (OMR) has been shown to be effective in the multidisciplinary treatment of OSA in children, adolescents and adults and is prescribed at several stages of OSA management. The main objective of this systematic literature review was to evaluate the effectiveness of active or passive orofacial myofunctional reeducation (OMR) in the treatment of obstructive sleep apnoea syndrome in children, adolescents and adults. The systematic literature review was undertaken from the three electronic databases: Medline (via PubMed), Cochrane Library, Web of Science Core Collection, and supplemented by a limited grey literature search (Google Scholar) in order to identify the studies evaluating the effectiveness of the OMR on OSA. The primary outcome of interest was a decrease in the Apnea-Hypopnea Index (AHI) of at least five episodes per hour compared to the baseline state. Secondary outcomes were an improvement in subjective sleep quality, sleep quality measured by night polysomnography and subjectively measured quality of life. Only ten studies met all the inclusion criteria. Eight were randomized controlled clinical trials, one was a prospective cohort study and another was a retrospective cohort study. Six studies were devoted to adult OSA and four to pediatric OSA. All included studies were assessed as "low risk of bias" based on the 12 bias risk criteria of the Cochrane Back Review Group. Based on the available evidence, RMO allows a significant reduction in AHI, up to 90.6% in children and up to 92.06% in adults. It significantly reduces the intensity and frequency of snoring, helps reduce daytime sleepiness, limits the recurrence of OSA symptoms after adenoamygdalectomy in children and improves adherence to PPC therapy. Passive RMO, with the assistance provided to the patient by wearing a custom orthosis, increases adherence to reeducation, significantly improves snoring intensity, AHI and significantly increases the upper airway. Published data show that orofacial myofunctional rééducation is effective in the multidisciplinary treatment of OSA in children, adolescents and adults and should be widely prescribed at several stages of OSA management. Passive RMO, with the pearl mandibular advancement orthosis designed by Michèle Hervy-Auboiron, helps to compensate for the frequent non-compliance observed during active RMO treatments.

Sleep Apnea throughout the First Two Years of Life: Assessment of the Effect of Pacifiers in Patients with ALTE

Background:

Apparent Life-Threatening Event (ALTE), Obstructive Sleep Apnea syndrome (OSAs) and Sudden Infant Death Syndrome (SIDS) are strongly correlated and few studies analyze the role that pacifiers play in such conditions.

Objective:

The aim of the study is to evaluate how pacifiers affect sleep apnea among children with a history of ALTE.

Methods:

10 subjects between 1 month and 2 years of age with a history of idiopathic ALTE were non-selectively recruited. Patients were subjected to cardio-respiratory monitoring at home for two consecutive nights; during the first night, the pacifier was not used, whereas the second night, the pacifier was used by the child for at least four hours sleep. Parents were given an assessment questionnaire to evaluate and report any irritation due to the pacifier use. All obtained traces were blindly analyzed by a pediatric specialist in sleep disorders, more specifically: Peripheral oxygen saturation (SpO2), heart rate (FC), Electrocardiogram (ECG) and the presence of apneas and/or hypopneas were assessed. In order to evaluate the differences between the average values collected from the two groups, a t-test was performed.

Results:

The use of the pacifier resulted in a statistically significant reduction in the number of pathological apneas/night (-1.7%;p= 0,0024), an improvement in the average SpO2(+ 0.8%;p= 0.3328) and an increase in the value of the minimum SpO2detected (+ 2%;p= 0.2571).

Conclusion:

The results show that the use of pacifiers improves the respiratory capacity of children that suffer from nocturnal apneas at night.