Aims: Review of evidence in support of an oral-facial growth impairment in the development of pediatric sleep apnea in non-obese children.

Method: Review of experimental data from infant monkeys with experimentally induced nasal resistance. Review of early historical data in the orthodontic literature indicating the abnormal oral-facial development associated with mouth breathing and nasal resistance. Review of the progressive demonstration of sleep-disordered-breathing (SDB) in children who underwent incomplete treatment of OSA with adenotonsillectomy, and demonstration of abnormal oral-facial anatomy that must often be treated in order for the resolution of OSA. Review of data of long-term recurrence of OSA and indication of oral-facial myofunctional dysfunction in association with the recurrence of OSA.

Results: Presentation of prospective data on premature infants and SDB-treated children, supporting the concept of oral-facial hypotonia. Presentation of evidence supporting hypotonia as a primary element in the development of oral-facial anatomic abnormalities leading to abnormal breathing during sleep. Continuous interaction between oral-facial muscle tone, maxillary-mandibular growth and development of SDB. Role of myofunctional reeducation with orthodontics and elimination of upper airway soft tissue in the treatment of non-obese SDB children.

Conclusion: Pediatric OSA in non-obese children is a disorder of oral-facial growth.


Since obstructive sleep apnea syndrome (OSAS) first was reported in children in Guilleminault et al. (1976), recognition of abnormal breathing during sleep has progressed. Prior to the introduction of the nasal cannula-pressure transducer (Serebrisky et al., 2002), thermistors were used to score abnormal breathing during sleep in association with esophageal manometry (Pes). The nasal cannula- pressure transducer is more accurate than its predecessor, and it allows for recognition of the “flow limitation” breathing pattern. This pattern is associated with an abnormal increase or decrease in respiratory effort associated with EEG changes that occur during sleep disturbances (Hosselet et al., 1998; Aittokallio et al., 2001; Lin and Guilleminault, 2011). These sleep EEG changes were also shown to be better recognized using the “cyclic alternating pat- tern” (CAP) scoring system, a visual scoring system commonly used in Europe and Latin America (Terzano et al., 2002). This visual scoring system recognizes sleep disturbances, particularly arousals indicative of sleep disruption, better than the most commonly used atlas, which requires disturbances to occur for at least 3 s to be scored. More accurate approaches have been used, such as computerized analyses of the sleep EEG based on specific algorithms (Chervin et al., 2004) or using well-known EEG analysis programs (e.g., fast-Fourier Transform, Wavelet, and Hiller– Huang Transform programs). Usage of these recording techniques has improved recognition of Sleep-Disordered-Breathing (SDB).  Poor tolerance of early cases of children treated with tracheostomy and home nasal CPAP (Sullivan et al., 1981) led to the advent of maxillomandibular advancement (MMA) surgery as a procedure designed to target more specifically the upper air- way (Powell et al., 1983). Follow-up of one case for more than 25 years post-MMA demonstrated lasting and complete resolution of OSAS.


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