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R maxillary expansion (RME), also known as rapid palatal expansion, is gaining interest in the medical and dental community as a potential therapeutic modality to treat sleep disordered breathing in pediatric patients. RME is an orthodontic procedure indicated for children who demonstrate a transverse deficiency in the width of their maxilla, usually manifested by the presence of a posterior crossbite. Increase in the width of the maxilla is accomplished by placement of an expansion screw in the palate that is secured to the dentition. Generally RME appliances are deferred until the maxillary permanent first molars have erupted. Two-band expanders are secured to permanent first molars; 4-band expanders also incorporate either second primary molars or first or second premolars (Figure 1). The goal is to increase maxillary width by skeletal expansion (orthopedic) and not by dental expansion (orthodontic), but in reality both skeletal and dental expansion occur. Activation of the expansion screw separates the two halves of the maxilla at the midline suture but also impacts the other circumaxillary sutures. The zygomaticomaxillary, zygomaticotemporal, zygomaticofrontal, nasomaxillary, and nasofrontal sutures are also impacted by this procedure.1,2 Occasionally patients report feeling pressure at the nasofrontal suture or other circumaxillary sutures when the expander is activated. Sufficient expansion occurs in days to a few weeks, and a telltale sign of skeletal expansion is the appearance of a transient maxillary midline diastema (Figure 2). Typical expansion rates vary from 0.25 mm to 0.5 mm per day until the desired expansion is achieved. The maxilla is intentionally over-expanded to accommodate anticipated dental and skeletal relapse.3 Bone remineralization of the expanded suture requires 3-6 months, during which the expander must remain in place.4 To manage relapse when the expander is removed,3,5 another form of retention is indicated as discussed below. As early as 1965, Haas described the ability of RME to increase nasal cavity volume and to improve nasal respiration,6 and other studies followed that investigated the association between RME and nasal airway resistance with variable results.7-10 These reports preceded the widespread medical recognition of sleep disordered breathing (SDB), and thus the technique was not advanced at the time as a treatment option for SDB. In 2004 Pirelli and coworkers described a case series of 31 children diagnosed with obstructive sleep apnea syndrome (OSAS) whose AHI normalized after RME and remained stable at 4 months.11 Villa evaluated 14 OSAS children who underwent RME and demonstrated significant improvement in sleep parameters and symptoms of SDB at 12 months and again in 36 months in a follow-up study of 10 of the original 14 children.12,13 Limitations of these studies included the small sample size and absence of a control group, but they nevertheless demonstrated the potential value of the procedure in the management of pediatric SDB. To date, no randomized clinical trials have been conducted to assess more rigorously the effect of RME on pediatric sleep disordered breathing. Studies are lacking to identify the optimal age for RME and to determine the stability of improvement in respiratory parameters, the effect on behavioral and cognitive outcomes, and the long-term impact on health outcomes.

Rapid Maxillary Expansion for Pediatric Sleep Disordered Breathing