What are the dental and craniofacial characteristics of children with sleep apnoea (OSA)?
Obstructive Sleep Apnoea is a problem that may be related to the dentofacial characteristics of children. Therefore, it is important to identify these features as they may be potential treatment targets. This new systematic review identifies the characteristics of children with OSA.
The authors of this interesting paper provided us with a well-constructed literature review. They highlighted:
- The prevalence of childhood OSA ranges from 1-5% and peaks at the age of 2-8.
- Early detection and possible treatment are necessary
- The AAO white paper on OSA strongly recommended that orthodontists be familiar with the signs and symptoms of OSA and refer where necessary.
- Children with OSA may have clear signs of malocclusion that are reflected in an increased ANB, increased lower facial height and narrowed maxilla.
- There is limited evidence to suggest that malocclusion is associated with OSA.
A team from Wuhan, China, did this systematic review. The EJO published the paper.
Yanxiaoxue Liu et al. EJO advanced access: https://doi.org/10.1093/ejo/cjac074
What did they ask?
They undertook the review to answer the following;
“Is there an association between paediatric OSA and children’s dental and craniofacial characteristics”?
What did they do?
The inclusion criteria were;
Children less than 18 years old. The study group was children with OSA, who they compared with healthy children. OSA had to be diagnosed with overnight polysomnography. The outcomes were any craniofacial or dental characteristic detected by any method.
The authors decided to concentrate on ANB and overbite as the primary outcomes. However, they also included some secondary outcomes derived from a limited set of cephalometric and relevant dental measurements. For example, arch width, overjet and presence of crossbites.
They included cross-sectional studies in the review.
They followed the standard steps of electronic and hand searching—identification and filtering of papers followed by data extraction and meta-analysis. Two examiners then measured the risk of bias with the Joanna Briggs Institute critical appraisal checklist for cross-sectional studies. Finally, they classified the certainty of evidence using the GRADE evaluations tool.
What did they find?
They identified a final sample of 16 studies and included 14 in the meta-analysis. Interestingly, they excluded two papers because they were multiple publications of the same study.
When they looked at the risk of bias, most studies had an unclear risk of bias. Notably, the GRADE analysis revealed that there was a very low to low certainty for the outcomes. So, things aren’t looking too good at this point, but we shall press on.
The team presented a large amount of data on many outcome measures and relevant meta-analyses. They did an excellent job confining the amount of cephalometric data, which was great. However, I do not have enough space to analyse all this data. I thought that the main points were that children with OSA had greater;
- Overjet (mm) compared to the control group MD = 0.86, 95% CI: 0.20 to 1.51; P = 0.01)
- ANB angle; MD = 1.78, 95% CI: 1.04 to 2.52; P < 0.00001
- FH-MP and SN-MP angles; FH-MP angle; MD = 3.65, 95% CI: 2.45 to 4.85; P < 0.00001), (SN-MP angle; MD = 2.02, 95% CI: 0.91 to 3.13; P = 0.0004.
The OSA group had smaller inter-molar width than the control group; MD = −1.86, 95% CI: −3.52 to −0.20; P = 0.03).
Their overall conclusions were:
“Children with OSA had a decreased upper arch width, increased overjet, decreased mandibular growth, short hard palate and increased vertical growth”.
However, they also pointed out that the overall level of evidence was low. Most importantly, the statistically significant differences were minor.
What did I think?
Some readers will remember that we decided only to include interesting and scientifically sound systematic reviews in our posts. This was because we are under an onslaught of systematic reviews that add little to our knowledge. I decided to include this review because it was well written. Importantly, it attempted to answer a relevant and interesting clinical question. When I started reading the paper, I was concerned that I was heading for a “cephalometric festival of superfluous findings adding nothing” (CFSFAN). However, it was great that the authors confined their analysis to a few relevant measurements. As a result, I thought that the review was a good addition to knowledge.
When I looked at the results, I saw that they reinforced our clinical impression that children with OSA have increased overjets and mandibular deficiency with high angle and narrow maxilla. Nevertheless, I must be cautious in interpreting this data because the effect sizes were tiny, even though these were statistically significant differences. Therefore, these results represent a tendency rather than clear findings.
So, we must be cautious before we all identify OSA with cephalograms and expand maxillae as a first line of treatment. We also need to consider that association does not mean causation. I am sorry to be Professor misery!
In summary, this paper provides information that may point the direction of future clinical research into the orthodontic treatment of this important group of children.
Emeritus Professor of Orthodontics, University of Manchester, UK.