Long-term recurrence-free survival of orthodontic treatments for Class II malocclusion as the important supplement protocol to adenotonsillectomy in children with obstructive sleep apnea syndrome: a case-control retrospective study

Background: To estimate the long-term recurrence-free-survival of three orthodontic treatments in the management of residual obstructive sleep apnea syndrome (OSAS) after adenotonsillectomy in children combined with Class II malocclusion taking conventional positive airway pressure (PAP) as control. Methods: A retrospective case-control cohort study, enrolled pediatric OSAS with Class II after adenotonsillectomy. The records of the patients were divided into a rapid maxillary expansion (RME), mandibular advancement appliances (MAA) and myofunctional therapy (MFT) group based on the therapy they received. Control group comprised patients used PAP at the same admission time. The primary endpoint was a long-term recurrence-free-survival. Secondary outcomes measures included the immediate post-operative success rate, improvements in the Epworth Sleepiness Scale (ESS) scores, craniofacial changes, s-electromyogram (s-EMG) changes of masticatory muscle and long-term OSAS sequelae. Results: A total of 1217 cases were analyzed. The estimated 1-, 3- and 5-year recurrence-free rate was 81.9%, 70.8% and 56.4% in PAP vs. 86.2%, 81.0% and 77.5% in RME vs. 85.5%, 78.0%and 74.7% in MAA vs. 83.0%, 74.9% and 58.3% in MFT, respectively. Significantly greater median of recurrence-free-survival was observed in RME, MAA and MFT group as opposed to PAP-control group (122.04 ± 3.04 (95% CI (confidence interval): 116.08, 127.99), 20.04 ± 4.21 (95% CI: 111.79, 128.28), 68.96 ± 4.95 (95% CI: 59.24, 78.68) vs. 54.96 ± 2.51 (95% CI: 50.05, 59.87)). The post-treatment ESS scores, craniofacial variables, s-EMG parameters greatly improved at post-treatment from the baseline value and sustained during long-term follow-up. No severe complications were observed. Conclusions: As opposed to conventional PAP, a better long-term RFS (recurrence free survival) was associated with the therapeutic trial using RME and MAAs, which provided a reasonable alternative for residual OSAS after adenotonsillectomy in children combined with Class II malocclusion. Their benefits appeared especially in children due to poor compliance to conventional PAP.

Residual obstructive sleep apnea syndrome; Class II malocclusion; Positive airway pressure; Rapid maxillary expansion; Mandibular advancement appliances; Myofunctional therapy

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