Obstructive sleep apnea in children with Marfan syndrome: Relationships between three-dimensional palatal morphology and apnea-hypopnea index

Unique Features of Cardiovascular Involvement and Progression in Children with Marfan Syndrome Justify Dedicated Multidisciplinary Care

Marfan syndrome (MIM: # 154700; MFS) is an autosomal dominant disease representing the most common form of heritable connective tissue disorder. The condition presents variable multiorgan expression, typically involving a triad of cardiovascular, eye, and skeletal manifestations. Other multisystemic features are often underdiagnosed. Moreover, the disease is characterized by age related penetrance. Diagnosis and management of MFS in the adult population are well-described in literature. Few studies are focused on MFS in the pediatric population, making the clinical approach (cardiac and multiorgan) to these cases challenging both in terms of diagnosis and serial follow-up. In this review, we provide an overview of MFS manifestations in children, with extensive revision of major organ involvement (cardiovascular ocular and skeletal). We attempt to shed light on minor aspects of MFS that can have a significant progressive impact on the health of affected children. MFS is an example of a syndrome where an early personalized approach to address a dynamic, genetically determined condition can make a difference in outcome. Applying an early multidisciplinary clinical approach to MFS cases can prevent acute and chronic complications, offer tailored management, and improve the quality of life of patients.

ERS technical standards for using type III devices (limited channel studies) in the diagnosis of sleep disordered breathing in adults and children

For more than three decades, type III devices have been used in the diagnosis of sleep disordered breathing in supervised as well as unsupervised settings. They have satisfactory positive and negative predictive values for detecting obstructive and central sleep apnoea in populations with moderately high pre-test probability of symptoms associated with these events. However, standardisation of commercially available type III devices has never been undertaken and the technical specifications can vary widely. None have been subjected to the same rigorous processes as most other diagnostic modalities in the medical field. Although type III devices do not include acquisition of electroencephalographic signals overnight, the minimum number of physical sensors required to allow for respiratory event scoring using standards outlined by the American Academy of Sleep Medicine remains debatable. This technical standard summarises data on type III studies published since 2007 from multiple perspectives in both adult and paediatric sleep practice. Most importantly, it aims to provide a framework for considering current type III device limitations in the diagnosis of sleep disordered breathing while raising research- and practice-related questions aimed at improving our use of these devices in the present and future.

Dynamics of Circulating CD14/CD16 Monocyte Subsets in Obstructive Sleep Apnea Syndrome Patients upon Hypoglossal Nerve Stimulation

Background: Obstructive sleep apnea syndrome (OSAS) is a widespread respiratory disease that is associated with recurrent breathing intermissions at night. The corresponding oxidative stress triggers a low-grade systemic inflammation which leads to alterations of different immune cells in the peripheral blood. The current standard treatment for OSAS is continuous positive airway pressure (CPAP), whereas hypoglossal nerve stimulation (HNS) has been established as a second-line treatment option for CPAP failure. The aim of the study was to investigate the influence of HNS for OSAS patients on the distribution and differentiation of circulating monocyte subsets in connection with the clinical parameters. Materials and Methods: Therefore, a detailed analysis of the distribution of CD14/CD16 characterized monocyte subsets in the peripheral blood of OSAS patients before and after HNS therapy was performed by flow cytometry. Furthermore, values of BMI (body mass index), ODI (oxygen desaturation index), and ESS (Epworth Sleepiness Scale) were measured. Results: These OSAS patients significantly improved AHI and ESS scores under HNS. In addition, HNS revealed the potential to ensure normal distributions of blood monocyte subsets and even improved the monocyte dynamics in selected OSAS patients, but there were no significant correlations with AHI, ODI, HNS usage, and daytime sleepiness. Conclusions: We conclude that HNS-related positive effects on the oxygenation of the peripheral blood as well as affect the distribution of circulating monocyte subsets, but clinical OSAS correlations are missing. Far more individual clinical, cellular and molecular factors are involved in this sensitive and complex regulatory network and have to be elucidated in further studies.

Three-dimensional analysis of the palatal morphology in growing patients with Apert syndrome and Crouzon syndrome

Patients with Apert syndrome or Crouzon syndrome present with severe defects in oral-maxillofacial growth and development. In this study, we conducted a quantitative three-dimensional (3D) analysis of the palatal morphology of patients with Apert syndrome and Crouzon syndrome. Four patients with Apert syndrome (average age, 11.0 ± 0.8 years) and five with Crouzon syndrome (average age, 10.1 ± 1.6 years) were investigated. The participants' maxillary dental casts were scanned and analyzed using 3D imaging. Palatal width, depth, cross-sectional area, and palatal angle (PW, PD, PCA, and PA, respectively) were measured, and standard scores were calculated based on sex- and age-matched Japanese standard values; the actual palatal surface areas (PSA) and palatal volumes (PV) were also measured. Our results show that patients with Apert syndrome and Crouzon syndrome had a very narrow PW (standard score: -3.79 and - 0.47, respectively). 3D analysis revealed that patients with Apert syndrome had a significantly shallower PD (standard score: -1.35) than those with Crouzon syndrome (standard score: 2.47), resulting in a smaller PCA (standard score: -5.13), PSA (5.49 cm² ), and PV (1.11 cm³ ) and larger PA (standard score: -0.12) than those in patients with Crouzon syndrome. This might be due to the former having a narrower and shallower palate caused by the predominant swelling of the palatal mucosa. These findings improve our understanding of the differences in palatal morphology between Apert syndrome and Crouzon syndrome patients.

Stability prediction of early orthopedic treatment in Class III malocclusion: morphologic discriminant analysis

Background

To evaluate morphologic differences between class III malocclusion success and failure treatment subjects in order to identify which variables are more predictive for long-term stability in early orthopedic treatment. In this retrospective study, 31 patients were enrolled from the Department of Orthodontics (Rome Tor Vergata). Inclusion criteria were as follows: white ancestry, class III malocclusion, mixed dentition, cervical stage (CS) 1-2, no pseudo-class III. Pre-treatment radiographic and cast records were collected. Each patient underwent rapid maxillary expansion/facial mask/bite block (RME/FM/BB) orthopedic treatment until correction. At T1 (permanent dentition, CS4), records were recollected. According to treatment stability, relapse group (RG, 19) and success group (SG, 12) were identified. Sagittal and vertical cephalometric and digital cast measurements were performed. Student’s t tests were used for statistically significant differences inter and intra groups. For discriminant analysis, relapse or success status was added to each patient’s T0 data.

Results

At T0, RG showed larger upper anterior transversal width (p = 0.0266), while at T1 the upper anterior length was shorter than SG (p = 0.0028). Between T1 and T0, both groups showed larger upper anterior and posterior transversal widths. SG had greater upper anterior (p = 0.0066) and posterior (p = 0.449) sagittal length. RG presented larger lower anterior (p = 0.0012) and posterior (p = 0.0002) transversal widths, while there were no differences in SG lower arch. Discriminant analysis provided two predictive variables with an accuracy of 80.6%: upper anterior length and upper posterior length.

Conclusion

A shorter and wider maxilla could be a predisposing factor for relapse and failure of the early orthopedic treatment of class III malocclusion patients. The absence of mandibular changes could be predictable for treatment success.

The Efficacy of Lingual Laser Frenectomy in Pediatric OSAS: A Randomized Double-Blinded and Controlled Clinical Study

This randomized, double-blind and controlled clinical trial investigates how a diode laser lingual frenectomy can improve obstructive sleep apnea syndrome (OSAS) in pediatric patients. Background: Several authors have shown that a short lingual frenulum causes a reduction in incoming air flow and the relationship between OSAS and a short lingual frenulum. Methods: Thirty-two pediatric patients were equally randomly divided into a Study Group (SG) and a Control Group (CG). On each SG patient a polysomnography 1 (PSG1) and a lingual frenectomy were performed using a diode laser via Doctor Smile Wiser technology, power 7 W. After three months, a new polysomnography (PSG2) was performed to evaluate the lingual frenectomy efficacy in pediatric patients. The pain was assessed by a numerical rating scale (NRS) before and after surgery. The CG followed the same protocol without a lingual frenectomy but myofunctional and speech therapy were conducted to qualitatively and quantitatively improve the lingual functionality. In the SG, eight subjects (50%) had severe OSAS and eight had moderate (50%) while in the CG, three subjects had severe OSAS (18.8%) and thirteen had moderate (81.2%). Results: In the SG, 93.8% were classified as mild OSAS and 6.2% as moderate. In contrast, in the CG, 18.75% were classified as mild OSAS, 62.5% as moderate and 18.75% as severe. Conclusion: The study demonstrates how a lingual laser frenectomy can improve OSAS in pediatric patients.

Obstructive Sleep Apnea, Palatal Morphology, and Aortic Dilatation in Marfan Syndrome Growing Subjects: A Retrospective Study

The main cause of mortality in Marfan syndrome (MS) is aortic disease. Obstructive sleep apnea (OSA) is highly prevalent in MS, and it is also associated with cardiovascular risk and maxillary deformities. The aim of this research was to analyze the possible relations between OSA, palatal morphology, and aortic root diameters in growing subjects. A group of 15 growing subjects with MS and a control group of healthy peers was selected. All of them underwent nocturnal polygraphic monitoring, digital dental casts, and transthoracic echocardiography. The results showed that OSA indexes and aortic diameters were significantly higher in the study group. Transversal palatal dimension was smaller in MS patients. Moreover, OSA severity was not related with maxillary contraction severity in MS. No correlation between OSA severity and increased aortic diameters occurred. A high prevalence of OSA, increased aortic dimensions, and significant contraction of palatal dimensions were observed in MS compared with the control group. None of these single factors may directly be associated with aortic dilation, but together, they might contribute to the development and progression of aortic aneurysm from a young age.

Risk Factors and Inadequacy of Screening for Sleep-Disordered Breathing in Children with Marfan Syndrome

The prevalence of obstructive sleep apnea (OSA) is increased in children and adults with Marfan syndrome (MFS) compared to the general population and has been shown to be associated with rapid aortic root dilation and dissection in adults. Early diagnosis and treatment of OSA may decrease long-term cardiac morbidity. We therefore studied the utility of noninvasive OSA screening tools in children with MFS. We hypothesized that youth with MFS would have higher OSA screening scores than the general pediatric population. Subjects with confirmed MFS were recruited from a single pediatric center. Data collected included cardiac history, retrospective polysomnogram (PSG) data, and prospectively collected Pediatric Sleep Questionnaire (SRBD-PSQ) and Epworth Sleepiness Scale (ESS-CHAD) scores. Fifty-one individuals aged 2-21 years old were identified. Nineteen subjects completed the surveys, 53% female, median age 16 years. Of those that completed the survey, mean SRBD-PSQ score was 0.24 ± 0.21 and mean ESS-CHAD was 6.4 ± 3.7. Comparatively, published normative data for pediatric control subjects were 0.24 ± 0.21 for SRBD-PSQ and 5.4 ± 3.7 for ESS-CHAD. In conclusions, youth with MFS had similar OSA screening scores compared to published pediatric controls. Given these findings and high prevalence of OSA in MFS youth, standard questionnaires may not be an appropriate tool for identifying children at risk for OSA in this population. In the absence of evidence-based guidelines, physicians caring for children with MFS should consider referral for PSG, even in the absence of classic symptoms.

Management of unilateral temporomandibular joint ankylosis & orthomorphic correction in a patient with Marfan syndrome: A rare case report

INTRODUCTION

Marfan syndrome (MFS) is a disorder of the connective tissue that is inherited in an autosomal dominant fashion and is caused by mutations in the gene coding for fibrillin-1 (FBN1). This condition commonly affects the skeletal system, pulmonary system, ocular system and the cardiovascular system. Surgical intervention is often needed to correct the various deformities affecting the patients to restore the function, improving the patient's aesthetic appearance and quality of life.

PRESENTATION OF CASE

It's a rare case report of a young male patient suffering through unilateral temporomandibular joint ankylosis, obstructive sleep apnea and unaesthetic appearance while being a case of Marfan syndrome.

DISCUSSION

This paper highlights the various surgical procedures undertaken to correct the deformities affecting the individual and improving the overall health of the patient.

CONCLUSION

Our patient's management shows the necessity of a multidisciplinary, multi factorial and multi-faceted approach with early visual identification and diagnosis.

Postural control abnormalities related to sleep deprivation in patients with Marfan Syndrome

BACKGROUND

Marfan syndrome (MFS) is a rare autosomal dominant connective tissue disorder affecting virtually every organ. Sleep disturbances, associated to high collapsibility in upper airways, are common in MFS; daytime sleepiness could lead to reduction in attention and motor coordination, with detrimental effects on balance.

OBJECTIVE

To evaluate otoneurological function in MFS patients, compared to healthy subjects, and to investigate possible correlations with sleep deprivation extent.

METHODS

Forty-one MFS patients underwent a thorough otoneurological examination, video Head Impulse Test (vHIT), and static posturography. Sleep parameters were recorded by home monitoring. Daytime sleepiness and dizziness-related handicap were screened by means of Dizziness Handicap Inventory (DHI) and Epworth Sleepiness Scale (ESS). Results were compared with 49 healthy controls (HC).

RESULTS

DHI and ESS scores were increased in MFS patients (p < 0,01). vHIT scores showed no between-group effect. Classical (surface and length) and frequency-domain posturographic parameters were significantly increased in MFS with respect to HC (p < 0,01). A positive correlation was found between ESS scores and posturographic parameters in MFS patients.

CONCLUSIONS

An impaired postural control, related to the extent of sleep deprivation, was found in MFS patients. Such results could advocate for screening and treating sleep deprivation and balance dysfunctions in MFS patients.

Gelatinolytic activity in gingival crevicular fluid and saliva of growing patients with Marfan syndrome: a case-control study

Background

Aim of the study was to evaluate the gelatinolytic activity in the saliva and gingival crevicular fluid from a sample group of subjects with Marfan syndrome.

Methods

Two groups were analyzed in this case-control study. A group of 28 subjects with Marfan syndrome (MG) was recruited from the Centre for Rare Disease, Marfan Clinic of Tor Vergata University Hospital. The second sample, 23 subjects, with the same characteristics and without any syndrome, was the control group (CG). Saliva and gingival crevicular fluid were collected and transferred to a sterile test tube and stored frozen at − 20 °C until analysis at the Medical Chemistry Laboratory. Gelatin substrate zymography was used for the evaluation and characterization of saliva and crevicular fluid proteinases. Correlation test and Student’s t-test have been used to analyze data.

Results

In all samples different gelatin-degrading activities were observed. Two bands, which are related to the molecular weights of pro-MMP-9 and active MMP-9, respectively, were detectable in 100% of Marfan and control samples. MMP-2 activity was higher in Marfan group. Additional bands (55/48 kDa), corresponding to the activated forms of collagenase (MMP-13), were observed in saliva samples of both groups.

Conclusions

The association of an enhanced activity by MMP-13 with an increased amount of active MMP-9 might be an important biomarker for the diagnosis of Marfan syndrome.

Periodontal condition in growing subjects with Marfan Syndrome: a case-control study

Background

Marfan's syndrome (MFS) is a systemic disorder of connective tissue caused by mutations in the extracellular matrix protein fibrillin-1. Orofacial characteristics may be useful in identification of the syndrome. Severe periodontitis is sometimes observed in MFS patients, but no in-depth information has been reported in Italian groups of growing subjects with MFS. The aim of this study was to analyze the periodontal condition on a group of growing subjects affected by MFS, in comparison with a typically developed control group.

Methods

A group of 16 subjects with diagnosed MFS were recruited from the Centre for Rare Diseases for Marfan Syndrome and Related Disorders of Tor Vergata University Hospital. The Marfan Group (MG) was compared with a Control Group (CG) composed by 20 nonsyndromic subjects. The periodontal clinical parameters like Marginal Gingival Thickness (GT), Plaque Index (PI), Bleeding On Probing (BOP) and Modified Periodontal Screening and Recording (PSR) were assessed.

Results

The mean value of PI in MG was 59%, instead in CG it reached 21%. Analysis showed a significant difference between MG and CG also for the BOP. In MG the mean value of BOP attained 36% and in CG it reached 16%. A statistical significant difference of distribution of PSR index between the two groups was found for all sextant examined.

Discussion

Patients with Marfan syndrome reveal a higher presence of plaque and consequently a generalized inflammation in the oral cavity when compared with a control group.

3D evaluation of maxillary morphology in Marfan growing subjects: a controlled clinical study

Background

Marfan syndrome is a rare autosomal dominant inherited disease of the connective tissue associated with various craniofacial abnormalities. Aim of the present study was to assess the variability of palatal shape in a sample of 31 Marfan patients compared to a control group of no syndromic subjects, in two stages of dentition, by using 3D geometric morphometric analysis.

Methods

Thirty one growing subjects with Marfan syndrome were selected and divided into two subgroups: MG1 with mixed dentition (10 M, 6F, mean age 7+/− 0.7 years), MG2 with permanent dentition (8 M, 7F, mean age 13+/− 0,5 years). Each subgroup was compared to a control group (CG1 mixed dentition, 9 M, 7F, mean age 7.6+/− 0.5 years; CG2 permanent dentition, 9 M, 6F, mean age 12.8+/− 0.7 years) matched on age, sex distribution, stage of dentition and skeletal maturation. Then the two subgroups were compared one to each other. For each patient maxillary dental casts were taken, scanned and digitized. 3D geometric morphometric methods were applied. Procrustes analysis was used and principal component analysis was performed to reveal the main patterns of palatal shape variation.

Results

Both Marfan subgroups showed important reductions in the transversal plane associated with a deep palatal vault when compared to the control groups (MG1 vs CG1 P = 0,003; MG2 vs CG2 P = 0,07). Moreover a statistically significant difference between the palatal shape of MG1 and MG2 was found (P = 0.017) showing a significant worsening of palatal depth and constriction from mixed to permanent dentition in Marfan subjects.

Conclusion

Marfan subjects showed a specific palatal morphology with maxillary constriction and deeper palatal vault when compared to a control group of healthy subjects. The constriction and the depth of the palatal vault in Marfan patients worsen from mixed dentition to permanent dentition more then in no syndromic subjects.

Oculo-Facio-Cardio-Dental Syndrome: A Case Report about a Rare Pathological Condition

(1) Background: Oculo-facio-cardio-dental (OFCD) syndrome is a rare pathological condition with an X-linked dominant trait that only occurs in females; no males are born with OFCD syndrome. This syndrome is characterized by congenital cataracts with secondary glaucoma ocular defects, ventricular and atrial septal defects, or mitral valve prolapses. Facial traits are a long narrow face and a high nasal bridge with a bifid nasal tip. Dental anomalies include radiculomegaly, oligodontia, root dilacerations, malocclusion, and delayed eruption. (2) Methods: This clinical report describes a 26-year-old girl who suffers from OFCD syndrome and who was treated with a multidisciplinary approach. The treatment plan included orthodontic treatment, orthognathic surgery, namely LeFort I and a Bilateral Sagittal Split Osteotomy, and occlusal rehabilitation with implants. (3) Discussion: Early diagnosis and multidisciplinary treatment of orthodontic, orthognathic surgery and occlusal rehabilitation with implants make it possible to maintain tooth function and improve aesthetics with good prognoses for success. In this paper, we report a case of a female patient with OFCD syndrome, who was referred for orthodontic treatment and occlusal rehabilitation and treated with a multidisciplinary approach.

Prevalence of Obstructive Sleep Apnea in Joint Hypermobility Syndrome: A Systematic Review and Meta-Analysis

STUDY OBJECTIVES

Because of associated abnormalities affecting connective tissue in various organs including airways, hypermobility syndrome has been associated with high risk for the development sleep apnea. Ehlers-Danlos syndrome (EDS) and Marfan syndrome (MFS) represent the most common hypermobility syndromes; therefore, the purpose of this review was to examine the prevalence of obstructive sleep apnea (OSA) in these populations.

METHODS

All publications and poster presentations written in English found through August 2018 that describe the prevalence of sleep apnea among people with EDS or MFS were included.

RESULTS

A total of 13 studies were identified, 7 for EDS and 6 for MFS. A combined random prevalence rate of OSA across both populations was 48.9% (95% confidence interval 38.3-59.6), with a slightly higher rate of 59.7% (39.7-77.0) for MFS versus 39.4% (28.8-51.1) for EDS. However, a high degree of heterogeneity across studies was found in both groups (EDS group: Q = 28.6 and I2 = 79.0; MFS group: Q = 37.1 and I2 = 86.5). When directly compared to the general population, patients with EDS/MFS were on average six times more likely (odds ratio 6.28 [95% confidence interval 3.31-11.93], P < 0.001, Z = 5.61) to have a diagnosis of OSA.

CONCLUSIONS

OSA is a previously underestimated EDS/MFS-related complication. The high prevalence of OSA might be the result of bony and soft-tissue abnormalities associated with these hypermobility syndromes. Untreated OSA is thought to worsen cardiovascular complications especially among those with MFS. Further research is needed to better delineate whether the prevalence of OSA is moderated by factors such as sex, body mass index, bony structure, and disorder subtype.