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Cited by 10Obstructive Sleep Apnea ResearchOrthodontics and Dentofacial OrthopedicsTemporomandibular Joint Disorders

Mandibular Advancement Appliances in Pediatric Obstructive Sleep Apnea: An Umbrella Review

Open access
Cozzi-Machado, Carolina, Albertini, Fátima Rosana, Silveira, Silvana, Machado-Júnior, Almiro José·2023·Sleep Science
DOI 10.1055/s-0043-1776747PMC PMC10773500
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Abstract

Introduction Obstructive sleep apnea (OSA) is defined as intermittent partial or complete collapse of the upper airway during sleep. It is a common condition in childhood, with an incidence ranging from 1.2% to 5.7%, and it can harm several aspects of children's life, such as cognitive, metabolic and cardiovascular functions, among others. There are treatment options, such as adenotonsillectomy, myofunctional therapy, mandibular advancement appliances (MAAs), rapid maxillary expansion, and positive airway pressure devices, but there is still doubt about which method is more suitable for the treatment of OSA in children. Objective To analyze the effectiveness of MAAs in the treatment of pediatric OSA. Materials and Methods The search was conducted in August 2021 in different electronic databases, such as PubMed, EBSCO (Dentistry & Oral Sciences Source), LILACS, Ovid, SciELO, Web of Science, EMBASE BIREME, BBO BIREME, and the Cochrane Library. Results Only three systematic reviews and two meta-analyses were included in the present study. All studies showed improvement in the score on the apnea-hypopnea index after using MAAs in the treatment of pediatric OSA. Conclusion Although more randomized studies are needed, based on the present umbrella review, MAAs must be considered part of the multidisciplinary treatment for pediatric OSA.

AI snapshot

Written from the paper’s full text.

TL;DR

This umbrella review of three systematic reviews and two meta-analyses found that mandibular advancement appliances reduced AHI in pediatric obstructive sleep apnea, with at least 50% AHI reduction in three included reviews/meta-analyses. The authors conclude MAAs should be considered part of multidisciplinary treatment, while calling for more randomized studies.

Key findings

  • Five studies were included (3 systematic reviews, 2 meta-analyses); sample sizes ranged from 32 to 269 individuals aged 3.5 to 14 years, and treatment duration ranged from 3 weeks to 20 months. Long-term treatment (6 to 12 months) was more effective than short-term treatment.
  • AHI reductions included: Yanyan et al. −1.75 events/h (95% CI −2.07 to −1.44; p = 0.00001), with 50% reduction for mild, 57% for moderate, and 76% for severe cases; Carvalho et al. −4.5 events/h (p < 0.001), 50% in 9 of 14 subjects, and 64.2% success; Huynh et al. −4.5 events/h (p < 0.001) and −4.22 events/h (p = 0.0003). Nazarali et al. reported ≥50% reduction (1 study used RDI), while Bariani et al. reported 12 studies with reduced AHI but could not statistically analyze the data due to heterogeneity.
  • All studies showed AHI reduction after MAAs except Rădescu et al., a single case report in which AHI increased from 2.6 to 10.2. No included study reported cure (AHI < 1 event/h), and there were only 14 treatment dropouts (6 controls and 8 MAA-treated patients).

Methods

  • Umbrella review following the PRISMA checklist; search conducted until August 2021 in PubMed, EBSCO (Dentistry & Oral Sciences Source), LILACS, Ovid, SciELO, Web of Science, EMBASE BIREME, BBO BIREME, and the Cochrane Library.
  • Inclusion criteria: children and adolescents (age ≤ 18 years) diagnosed with OSA without craniofacial syndromes; intervention with MAAs; comparison with and without a control group; outcome AHI; study design systematic review and meta-analysis. Two reviewers independently selected articles and assessed risk of bias using the ROBIS tool.
  • From 36 identified articles, 32 remained after duplicates were removed, 27 were excluded, and 5 were included (3 systematic reviews and 2 meta-analyses). Extracted data included author, year, study design, age of sample, treatment, and AHI before and after MAAs.

Limitations

  • Stated: the few studies analyzed had small samples, except for Bariani et al., whose larger sample could not be statistically analyzed due to heterogeneity; results must be analyzed carefully; more randomized studies are needed; this is a relatively new field with many questions to be explained.
  • Evident from the text: only five reviews/meta-analyses were included, heterogeneity prevented statistical analysis in some, one included study was a single case report with AHI worsening, and no included study reported cure (AHI < 1 event/h).

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

Integrity signals

Registry

Crossref · 10.1055/s-0043-1776747

Cites

37 of 37 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 43 cited sources checked · 0 supported · 0 flagged

  • Findingnone given

    Long-term mandibular advancement appliance treatment of 6 to 12 months was more effective than short-term treatment for pediatric obstructive sleep apnea.

    “Long-term treatment (6 to 12 months) was more effective than short-term treatment.”
    • Also stated in: § Discussion · plain
      “Long-term treatment (of at least 6 months) is superior to the short-term treatment.”
    Quote in the paperSubstantial claim
  • Findingnone given

    Studies 17 through 21 were carried out with children who had not undergone adenotonsillar surgery.

    “Studies 17 18 19 20 21 were carried out with children who had not undergone adenotonsillar surgery.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [17] M Yanyan, 2019, Mandibular advancement appliances for the treatment of obstructive sleep apnea in children: a systematic review and meta-analysis, Sleep Med source

      Not checked in the free run.

    • cites [18] R CB Bariani, 2022, Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review, Rev Bras Otorrinolaringol (Engl Ed) source

      Not checked in the free run.

    • cites [19] N Nazarali, 2015, Mandibular advancement appliances for the treatment of paediatric obstructive sleep apnea: a systematic review, Eur J Orthod source

      Not checked in the free run.

  • Findingown data

    All included studies except Rădescu et al. showed a reduction in the apnea-hypopnea index after mandibular advancement appliance treatment in pediatric obstructive sleep apnea.

    “All studies presented a reduction in the AHI after treatment with MAAs, except those in the study by Rădescu et al. 31”
    • Also stated in: § Discussion · plain
      “All studies included in the present review showed AHI reduction, except for Rădescu et al., 31 who observed an AHI increase.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] OD Rãdescu, 2017, Results in the treatment with twin block polymeric appliance of the retrognathic mandible in sleep apnea patients, Rev Mater Plast source

      Not checked in the free run.

  • Interpretationown data

    The data obtained in this umbrella review show that mandibular advancement appliances are a viable and complementary therapeutic resource for the treatment of obstructive sleep apnea in children and adolescents with craniofacial disorders such as Angle class-II malocclusion, maxillary narrowing, and mandibular retrognathia.

    “The herein data obtained show that MAAs are a viable and complementary therapeutic resource for the treatment of OSA in children and adolescents with craniofacial disorders, such as those with Angle class-II malocclusion, maxillary narrowing, and mandibular retrognathia, which are very frequent alterations in mouth breathers.”
    Quote in the paperSubstantial claim
  • Interpretationcitation

    If skeletal and dentoalveolar correction is accomplished permanently, pediatric patients no longer need to wear mandibular advancement appliances, because skeletal growth is complete and the obstructive sleep apnea predisposing factor is solved.

    “If these changes are accomplished permanently, pediatric patients no longer need to wear the MAAS, since the skeletal growth is complete and this important OSA predisposing factor will be solved. 19”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19] N Nazarali, 2015, Mandibular advancement appliances for the treatment of paediatric obstructive sleep apnea: a systematic review, Eur J Orthod source

      Not checked in the free run.

  • May combine two claims. 24
  • The quote only partly states this claim. 2
  • Classified as probably not a substantial claim. 8

  • May combine two claims. The quote only partly states this claim.

    Findingcitation

    In three included studies, Yanyan et al., Carvalho et al., and Huynh et al., a reduction of at least 50% in the apnea-hypopnea index was observed after mandibular advancement appliance treatment, and this was considered therapeutic success.

    “In the other 3 studies, 17 20 21 a reduction of at least 50% in the AHI was observed, which was considered as therapeutic success, even if the scores were not within the normal range.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [17] M Yanyan, 2019, Mandibular advancement appliances for the treatment of obstructive sleep apnea in children: a systematic review and meta-analysis, Sleep Med source

      Not checked in the free run.

    • cites [20] FR Carvalho, 2016, Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children, Cochrane Database Syst Rev source

      Not checked in the free run.

    • cites [21] NT Huynh, 2016, Orthodontics treatments for managing obstructive sleep apnea syndrome in children: A systematic review and meta- analysis, Sleep Med Rev source

      Not checked in the free run.

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

    Findingown data

    Only three systematic reviews and two meta-analyses were included in the present umbrella review.

    “Only three systematic reviews and two meta-analyses were included in the present study.”
    • Also stated in: § Results · plain
      “Five articles remained: three systematic reviews and two meta-analyses.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Zhang et al. and Rose and Schessl excluded children with adenotonsillar hypertrophy.

    “Zhang et al. 28 and Rose and Schessl 32 excluded children with adenotonsillar hypertrophy.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [28] C Zhang, 2013, Effects of twin block appliance on obstructive sleep apnea in children: a preliminary study, Sleep Breath source

      Not checked in the free run.

    • cites [32] E Rose, 2006, Orthodontic procedures in the treatment of obstructive sleep apnea in children, J Orofac Orthop source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    In most included studies, mandibular advancement appliance treatment had a minimum duration of 6 months, except for a subgroup treated for 3 weeks in Yanyan et al.

    “In most studies, the MAAs treatment had a minimum duration of 6 months, with the exception of a subgroup treated for 3 weeks in the study by Yanyan et al. 17”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] M Yanyan, 2019, Mandibular advancement appliances for the treatment of obstructive sleep apnea in children: a systematic review and meta-analysis, Sleep Med source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Mandibular advancement appliances were well tolerated in the pediatric population, with only 14 treatment dropouts, 6 controls and 8 patients treated with mandibular advancement appliances, in the included studies.

    “In general, MAAs were well tolerated in the pediatric population, with only 14 treatment dropouts (6 controls and 8 patients treated with MAAs), in the included studies.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Modesti-Vedolin et al. treated children in the Otolaryngology Service who were on the waiting list for amygdalectomy and observed a reduction in the respiratory disturbance index from 10 to 4.5 per hour.

    “Modesti-Vedolin et al, 34 treated children in the Otolaryngology Service who were in the waiting list for amygdalectomy, and they observed a reduction in the respiratory disturbance index from 10 to 4.5/h.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34] G Modesti-Vedolin, 2018, Efficacy of a mandibular advancement intraoral appliance (MOA) for the treatment of obstructive sleep apnea syndrome (OSAS) in pediatric patients: A pilot-study, Med Oral Patol Oral Cir Bucal source

      Not checked in the free run.

  • The quote only partly states this claim.

    Findingown data

    In two included studies, Bariani et al. and Nazarali et al., the reduction in apnea-hypopnea index after mandibular advancement appliance treatment could not be statistically analyzed because of considerable heterogeneity of the data.

    “In two studies, 18 19 although there was a reduction in the AHI, it could not be statistically analyzed due to the considerable heterogeneity of the data.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [18] R CB Bariani, 2022, Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review, Rev Bras Otorrinolaringol (Engl Ed) source

      Not checked in the free run.

    • cites [19] N Nazarali, 2015, Mandibular advancement appliances for the treatment of paediatric obstructive sleep apnea: a systematic review, Eur J Orthod source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Villa et al. included children with adenotonsillar hypertrophy and observed an improvement in apnea-hypopnea index from 7.1 to 2.6 per hour, as well as a reduction in adenotonsillar hypertrophy after 6 months.

    “Villa et al 22 included children with adenotonsillar hypertrophy and they still observed an improvement in the AHI, from 7.1 to 2.6/h, as well as a reduction in adenotonsillar hypertrophy after 6 months. 22”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [22] MP Villa, 2002, 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 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    There is a lack of statistically significant data in this field.

    “There is a lack of statistically significant data in this field.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Mandibular advancement is well established in adult obstructive sleep apnea treatment.

    “Another therapeutic resource can be found in MAAs: mandibular advancement is well established in adult OSA treatment; in children, the aim is to correct mandibular retrognathia through redirection and stimulation of anterior mandibular growth, in a passive or active manner, which can be achieved through different appliances, such as the Herbst, Frankell II, twin-block, and others. 17”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] M Yanyan, 2019, Mandibular advancement appliances for the treatment of obstructive sleep apnea in children: a systematic review and meta-analysis, Sleep Med source

      Not checked in the free run.

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

    Study design and conductown data

    Two reviewers independently evaluated the quality of the included studies using the ROBIS tool.

    “To evaluate the risk of bias in individual studies, the University of Bristol's Risk of Bias in Systematic Reviews (ROBIS) tool was used. Two reviewers (CCM and FRA) independently evaluated the quality of the studies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The few studies analyzed had small samples, except for Bariani et al., whose sample was larger, but statistical analysis was not possible because of heterogeneity of the data.

    “However, the few studies analyzed had small samples, except for the one by Bariani et al., 18 in which the sample was larger, but the statistical analysis was not possible due to the heterogeneity of the data.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] R CB Bariani, 2022, Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review, Rev Bras Otorrinolaringol (Engl Ed) source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Although none of the included studies reported a cure for obstructive sleep apnea, defined as apnea-hypopnea index less than 1 event per hour, after mandibular advancement appliance use, the reduction of at least 50% in respiratory events in children who had not undergone adenotonsillar surgery, associated with adherence, shows the effectiveness of mandibular advancement appliances.

    “Although none of the studies included reported a cure for OSA (AHI < 1 event/h) after the use of MAAS, the reduction of at least 50% in respiratory events in children who had not undergone adenotonsillar surgery, associated with adherence, shows its effectiveness.”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    The present umbrella review followed the PRISMA checklist.

    “The present umbrella review followed the checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Functional orthopedic appliances are able to increase upper airway space, reduce airway collapsibility, and improve muscle tone.

    “They are able to increase upper airway space, reduce airway collapsibility, and improve muscle tone. 18 20”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [18] R CB Bariani, 2022, Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review, Rev Bras Otorrinolaringol (Engl Ed) source

      Not checked in the free run.

    • cites [20] FR Carvalho, 2016, Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children, Cochrane Database Syst Rev source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    Two reviewers independently selected the articles, and only full-text articles were included.

    “Two reviewers (CCM and FRA) independently selected the articles, and only full-text articles were included.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Mandibular advancement appliances improve the apnea-hypopnea index and increase posterior airway space, reducing airway collapsibility.

    “Mandibular advancement appliances improve the AHI and increase posterior airway space, reducing airway collapsibility.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] M Yanyan, 2019, Mandibular advancement appliances for the treatment of obstructive sleep apnea in children: a systematic review and meta-analysis, Sleep Med source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    These undesirable effects of mandibular advancement appliances are most common in long-term treatment of at least 5 years, which exceeds the treatment period of the studies included in the umbrella review.

    “All these undesirable effects are most common in the long-term treatment (of at least 5 years), 36 which exceeds the treatment period of the studies included in the present umbrella review.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    High-quality meta-analyses support mandibular advancement in obstructive sleep apnea patients, even in severe cases, as long as treatment is established before pubertal peak.

    “According Yanyan et al., 17 high-quality meta-analyses support mandibular advancement in OSA patients, even in severe cases, as long as the treatment is established before pubertal peak.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] M Yanyan, 2019, Mandibular advancement appliances for the treatment of obstructive sleep apnea in children: a systematic review and meta-analysis, Sleep Med source

      Not checked in the free run.

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

    Premisecitation

    Adenotonsillectomy is curative in 25% to 75% of pediatric obstructive sleep apnea patients.

    “However, some studies 8 9 10 have reported that adenotonsillectomy is curative in 25% to 75% of the patients.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [8] S E Brietzke, 2006, The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis, Otolaryngol Head Neck Surg source

      Not checked in the free run.

    • cites [9] M Friedman, 2009, Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome, Otolaryngol Head Neck Surg source

      Not checked in the free run.

    • cites [10] R Tauman, 2006, Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy, J Pediatr source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Functional orthopedic appliances, if correctly prescribed, are well tolerated and are able to increase airway space during sleep, reduce airway collapsibility, and improve muscle tone.

    “Therefore, functional orthopedic appliances, if correctly prescribed, are well tolerated and are able to increase airway space during sleep, reduce airway collapsibility, and improve muscle tone. 18 20”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [18] R CB Bariani, 2022, Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review, Rev Bras Otorrinolaringol (Engl Ed) source

      Not checked in the free run.

    • cites [20] FR Carvalho, 2016, Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children, Cochrane Database Syst Rev source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Many adults begin snoring and experiencing other respiratory disturbances, such as obstructive sleep apnea, in childhood, so early diagnosis and treatment are relevant to prevent long-term complications in adult life.

    “Many adults begin snoring and experiencing other respiratory disturbances, such as OSA, in childhood; hence, the relevance of early diagnosis and treatment to prevent long-term complications in adult life. These measures also contribute to reduce costs to the healthcare system and improve quality of life. 20”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] FR Carvalho, 2016, Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children, Cochrane Database Syst Rev source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    From the orthodontic perspective, mandibular advancement appliances promote dentoalveolar changes and bone growth.

    “From the orthodontic perspective, MAAs also promote dentoalveolar changes and bone growth. 17”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] M Yanyan, 2019, Mandibular advancement appliances for the treatment of obstructive sleep apnea in children: a systematic review and meta-analysis, Sleep Med source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Although adenotonsillectomy is widely performed to treat pediatric obstructive sleep apnea around the world, recurrence is very common, particularly in children with skeletal deformities such as mandibular retrognathia, maxillary constriction, or both.

    “Although adenotonsillectomy is widely performed to treat pediatric OSA around the world, recurrence is very common, particularly in children with skeletal deformities, such as mandibular retrognathia, maxillary constriction, or both. 20”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] FR Carvalho, 2016, Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children, Cochrane Database Syst Rev source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A significant number of children do not respond to adenotonsillectomy, and most of them do not tolerate continuous positive airway pressure therapy.

    “A significant number of children do not respond to adenotonsillectomy, which is still the primary treatment for OSA, and most of them do not tolerate CPAP therapy.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [18] R CB Bariani, 2022, Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review, Rev Bras Otorrinolaringol (Engl Ed) source

      Not checked in the free run.

    • cites [20] FR Carvalho, 2016, Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children, Cochrane Database Syst Rev source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Some possible side-effects related to mandibular advancement appliances are more likely in patients with Angle class-I and III malocclusion, because mandibular advancement can lead class-I patients to class III and can worsen class-III patients.

    “Some possible side-effects related to the MAAs are more likely to happen in patients with Angle class-I and III malocclusion, because the mandibular advancement can lead class-I patients to class III, and, in the condition of class-III patients can be worsened by the mandibular advancement. 36”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36]

      Not checked in the free run.

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

    Premisecitation

    Adenotonsillectomy is still the most performed treatment in pediatric obstructive sleep apnea and has been highly effective in non-obese children, even improving oximetry results.

    “Adenotonsillectomy is still the most performed treatment in cases of pediatric OSA, and it has been highly effective throughout the years in non-obese children, even resulting in an improvement in oximetry results. 7”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] R B Mitchell, 2007, Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight children, Otolaryngol Head Neck Surg source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    As a functional appliance brings the jaw forward, superior airway space increases, and therefore the apnea-hypopnea index improves as long as the patient is wearing the appliance.

    “As the functional appliance brings the jaw forward, an increase in the superior airway space occurs. Therefore, the AHI will be improved, as long as the patient is wearing the appliance.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Mandibular advancement appliances may cause posterior dental disocclusion, orofacial and temporomandibular joint pain, and tooth breakage during mastication.

    “Mandibular advancement appliances may cause posterior dental disocclusion, orofacial and temporomandibular joint pain, and tooth breakage during mastication.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Continuous positive airway pressure is considered the first-line treatment in pediatric obstructive sleep apnea without adenotonsillar hypertrophy, although with low tolerance of 25% to 50% and risk of craniofacial sequels after long-term use.

    “Continuous positive airway pressure (CPAP) is considered the first-line treatment in pediatric OSA without adenotonsillar hypertrophy, although with low tolerance (25% to 50%) 11 12 13 and risk of craniofacial sequels after long-term use. 14 15”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [11] S D Roberts, 2016, Midfacial and Dental Changes Associated with Nasal Positive Airway Pressure in Children with Obstructive Sleep Apnea and Craniofacial Conditions, J Clin Sleep Med source

      Not checked in the free run.

    • cites [12] S M Hawkins, 2016, Correlates of Pediatric CPAP Adherence, J Clin Sleep Med source

      Not checked in the free run.

    • cites [13] M S Xanthopoulos, 2017, Self-Efficacy and Short-Term Adherence to Continuous Positive Airway Pressure Treatment in Children, Sleep source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Mandibular advancement appliances may decrease the intraoral space for the tongue, which can be displaced backwards, leading to a collapse of the tongue base.

    “Another aspect that should be considered is that MAAs may decrease the intraoral space for the tongue, which can be displaced backwards, leading to a collapse of the tongue base.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] A J Machado-Júnior, 2016, Randomized controlled study of a mandibular advancement appliance for the treatment of obstructive sleep apnea in children: A pilot study, Med Oral Patol Oral Cir Bucal source

      Not checked in the free run.

31 of 31

  • The paper relies on this without support.

    There is still uncertainty about which treatment method is more suitable for the treatment of obstructive sleep apnea in children.

    “There are treatment options, such as adenotonsillectomy, myofunctional therapy, mandibular advancement appliances (MAAs), rapid maxillary expansion, and positive airway pressure devices, but there is still doubt about which method is more suitable for the treatment of OSA in children.”
1 of 1

Claims other papers make about this one

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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.

  • Modesti-Vedolin is assigned Idris's reference number

    Minor

    Table 3 assigns reference 25 to Modesti-Vedolin et al., while the reference list assigns 25 to Idris et al. Modesti-Vedolin et al. appears as reference 34.

  • Cozza is cited with Rose and Schessl's reference number

    Minor

    Table 2 labels Cozza et al. as reference 32, but the reference list assigns 32 to Rose and Schessl. Table 3 identifies Cozza et al. as reference 26.

  • A reported post-treatment AHI meets the paper's cure criterion

    Minor

    The paper says no included study reported cure, defined as AHI below 1 event/h. Table 3 reports a post-treatment AHI of 0.30 for Machado-Júnior et al.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. American Academy of Sleep Medicine, 2014, International classification of sleep disorders. 3rd ed

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Authors
Cozzi-Machado, C., Albertini, F. R., Silveira, S., & Machado-Júnior, A. J.
Affiliations
  • Universidade Estadual de Campinas (UNICAMP) (BR)
  • Department of Otorhinolaryngology, Head and Neck Surgery, Faculdade de Ciências Médicas (FCM), Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil; Institute of Science and Technology, Universidade Estadual de São Paulo (UNESP), São José dos Campos, SP, Brazil
Corresponding author
Cozzi-Machado, Carolina
ORCID
Cozzi-Machado, Carolina
Venue
Sleep Science
Publisher
Georg Thieme Verlag KG
Published
2023-11-22
Volume
16
Issue
04
Pages
e468-e475
ISSN
  • 1984-0063 (ISSN-L)
  • 1984-0659
DOI
10.1055/s-0043-1776747
PMC
PMC10773500
OpenAlex
W4388892209
Semantic Scholar
eb92fc12bc851cae700c95d22e71e58a9ae68687
Cited by
10
References
37
Citations by year
2026: 5 · 2025: 2 · 2024: 3
FWCI
0.36
Type
journal article
Language
en
Open access
Licence
Locations
  • Sleep Science (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
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
mandibular advancement device, pediatric obstructive sleep apnea, apnea-hypopnea index, upper airway collapse, adenotonsillectomy, myofunctional therapy, rapid maxillary expansion, positive airway pressure, treatment effectiveness

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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