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The nasomaxillary complex, the mandible, and sleep-disordered breathing

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This study aims to use clinical scales in a standardized fashion in evaluating the frequency of a high and narrow hard palate and/or small and retroplaced mandible in children with polysomnographically demonstrated sleep-disordered breathing (SDB).


This is a retrospective review of clinical and polysomnographic data from children (2–17 years old) with SDB. Exclusion criteria were obesity, presence of a syndromic disorder, and incomplete chart information. Data on demographics, reason for referral, sleep history, Mallampati scale, size of the tonsils (Friedman scale), bite occlusion (dental positioning), and correlating clinical presentation and comparative physical exam of nasomaxillary and mandibular features (using subjective grading scales) were collected, as were results of pre- and post- treatment polysomnography.


Data from 400 children were analyzed. With increasing age, fewer referrals were made for abnormal breathing during sleep and more were made for daytime impairment and generally poor sleep. There were 290 children (72.6%) who had tonsils graded 3+ or 4+, but 373 (93.3%) had craniofacial features considered to be risk factors for SDB, including small mandible and/or high and narrow hard palate associated with a narrow nasomaxillary complex. Mean pretreatment apnea–hypopnea index (AHI) was 14.6 ± 17.1 and AHI was similar in the three age groups. Initial treatment was adenotonsillectomy. Follow-up was obtained in 378 subjects, and 167 cases demonstrated residual AHI. Incomplete response to adenotonsillectomy was seen more often in children with Mallampati scale scores of 3 and 4.


Non-obese children with SDB had different initial clinical complaints based on age. Independently of age, facial anatomic structures limiting nasal breathing and those considered to be risk factors for SDB were commonly seen in the total group. Clinical assessment of craniofacial features considered as risk factors for SDB and more particularly a Mallampati scale score of 3 or 4 can be useful in identifying children who may be more at risk for limited response to adenotonsillectomy, suggesting a subsequent need for post-surgery polysomnography.

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Dr. Jee Hyun Kim was supported by a post doctoral fellowship from South Korea. This was orally presented at the World Congress on Sleep Apnea, Seoul (Korea) 2009.

We greatly thank Shannon S. Sullivan, M.D., and Christina V. Darby, M.D., for their help in the preparation of this manuscript.

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Correspondence to Christian Guilleminault.

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Kim, J.H., Guilleminault, C. The nasomaxillary complex, the mandible, and sleep-disordered breathing. Sleep Breath 15, 185–193 (2011).

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