REVIEW Mandibular advancement devices are an alternative and valid treatment for pediatric obstructive sleep apnea syndrome Maria Pia Villa & Silvia Miano & Alessandra Rizzoli Received: 15 June 2011 /Revised: 7 September 2011 /Accepted: 12 September 2011 /Published online: 23 September 2011 # Springer-Verlag 2011 Abstract Background Orthodontic and craniofacial abnormalities have often been reported in pediatric sleep-disordered breathing (SDB). While the reversibility of these craniofa- cial abnormalities by means of adenotonsillectomy has yet to be established, orthodontic treatment based on oral appliances is considered to be a potential additional treatment for pediatric SDB. Discussion Oral appliances may help improve upper airway patency during sleep by enlarging the upper airway and/or by decreasing upper airway collapsibility, thereby enhancing upper airway muscle tone. Orthodontic therapy should be encouraged in pediatric OSAS, and an early approach may permanently modify nasal breathing and respiration, thereby preventing obstruction of the upper airway. Keywords Obstructive sleep apnea . Children . Rapid maxillary expander . Malocclusion . Apnea–hypopnea index . Polysomnography Introduction Orthodontic and craniofacial abnormalities have often been reported in pediatric sleep-disordered breathing (SDB): a narrow upper airway accompanied by maxillary constric- tion and mandibular retrusion is believed to be a common phenotype of pediatric obstructive sleep apnea syndrome (OSAS) [1–7]. Children with SDB who do not have congenital craniofacial anomalies may display mild cranio- facial morphometric features [4, 6, 8–10]. These morpho- metric features may indicate a hyperdivergent skeletal growth pattern, which increases the craniomandibular, intermaxillary, goniac, and mandibular plane angles [11]. Whether this skeletal conformation is genetically deter- mined or influenced by the early onset of habitual snoring has yet to be determined [11]. Some investigators suggest that these craniofacial changes may be reversed by adenotonsillectomy [1], while others believe that children with SDB have a special craniofacial morphology from the outset [2, 11]. This persistent abnormal mandibular devel- opment and malocclusion affects the skeletal structures involved in respiratory dynamics [4, 12] and leads to mandibular retroposition, which in turn predisposes patients to the collapse of the upper airway during sleep [13]. Moreover, mandibular retroposition is associated with posterior displacement of the tongue base, which results in a further narrowing of the upper airway and leads to a high-arched (ogival) palate [11, 14]. While the reversibility of these craniofacial abnormali- ties by means of adenotonsillectomy has yet to be established, orthodontic treatment based on oral appliances is considered to be a potential additional treatment for pediatric SDB [15–17]. Oral appliances may help improve upper airway patency during sleep by enlarging the upper airway and/or by decreasing upper airway collapsibility, thereby enhancing upper airway muscle tone [17]. In 1995, the American Sleep Disorders Association published a position paper, which has recently been updated, regarding the clinical use of oral appliances to treat snoring and obstructive sleep apnea [18, 19]. Since the publication of these practice guidelines, the body of literature regarding oral appliances in adulthood has grown significantly [20, 21]. Epidemiological studies reported that M. P. Villa (*) : S. Miano : A. Rizzoli Department of Pediatrics, Sleep Disease Centre, University of Rome La Sapienza-Sant’Andrea Hospital, Via Grottarossa 1035/1039, Rome 00189, Italy e-mail: mariapia.villa@uniroma1.it Sleep Breath (2012) 16:971–976 DOI 10.1007/s11325-011-0595-9