Palatal Expansion in Children
Sparkle Dental | 27/07/2017
Palatal expansion is a form of orthodontic treatment that is often useful in the early intervention of orthodontic problems in children.
Widening the palate increases the perimeter of the dental arch to create more space for crooked teeth so the teeth can align without the need for extractions.
But did you know beyond straight teeth for your child, there are several other benefits including better breathing and sleep?
The problem with underdeveloped palates
Most people would be aware that if the palate is too narrow, there is an increased risk of crooked teeth and bite problems.
Even when no dental crowding is evident, a narrow palate does not allow proper space for the tongue to rest properly in the roof of the mouth. In young children, lowered tongue posture is associated with poor palate and facial development, sleep disordered breathing and sometimes problems with speech articulation.
The bigger problem with poor palate development is that it is intimately linked with poorer nasal breathing. The palate forms the floor of the nose and sinuses, and when it is high and narrow it narrows these air passages. This increases the resistance to airflow, and can predispose a person to mouth breathing and snoring.
It has been well established that narrow palates are a risk factor for the development of obstructive sleep apnoea. This is a serious breathing problem associated with increased risk of neurocognitive and behavioural problems in children, and many health risks into adulthood. From this perspective, early intervention whilst a child is still developing is a critical preventive strategy.
Benefits of early palatal expansion
Many studies have demonstrated that very small increases in the width of the palate lead to dramatic improvements in nasal airflow.
The most comprehensive review of current research on the palatal expansion and sleep disturbed breathing
was published in 2016 in The Larygnoscope. It found there was a consistent reduction in obstructive sleep apnoea and improvement in lowest oxygen saturation during sleep in children that had palatal expansion.
In addition, bedwetting has been associated with abnormal breathing during sleep, and there are several studies that have shown palatal expansion can help cure bedwetting. This example of a study published in 2015 in Angle Orthodontist
found complete dryness or a significant improvement after palatal expansion in a well selected group of bed-wetting children aged 6-15 years.
Interestingly, some of the earliest research
on palatal expansion to improve nasal breathing was conducted here in Perth at the Princess Margaret Hospital in the 1970s as part of a collaboration between a local ENT physician and orthodontist. It examined the impact of palatal expansion in 310 consecutive children with impaired nasal breathing in situations such as allergic rhinitis, asthma and deviated septums. 87 per cent of children had improved nasal breathing following palatal expansion.
Good resting tongue posture and nasal breathing are essential for good palatal development. Expanding the palate allows more room for the tongue to rest and function properly in the roof of the mouth. When this is done earlier in life when there is most growth potential remaining, there is greater potential to improve a child's trajectory of facial and airway development.
Normal palatal development is the template for normal lower jaw development.
This video by orthodontist Dr Derek Mahony, one of Dr Shereen Lim’s orthodontic teachers illustrates how poor jaw development contributes to abnormal lower jaw development.
Why is palatal expansion sometimes not offered as an option?
The traditional approach to orthodontics often relies on waiting until a child’s permanent teeth have come through, and then using braces to straighten the teeth.
When teeth are particularly crowded, the solution is to extract teeth and close up the excess spaces to align the teeth.
The rationale for delayed treatment is based on past studies that have compared early intervention in children with recessed lower jaws to no intervention in another group of those children. These studies found that in general there was no difference in the total treatment time for children who had an initial phase of orthodontic treatment or delayed treatment in one phase. The conclusion was that early treatment is of no additional benefit. As a result, orthodontic training often suggests to delay treatment to avoid burn out of children.
The problem with applying this conclusion across the board to palatal expansion, is that these studies did not include palatal expansion. Instead they focused only on appliances to move the lower jaw forward (and in some cases moving the upper jaw back at the detriment of airway space). This is a significant limitation because recessed lower jaws are associated with narrow palates, and these were not being addressed. In fact, orthodontists may not even consider a palate as narrow unless there is a cross-bite.
The alternative view is the palate is narrow if it does not house the tongue adequately regardless of whether there is a crossbite or not. Due to a continuous interaction between structure and function, a narrow palate can also be considered a reflection of the tongue not resting properly in the roof of the mouth during facial development. This understanding is gained from research that links mouth breathing, tongue ties, dummy sucking and poor muscle tone and low resting tongue posture in conditions like muscular dystrophy, Down’s syndrome and premature infants with poor palatal development.
Conventional orthodontics does not address muscle dysfunctions that contribute to poor palate development. This often leads to relapse of results. The studies concluding early treatment was of no additional benefit do not address these factors that lead to orthodontic relapse and therefore could negate any benefits of an earlier phase of orthodontics.
The myofunctional approach to orthodontics demands that in addition to palatal expansion, poor muscle function including mouth breathing, tongue ties, low tongue posture, thumb sucking and low muscle tone need to be addressed for long term stability at the same time. This is contrary to conventional orthodontic training.
With greater understanding that narrowed palates are linked to poorer breathing, experts in sleep medicine and facial growth all agree that delayed treatment is detrimental to a child’s long term sleep and breathing.
Case studies demonstrating the further potential impact of palatal expansion
The story of Finding Connor is an example of how poor sleep is often missed as a root cause of behavioural and learning difficulties in children.
Through the collaboration of paediatric sleep physician Dr Darius Loughmanee and paediatric dentist Dr Kevin Boyd, Connor’s poor sleep was identified as a contributing factor. His management plan included palatal expansion and tongue-tie release, and in this video his mother describes the journey of finding her son.
In this case report published in a peer-reviewed journal
, Dr Avram Gold and his colleagues demonstrated how improving sleep breathing through palatal expansion helped to cure severe chronic depression in an 18 year old. The depression had no longer been responsive to medication, and was only responsive to electronic shock therapy.
Despite there being no dental crossbites associated with the subject’s narrow palate, he had palatal expansion to improve his nasal airflow. His sleep and depression improved and he became free of symptoms of depression.
At this stage, there are many practitioners offering palatal expansion as a treatment option with similar results. Whilst this approach is very rational, more studies are required to support this approach as a universal standard of care and to promote greater change in orthodontic training programs.
Palatal expansion at Sparkle Dental
Dr Shereen Lim is a general dentist in Perth with training in palatal expansion in children and the myofunctional approach to orthodontics. She uses a variety of appliances specific for each individual patient.
For more information or for an assessment of your child’s suitability for this option please contact us
for an initial consultation.
Related blog categories: early, expander, orthodontics, palatal
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