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Cited by 28Obstructive Sleep Apnea ResearchOrthodontics and Dentofacial OrthopedicsTemporomandibular Joint Disorders

Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review

Open access
Bariani, Rita Catia Brás, Bigliazzi, Renato, Cappellette Junior, Mario, Moreira, Gustavo, Fujita, Reginaldo Raimundo·2022·Brazilian Journal of Otorhinolaryngology
DOI 10.1016/j.bjorl.2021.02.010PMC PMC9422464
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Abstract

INTRODUCTION: Obstructive sleep apnea syndrome is a common condition in childhood and if left untreated can result in many health problems. An accurate diagnosis of the etiology is crucial for obstructive sleep apnea treatment success. Functional orthodontic appliances that stimulate mandibular growth by forward mandibular positioning are an alternative therapeutic option in growing patients. OBJECTIVE: To perform a literature review about the effects of functional orthodontic appliances used to correct the mandibular deficiency in obstructive sleep apnea treatment. METHODS: The literature search was conducted in June 2020 using Cochrane Library; PubMed, EBSCO (Dentistry & Oral Sciences Source), LILACS Ovid; SciELO Web of Science; EMBASE Bireme and BBO Bireme electronic databases. The search included papers published in English, until June 2020, whose methodology referred to the types and effects of functional orthopedic appliances on obstructive sleep apnea treatment in children. RESULTS: The search strategy identified thirteen articles; only four articles were randomized clinical studies. All studies using the oral appliances or functional orthopedic appliances for obstructive sleep apnea in children resulted in improvements in the apnea-hypopnea index score. The cephalometric (2D) and tomographic (3D) evaluations revealed enlargement of the upper airway and increase in the upper airspace, improving the respiratory function in the short term. CONCLUSION: Functional appliances may be an alternative treatment for obstructive sleep apnea, but it cannot be concluded that they are effective in treating pediatric obstructive sleep apnea. There are significant deficiencies in the existing evidence, mainly due to absence of control groups, small sample sizes, lack of randomization and no long-term results.

AI snapshot

Written from the paper’s full text.

TL;DR

This literature review examined functional orthodontic appliances for treating obstructive sleep apnea in children and found short-term improvements in AHI and upper-airway dimensions across most included studies. The authors conclude that functional appliances may be an alternative treatment, but it cannot be concluded that they are effective for pediatric OSA because the existing evidence has major deficiencies.

Key findings

  • The search identified 754 studies; 13 met inclusion criteria. The abstract states only four were randomized clinical studies, while the results section categorizes the 13 as five clinical trials, three RCTs, three case reports, and two pilot studies.
  • Twelve studies reported reduced AHI after treatment. Examples include Cozza et al. (AHI from 7.88 to 3.66), Zhang et al. (mean AHI from 14.08 ± 4.25 to 3.39 ± 1.86, p < 0.01; lowest SaO₂ from 77.78 ± 3.38% to 93.63 ± 2.66%, p < 0.01), and Idris et al. (active MAS reduced overall AHI by 37%, 95% CI 15–53%, p = 0.002, versus sham). One case report by Rădescu et al. found AHI increased from 2.6 to 10.2 events/h.
  • Cephalometric (2D) and tomographic (3D) evaluations revealed enlargement of the upper airway and increase in upper airspace, improving respiratory function in the short term. Other reported improvements include Modesti-Vedolin et al. (RDI from 10 to 4.5 events/h; Nadir SpO₂ from 82.6% to 88.9%) and Villa et al. (apnea and hypopnea indices decreased, p = 0.001; 7 of 14 patients, 50%, had reduced symptoms and 7 had resolution of main respiratory symptoms).
  • The authors conclude functional appliances may be an alternative treatment for OSA, but cannot be concluded effective in pediatric OSA due to absence of control groups, small sample sizes, lack of randomization, and no long-term results.

Methods

  • Literature review; search conducted in June 2020 in Cochrane Library, PubMed, EBSCO (Dentistry & Oral Sciences Source), LILACS Ovid, SciELO Web of Science, EMBASE Bireme, and BBO Bireme. Two authors independently screened studies and extracted data. Inclusion followed PICOS: children/adolescents ≤14 years with OSA without craniofacial syndromes; intervention FOA; comparison with/without control group or pre-/post-treatment; primary outcome AHI; secondary outcomes oxygen saturation, sleep quality, sagittal maxilla-mandible relationship, and upper-airway space; polysomnography was mandatory.
  • A total of 754 studies were identified, 22 retrieved for full review, and 13 met inclusion criteria. The included studies investigated 271 growing subjects (range 3.5–14 years; mean age 7.61 ± 1.99 years), with mean treatment observation of 7.71 ± 5.13 months (range 1–20 months). The most used appliances were Twin Block, Frankel II, and Modified Monoblock.
  • Data extracted included author, year, study design, subjects, age, interventions, wearing time, drop out, AHI before and after FOA, and secondary outcomes. AHI data could not be statistically pooled due to considerable heterogeneity.

Limitations

  • The paper states significant deficiencies in the existing evidence, mainly absence of control groups, small sample sizes, lack of randomization, and no long-term results; it also notes low-quality evidence and differences in study protocols, appliance design, and subject selection.
  • The paper states that the AHI conclusion could not be statistically reached due to considerable heterogeneity of pooled data, and no included study allowed discussion of long-term effects of FOA treatment.
  • Evident from the text: the review is a narrative literature review, not a meta-analysis; most included evidence is non-randomized, case reports, or pilot studies (only four randomized clinical studies per the abstract, while the results list three RCTs), and one case report reported worsening AHI, so short-term improvements are not uniform.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.bjorl.2021.02.010

Cites

46 of 46 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 56 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    Rădescu et al. (2017) reported that in an 8-year-old girl with obstructive sleep apnea treated with a Twin Block for 12 months, the AHI increased significantly from 2.6 to 10.2 events per hour of sleep.

    “The AHI increased significantly from 2.6 to 10.2 events per hour of sleep.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Rădescu et al.26 2017 source

      Not checked in the free run.

  • Findingcitation

    Schessl et al. (2006) reported that Frankel II proved effective in treating obstructive sleep breathing disorders in a 3.5-year-old boy with primary dentition and without alteration of mandibular position.

    “Frankel II proved to be effective in the treatment of obstructive sleep breathing disorders in this specific clinical situation in children with primary dentition and without alteration of mandibular position.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Schessl et al.,28 2006

      Not checked in the free run.

  • Findingcitation

    Modesti-Vedolin et al. (2018) reported that in 18 patients aged 8.3 ± 2.3 years treated with a thermoplastic intraoral device for 2 months, the average RDI was significantly reduced from 10 to 4.5 events/h.

    “The average RDI was significantly reduced from 10 to 4.5 events/h.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Modesti-Vedolin et al.,29 2018

      Not checked in the free run.

  • Findingcitation

    Nunes Jr et al. (2019) reported that snoring improved significantly (p < 0.001) in snoring children with sleep-disordered breathing after six months of OOA treatment.

    “Snoring <0.001”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Nunes Jr et al.,25 2019 source

      Not checked in the free run.

  • Findingnone given

    All studies using oral appliances or functional orthopedic appliances for obstructive sleep apnea in children resulted in improvements in the apnea-hypopnea index score.

    “All studies using the oral appliances or functional orthopedic appliances for obstructive sleep apnea in children resulted in improvements in the apnea-hypopnea index score.”
    Quote in the paperSubstantial claim
  • The quote only partly states this claim. 1
  • May combine two claims. 22
  • Classified as probably not a substantial claim. 18

  • The quote only partly states this claim.

    Findingcitation

    Nunes Jr et al. (2019) reported that mouth breathing improved significantly (p < 0.001) in snoring children with sleep-disordered breathing after six months of OOA treatment.

    “Mouth breathing <0.001”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Nunes Jr et al.,25 2019 source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    The literature search identified 13 articles meeting inclusion criteria, of which only four were randomized clinical studies.

    “The search strategy identified thirteen articles; only four articles were randomized clinical studies.”
    • Also stated in: § Summary of included studies · plain
      “Therefore, only 13 articles met the inclusion criteria set for this study.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Rose et al. (2006) reported that in an 8-year-old girl with OSAS treated with Frankel II for 20 months, there was improvement in cardiorespiratory performance parameters, with less apnea and oxygen desaturation.

    “Improvement in cardiorespiratory performance parameters, with less apnea and oxygen desaturation.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Rose et al.,27 2006 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Rădescu et al. (2017) reported that snoring intensity indexes increased from 4.2 to 51.3 events/h.

    “Snoring intensity indexes increased from 4.2 to 51.3 events/h”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Rădescu et al.26 2017 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Nunes Jr et al. (2019) reported that six months of OOA treatment in snoring children with sleep-disordered breathing promotes enlargement of pharyngeal dimensions and beneficial cephalometric changes.

    “Six months of OOA treatment in snoring children with SDB promotes the enlargement of pharyngeal dimensions and beneficial cephalometric changes.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Nunes Jr et al.,25 2019 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Rose et al. (2006) reported that in the second case, it remains unclear whether the improved respiratory situation during sleep will be maintained in the long run.

    “it remains unclear in the second case whether the improved respiratory situation during sleep that will be maintained in the long run.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Rose et al.,27 2006 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Rădescu et al. (2017) reported that the initial pre-treatment rate for apnea-hypopnea was 34 events/h of sleep and increased to 81 events/h in the sleep period when polymer appliances were used.

    “The initial pre-treatment rate for apnea-hypopnea was 34 events/h of sleep and increased to 81 events/h in the sleep period, when the polymer appliances were used.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Rădescu et al.26 2017 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Schessl et al. (2006) reported that oxycardiorespirography 3 months later showed regular breathing for 80% of the night.

    “Oxycardiorespirography (PolyMESAM) 3 months later showed regular breathing for 80% of the night.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Schessl et al.,28 2006

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Rădescu et al. (2017) reported that the oxygen desaturation index had significantly variable changes from 3.2 to 10.8 events/h.

    “the oxygen desaturation index has significantly variable changes from 3.2 to 10.8 events/h.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Rădescu et al.26 2017 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Rose et al. (2006) reported that in the first case, OSAS could be eliminated long-term by the orthodontic procedure.

    “While the OSAS in the first case could be eliminated long-term by the orthodontic procedure”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Rose et al.,27 2006 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Schessl et al. (2006) reported that after treatment, while the device was worn during the night, snoring, apneic episodes, and daytime tiredness disappeared, and the boy stopped napping in the morning.

    “After: While the device was being worn during the night, snoring, apneic episodes and daytime tiredness disappeared and the boy stopped napping in the morning.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Schessl et al.,28 2006

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Cephalometric (2D) and tomographic (3D) evaluations revealed enlargement of the upper airway and increase in the upper airspace.

    “The cephalometric (2D) and tomographic (3D) evaluations revealed enlargement of the upper airway and increase in the upper airspace”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    Schessl et al. (2006) reported that before treatment, oxycardiorespirography revealed a flow pattern similar to repetitive obstructive apnea and an oxygen saturation periodically dropping to 80% for more than 70% of the entire sleep recording.

    “Oxycardiorespirography (Poly-MESAM) with videotaping revealed a flow pattern similar to repetitive obstructive apnea and an oxygen saturation periodically dropping to 80% for more than 70% of the entire sleep recording.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Schessl et al.,28 2006

      Not checked in the free run.

  • May combine two claims.

    Findingnone given

    The existing evidence on functional orthodontic appliances for pediatric obstructive sleep apnea has significant deficiencies, mainly absence of control groups, small sample sizes, lack of randomization, and no long-term results.

    “There are significant deficiencies in the existing evidence, mainly due to absence of control groups, small sample sizes, lack of randomization and no long-term results.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    The studies included in this review used different appliances to achieve mandibular advancement but similar results according to the type of appliance were observed.

    “The studies included in this review used different appliances to achieve mandibular advancement but similar results according to the type of appliance it was observed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    The review found that Villa et al. summarized sleep quality data as daytime and nighttime symptoms, expressed as the percentage of positive reports among treated subjects, and these questionnaires showed diminished symptoms following 6 months of treatment.

    “Villa et al.,23 summarized sleep quality (SQ) data as daytime and nighttime symptoms, expressed as the percentage of positive reports among treated subjects. These administered questionnaires showed diminished symptoms following 6 months of treatment.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Villa et al.,23

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    The review found that Cozza et al. discussed reduced daytime sleepiness following treatment, but without reporting any data.

    “Conversely, Cozza et al.,18, 21 discussed reduced daytime sleepiness following treatment, but without reporting any data.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Cozza et al.,18, 21

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    A manual review of reference lists of included studies and previously published systematic reviews and meta-analyses on obstructive sleep apnea and intraoral appliances was conducted.

    “A manual review of reference lists of included studies and previously published systematic reviews and meta-analyses on OSA and intraoral appliances was also conducted.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The enlargement of the upper airway and increase in upper airspace improve respiratory function in the short term.

    “The cephalometric (2D) and tomographic (3D) evaluations revealed enlargement of the upper airway and increase in the upper airspace, improving the respiratory function in the short term.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    No language restrictions were applied in the literature search.

    “No language restrictions were applied.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Functional orthodontic appliances are used for craniofacial abnormalities and may induce significant change in mandibular shape that leads to correction of dentoskeletal disharmony associated with mandibular retrusion.

    “Functional orthodontic appliances (FOA) are used for craniofacial abnormalities and may induce significant change in mandibular shape that leads to correction of dentoskeletal disharmony associated with mandibular retrusion.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] Perinetti G. Primozic J. Franchi L. Contardo L. Treatment effects of removable functional appliances in pre-pubertal and pubertal class II patients: a systematic review and meta-analysis of controlled studies PLoS One 10 2015 e0141198 26510187 PMC4624952 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    There is no evidence of contra-indications or significant side effects of functional appliances, as their use is short-term in nature.

    “Several studies in the literature have investigated the mechanisms of action and the effects of functional appliances and there is no evidence of contra-indications or even significant side effects as its use is short-term in nature.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Koretsi V. Zymperdikas V.F. Papageorgiou S.N. Papadopoulos M.A. Treatment effects of removable functional appliances in patients with class II malocclusion: a systematic review and meta-analysis Eur J Orthod 37 2015 418 434 25398303 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Evidence-based guidelines support continuous positive airway pressure treatment as an effective first-line treatment of obstructive sleep apnea in children without adenotonsillar hypertrophy, but it is complicated by low tolerance or high refusal (25%-50%).

    “Evidence-based guidelines support the use of continuous positive airway pressure treatment (CPAP) as an effective first-line treatment of OSA in children without adenotonsillar hypertrophy; however, this is complicated by low tolerance or high refusal level of treatment (25%–50%).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [8] Roberts S.D. Kapadia H. Greenlee G. Chen M.L. Midfacial and dental changes associated with nasal positive airway pressure in children with obstructive sleep apnea and craniofacial conditions J Clin Sleep Med 12 2016 469 475 26715402 PMC4795272 source

      Not checked in the free run.

    • cites [9] Hawkins S.M. Jensen E.L. Simon S.L. Friedman N.R. Correlates of pediatric CPAP adherence J Clin Sleep Med 12 2016 879 884 27092702 PMC4877321 source

      Not checked in the free run.

    • cites [10] Xanthopoulos M.S. Kim J.Y. Blechner M. Chang M.Y. Menello M.K. Brown C. Self-efficacy and short-term adherence to continuous positive airway pressure treatment in children Sleep 40 2017 28541508 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Any disagreement between reviewers was solved by consensus.

    “Any disagreement was solved by consensus.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Two authors screened studies and extracted data independently.

    “Two authors (R.C.B.B. and R.B.) screened studies and extracted data independently in Cochrane Library; PubMed, EBSCO (Dentistry & Oral Sciences Source), LILACS Ovid; SciELO Web of Science; EMBASE Bireme and BBO Bireme electronic databases.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Polysomnography was mandatory for inclusion of the chosen articles because the apnea-hypopnea index was one of the outcomes.

    “As one of the outcomes is the AHI, polysomnography was mandatory for inclusion of the chosen articles.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    High clinical therapeutic effectiveness for obstructive sleep apnea has been reported after adenotonsillectomy in nonobese children, and there is evidence of improvements in oximetry as well.

    “High clinical therapeutic effectiveness for OSA has been reported after adenotonsillectomy in nonobese children, and there is evidence of improvements in oximetry as well.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Mitchell R.B. Kelly J. Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight children Otolaryngol Neck Surg 137 2007 43 48 17599563 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    An et al. identified three phenotypes in OSA adults based on clustering using craniofacial variables in relation to OSA severity and obesity: Cluster-1 obesity type, Cluster-2 skeletal type, and Cluster-3 complex type.

    “The authors35 identified three phenotypes in OSA adults based on clustering using craniofacial variables in relation to OSA severity and obesity and characterized the phenotypes by differential correlation factors to OSA severity (AHI): Cluster-1, obesity type, Cluster-2, skeletal type, and Cluster-3, complex type.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35] An H.J. Baek S.H. Kim S.W. Kim S.J. Park Y.G. Clustering-based characterization of clinical phenotypes in obstructive sleep apnoea using severity, obesity, and craniofacial pattern Eur J Orthod 42 2020 93 100 31119286

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Removable functional appliances are less invasive and can be better tolerated than other modalities.

    “Removable functional appliances are less invasive and can be better tolerated than other modalities.24”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [24] Idris G. Galland B. Robertson C.J. Gray A. Farella M. Mandibular advancement appliances for sleep-disordered breathing in children: a randomized crossover clinical trial J Dent 71 2018 9 17 29357293 source

      Not checked in the free run.

    • Rests on an assumption: A significant number of children with OSA do not respond favorably to adenotonsillectomy or do not tolerate CPAP treatment.

  • May combine two claims.

    Premisecitation

    Growing adolescents with skeletal class II malocclusions treated with functional appliances demonstrated an increase in pharyngeal airway dimensions of the oropharyngeal region, and such changes were consistently maintained even after growth completion.

    “Growing adolescents with skeletal class II malocclusions treated with functional appliances demonstrated an increase in pharyngeal airway dimensions of the oropharyngeal region, and such changes were consistently maintained even after growth completion.32, 38”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [32] Pavoni C. Cretella Lombardo E. Franchi L. Lione R. Cozza P. Treatment and post-treatment effects of functional therapy on the sagittal pharyngeal dimensions in class II subjects Int J Pediatr Otorhinolaryngol 101 2017 47 50 28964309 source

      Not checked in the free run.

    • cites [38] Han S. Choi Y.J. Chung C.J. Kim J.Y. Kim K.H. Long-term pharyngeal airway changes after bionator treatment in adolescents with skeletal class II malocclusions Korean J Orthod 44 2014 13 19 24511511 PMC3915171 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Forward posturing of the mandible transforms the relationship between all structures adjacent to the mandible and increases the dimensions of the upper airways.

    “This change will also transform the relationship between all structures adjacent to the mandible, also increasing the dimensions of the upper airways.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Removable functional appliances can help improve the permeability of the upper airway during sleep, widening and decreasing the collapse of the upper airway, thus increasing its muscle tone.

    “Removable functional appliances can help improve the permeability of the upper airway during sleep, widening and decreasing the collapse of the upper airway, thus increasing its muscle tone.32”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [32] Pavoni C. Cretella Lombardo E. Franchi L. Lione R. Cozza P. Treatment and post-treatment effects of functional therapy on the sagittal pharyngeal dimensions in class II subjects Int J Pediatr Otorhinolaryngol 101 2017 47 50 28964309 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    The different therapeutic effects of a FOA in the treatment of obstructive sleep disorders might be due to differences in study protocols, appliance design and subject selection.

    “The different therapeutic effects of a FOA in the treatment of obstructive sleep disorders might be due to differences in study protocols, appliance design and subject selection.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Early treatment of craniofacial abnormalities can prevent the development of long-term respiratory failure, impacting quality of life in adulthood.

    “Therefore, early treatment of craniofacial abnormalities can prevent the development of long-term respiratory failure, impacting the quality of life in adulthood.23, 34, 39, 40, 41”
    Quote in the paperSubstantial claim0 of 5 sources checked
    • cites [23] Villa M.P. Bernkopf E. Pagani J. Broia V. Montesano M. Ronchetti R. Randomized controlled study of an oral jaw-positioning appliance for the treatment of obstructive sleep apnea in children with malocclusion Am J Respir Crit Care Med 165 2002 123 127 11779741 source

      Not checked in the free run.

    • cites [34] Villa M.P. Rizzoli A. Miano S. Malagola C. Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up Sleep Breath 15 2011 179 184 21437777 source

      Not checked in the free run.

    • cites [39] Villa M.P. Malagola C. Pagani J. Montesano M. Rizzoli A. Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up Sleep Med 8 2007 128 134 17239661 source

      Not checked in the free run.

    • cites [40] Pirelli P. Saponara M. De Rosa C. Fanucci E. Orthodontics and obstructive sleep apnea in children Med Clin North Am 94 2010 517 529 20451029 source

      Not checked in the free run.

    • cites [41] Pirelli P. Saponara M. Attanasio G. Obstructive Sleep Apnoea Syndrome (OSAS) and rhino-tubaric disfunction in children: therapeutic effects of RME therapy Prog Orthod 6 2005 48 61 English, Italian 15891784

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    When treating malocclusion and craniofacial orthopedic problems, orthodontists may eventually be treating the respiratory problems of their patients.

    “The orthodontist should be part of the health professional team involved in the multidisciplinary treatment of OSAS because, when treating malocclusion and craniofacial orthopedic problems, they may eventually be treating the respiratory problems of their patients.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    An early FOA approach can permanently change breathing and nasal breathing, thereby preventing upper airway obstruction.

    “FOA therapy should be encouraged in pediatric OSA, and an early approach can permanently change breathing and nasal breathing, thereby preventing upper airway obstruction.42”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [42] Villa M.P. Miano S. Rizzoli A. Mandibular advancement devices are an alternative and valid treatment for pediatric obstructive sleep apnea syndrome Sleep Breath 16 2012 971 976 21948042 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    FOA would also treat OSA because they promote mandibular replacement during sleep and increase the retroglossal space by anterior displacement of the tongue, improving respiratory function, especially at night.

    “Villa et al. in 200223 reports that, in addition to treating the craniofacial problem, FOA would also be treating OSA because they promote mandibular replacement during sleep and increase the retroglossal space by anterior displacement of the tongue, improving respiratory function, especially at night.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] Villa M.P. Bernkopf E. Pagani J. Broia V. Montesano M. Ronchetti R. Randomized controlled study of an oral jaw-positioning appliance for the treatment of obstructive sleep apnea in children with malocclusion Am J Respir Crit Care Med 165 2002 123 127 11779741 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Patients in Cluster-2, who have collapsible upper airway primarily driven by craniofacial anatomic vulnerability without non-anatomic problems, would be the best indication of orthopaedic or surgical modification of craniofacial structure.

    “airway primarily driven by craniofacial anatomic vulnerability without non-anatomic problems, would be the best indication of orthopaedic or surgical modification of craniofacial structure.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35] An H.J. Baek S.H. Kim S.W. Kim S.J. Park Y.G. Clustering-based characterization of clinical phenotypes in obstructive sleep apnoea using severity, obesity, and craniofacial pattern Eur J Orthod 42 2020 93 100 31119286

      Not checked in the free run.

38 of 38

  • The paper relies on this without support.

    A significant number of children with OSA do not respond favorably to adenotonsillectomy or do not tolerate CPAP treatment.

    “A significant number of children with OSA do not respond favorably to the primary treatment “adenotonsillectomy” or do not tolerate CPAP treatment.”

  • The paper relies on this without support.

    OSA has been associated with deviations in craniofacial growth in children.

    “OSA has been associated with deviations in craniofacial growth in children.”
2 of 2

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Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Abstract says every study improved AHI, but a case report found an increase

    Major

    The abstract says all studies found an improvement in AHI. The included Rădescu case report instead reports that AHI increased from 2.6 to 10.2 events per hour.

  • Reported absence of sleepiness data conflicts with Table 1

    Minor

    The Results text says Cozza et al. reported reduced daytime sleepiness without data. Table 1 gives before-and-after ESS values for Cozza et al.21.

  • English-only search description conflicts with inclusion of a German article

    Minor

    The abstract describes the search as including papers published in English, but the Results section says one included article was in German.

  • The number of randomized clinical studies differs

    Minor

    The abstract counts four randomized clinical studies, whereas the Results section counts three RCTs among the same 13 included articles.

  • Maspero age range excludes ages listed for its participants

    Minor

    The stated overall age range for the 40 patients begins at 9 years, but the same table entry lists female patients as young as 8.

  • Schessl study has conflicting publication years

    Minor

    Table 3 dates Schessl et al.28 to 2006, while reference 28 dates it to 2008.

6 of 6

Cites

Flagged first, then by citations

5 of the 51 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Bariani, R. C. B., Bigliazzi, R., Cappellette Junior, M., Moreira, G., & Fujita, R. R.
Affiliations
Universidade Federal de São Paulo (BR)
Corresponding author
Bariani, Rita Catia Brás
ORCID
Venue
Brazilian Journal of Otorhinolaryngology
Publisher
Elsevier BV
Published
2022-03
Volume
88
Issue
2
Pages
263-278
ISSN
  • 1808-8686 (ISSN-L)
  • 1808-8694
DOI
10.1016/j.bjorl.2021.02.010
PMC
PMC9422464
OpenAlex
W3136188738
Semantic Scholar
b5ebe9b69af8046e4d5f029a853dc10f73fd38ff
Cited by
28
References
51
Citations by year
2025: 8 · 2024: 8 · 2023: 7 · 2022: 4 · 2021: 1
FWCI
0.67
Type
journal article
Language
en
Open access
Licence
Locations
  • Brazilian Journal of Otorhinolaryngology (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (publishedVersion, other-oa)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (88882.430440/2019-01)
  • Associacao Fundo de Incentivo a Pesquisa
Topics
  • Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
  • Health Sciences › Dentistry › Orthodontics › Orthodontics and Dentofacial Orthopedics
  • Health Sciences › Health Professions › Complementary and Manual Therapy › Temporomandibular Joint Disorders
Keywords
obstructive sleep apnea, pediatric sleep apnea, functional orthodontic appliances, mandibular advancement, mandibular deficiency, oral appliances, apnea-hypopnea index, upper airway, cephalometric analysis, 3D tomography, treatment effectiveness
MeSH terms
Cephalometry, Child, Humans, Treatment Outcome, Orthodontic Appliances, Functional, Mandibular Advancement, Sleep Apnea, Obstructive

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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