Long-Term Efficacy of Orthopedic Mandibular Advancement Therapy in Pediatric Obstructive Sleep Apnea: A 7-Year Follow-Up Study

Long-Term Efficacy of Orthopedic Mandibular Advancement Therapy in Pediatric Obstructive Sleep Apnea: A 7-Year Follow-Up Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long-Term Efficacy of Orthopedic Mandibular Advancement Therapy in Pediatric Obstructive Sleep Apnea: A 7-Year Follow-Up Study Serife Kiran Aydil, Esen Kiyan, Refika Ersu, Hulya Kilicoglu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8901194/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Study Objectives: To evaluate the long-term effects of monoblock mandibular advancement therapy on craniofacial morphology, upper airway dimensions, and sleep-related parameters in children with obstructive sleep apnea (OSA). Methods: This prospective longitudinal cohort study included 13 children (mean age 10.97 ± 1.51 years) with OSA and mandibular retrognathia treated with a monoblock appliance. Assessments were conducted at baseline (T1), post-treatment (T2), and 7 years after treatment (T3), including lateral cephalometric radiographs, polysomnography, and Pittsburgh Sleep Quality Index (PSQI) scores. Pharyngeal airway changes were analyzed using a standardized cephalometric protocol across 11 sagittal reference planes. Repeated measures ANOVA and nonparametric equivalents were applied for longitudinal comparisons. Results: Increases in oropharyngeal and hypopharyngeal airway dimensions (S6–S10) observed after treatment were generally maintained over time. Skeletal parameters showed relative stability at follow-up. Although AHI decreased significantly after treatment, a moderate increase was noted at T3; however, values remained below the adult diagnostic threshold in most patients. PSQI scores improved initially and did not show significant long-term deterioration. An increase in REM sleep percentage at T3 may reflect normalization of sleep architecture following earlier first-night effects. Conclusions: Monoblock mandibular advancement therapy initiated during childhood may be associated with favorable and largely sustained changes in skeletal and airway parameters over a 7-year period. While partial recurrence of AHI was observed during adolescence, the overall pattern suggests a potential long-term benefit in selected patients, warranting further investigation in larger cohorts. Pediatric OSA mandibular retrognathia functional appliance long-term outcomes sleep Figures Figure 1 Figure 2 Introduction Sleep-disordered breathing includes a spectrum of conditions from habitual snoring to obstructive sleep apnea (OSA), the most severe form, characterized by intermittent upper airway obstruction during sleep.[ 1 ] OSA is associated with multiple factors such as adenotonsillar hypertrophy, reduced muscle tone, and craniofacial anomalies (e.g., transverse maxillary deficiency, mandibular retrognathia, micrognathia, macroglossia).[ 2 , 3 ] These anatomical deviations may reduce airway dimensions and contribute to OSA.[ 4 , 5 ] Pediatric OSA is increasingly recognized as a multifactorial disorder in which skeletal, neuromuscular, and behavioral components interact to influence airway patency.[ 6 ] Given its multifactorial nature, the optimal treatment for OSA remains debated. While adenotonsillectomy remains the first-line treatment for pediatric OSA and is effective in many cases, concerns about long-term outcomes and recurrence in certain patient populations have prompted interest in alternative or adjunctive therapies. [ 7 , 8 ] Since abnormal mandibular and maxillary growth contributes significantly to pediatric OSA [ 4 , 5 ], orthodontic treatments targeting these issues—such as rapid maxillary expansion [ 9 ], mandibular advancement appliances [ 10 ], and maxillary protraction devices [ 11 ]—have been explored. Several studies have explored the long-term impact of these devices, particularly their ability to sustain mandibular advancement and cephalometric gains in airway dimensions in growing children.[ 12 , 13 , 14 , 15 ] These changes appear to be stable over time and beneficial for sleep apnea. However, considering that OSA is influenced by not only skeletal parameters but also by neuromuscular, behavioral, and positional factors,[ 16 ] evaluating only craniofacial structures may not provide a comprehensive understanding of the disorder in the long term. However, to date, no study has examined the long-term effects of mandibular advancement therapy using both polysomnographic data and airway measurements in children. Therefore, this study aims to evaluate the long term (7 years) outcomes of children with mandibular retrognathia and OSA who were treated with a monoblock appliance, by assessing both polysomnographic and cephalometric variables. Materials and Methods This study builds upon a previous investigation [ 17 ] that included patients diagnosed with OSA via polysomnography (PSG) and aims to evaluate the long-term outcomes of that initial cohort. It was designed as a prospective longitudinal cohort study in which patients previously treated with a monoblock appliance were re-evaluated 7 years after treatment completion. Ethical approval for the present study was obtained from the Human Ethics Committee of Istanbul Medipol University, Istanbul, Turkey (Approval No: 10840098-604.01.01-E.65336). The initial cohort consisted of 16 consecutive pediatric patients with confirmed OSA (defined as an apnea–hypopnea index [AHI] ≥ 1) and skeletal Class II malocclusion (SNB angle < 78°). (17) Exclusion criteria included cleft lip and/or palate, obesity, cardiopulmonary diseases, syndromic conditions, dysmorphism, or other craniofacial anomalies. Orthopedic mandibular advancement was chosen for these patients because of their mandibular retrognathia and confirmed OSA after interdisciplinary evaluation. Each patient was treated with individualized custom-fabricated monoblock appliances (Fig. I). This functional orthopedic device is commonly used in orthodontics to achieve mandibular advancement in growing patients.[ 18 ] The appliance was a single-piece appliance that covers the palatal and occlusal surfaces of the maxillary teeth, as well as the occlusal and palatolingual surfaces of the mandibular teeth. Patients were instructed to wear the appliance for a minimum of 17 hours per day. Functional orthopedic therapy was discontinued once a stable Class I molar relationship was achieved, which occurred within a period ranging from 6 to 10 months. All of the individuals were invited to participate in the present follow-up study. One patient declined to participate, and two were excluded due to obesity, based on reassessed body mass index (BMI) values. These three patients who were not included in the final follow-up sample did not differ substantially from the included participants in terms of baseline age, craniofacial characteristics, or initial AHI values. None of the patients had undergone adenotonsillectomy during the initial treatment or prior to the follow-up assessment. Consequently, the remaining 13 patients (81% of the initial group; 6 boys, 7 girls) were enrolled in this study. At treatment initiation, the mean age was 10.97 ± 1.51 years. Following the active treatment phase, which lasted an average of 8.06 ± 1.29 months, the mean age was 11.64 ± 1.49 years. The patients were re-evaluated 7 years after completion of monoblock therapy. Lateral cephalometric radiographs, PSG recordings, and Pittsburgh Sleep Quality Index (PSQI) assessments were conducted at three time points: pre-treatment (T1), post-treatment (T2), and at the 7-year follow-up (T3).The radiographic images were obtained under standardized conditions (62 kVp, 8 mA, 14.1 s) using the same device (Sirona Orthophos XG Plus DS/Ceph, Bensheim, Germany), with the patient in natural head position, teeth in maximum intercuspation, and lips relaxed. The radiographs were analyzed using NemoCeph Software (Nemotec, Madrid, Spain). All cephalometric tracings were conducted by the same orthodontist (E.C) to ensure consistency. The analysis was based on pharyngeal anteroposterior width, as well as sagittal and vertical skeletal parameters. Six linear and five angular cephalometric measurements were used in the study. These measurements, along with their definitions, are presented in Table I and illustrated in Fig. II. Upper airway dimensions were analyzed using the method of Tsuiki et al.[ 19 ] Two reference planes were used for the analysis of lateral cephalometric radiographs: the S0 plane (line through anterior nasal spine and posterior nasal spine) and the N⊥ plane (perpendicular to the S0 plane and passing through the Nasion point). The airway was segmented by drawing 11 parallel lines, numbered from S0 to S10, at equal intervals from the upper border of the velopharynx to the base of the epiglottis. The distances between the anterior and posterior pharyngeal walls were measured along each of these lines. The superior boundary of the velopharynx was defined by the backward extension of the S0 line, and the inferior boundary by a line drawn through the tip of the soft palate, parallel to S0. Similarly, the boundary between the oropharynx and hypopharynx was demarcated by a line passing through the tip of the epiglottis, also parallel to S0, while the inferior margin of the hypopharynx was defined by the backward extension of the S10 line. Accordingly, the S0–S4 region was defined as the velopharynx, S4–S8 as the oropharynx, and S8–S10 as the hypopharynx. PSG studies were performed in the Sleep Laboratory of the Department of Pulmonary Medicine, Istanbul University Faculty of Medicine, using the ALICE 5 system (Philips Respironics, USA). AASM (American Academy of Sleep Medicine) pediatric scoring was used, including EEG, EOG, EMG, oronasal airflow, oxygen saturation, respiratory effort, body position, and ECG.[ 20 ] Polysomnographic recordings were evaluated by pediatric pulmonology specialists, and management decisions were guided by interdisciplinary collaboration among orthodontists, pediatric pulmonologists, and otorhinolaryngologists. Orthopedic mandibular advancement was selected as the treatment modality based on the presence of mandibular retrognathia and polysomnographically confirmed pediatric OSA, following interdisciplinary clinical evaluation. Finally, the Pittsburgh Sleep Quality Index (PSQI) was used in the study. The PSQI is a 24-item questionnaire designed to assess changes in multiple dimensions of sleep over time. The instrument provides researchers and healthcare providers with a comprehensive assessment of an individual's sleep patterns, and can be used to inform treatment decisions and interventions for sleep disorders.[ 21 ] Statistical Analysis The data were analysed using IBM SPSS v23. The normality of distribution was examined using the Shapiro-Wilk test. For the purpose of comparing dependent variables across time points, normally distributed quantitative data were analysed using Repeated Measures ANOVA. Post-hoc comparisons were conducted using the Bonferroni test. For the comparison of dependent variables between time points, non-normally distributed quantitative data were analysed using the Friedman test. Post-hoc comparisons were conducted using the Dunn test. Descriptive statistics for quantitative variables were presented as mean ± standard deviation and median (minimum-maximum). The significance level was set at p < 0.05. To evaluate measurement consistency, cephalometric radiographs was re-measured by the same examiner after a 2-week interval. Intra-observer reliability was assessed using intraclass correlation coefficients (ICC) and method error was calculated using Dahlberg’s formula. Results A total of 16 consecutive children completed monoblock appliance therapy, as previously described by Capan et al.[ 17 ] Of these, 13 patients (6 males) participated in the 7-year follow-up assessment. Following the completion of appliance therapy, patients were in the pre-peak or peak phases of skeletal development; by the reevaluation stage (T3), they had reached late adolescence or early adulthood. The cephalometric variables at the follow up (T3) visit compared with the pre- (T1) and post-treatment (T2) data are presented in Table II. The results for the skeletal (SNA, SNB, Go-Me, SN-GoMe, ANS-PNS) and dental (1-SN, 1-NA, IMPA, 1-NB, overjet, overbite) parameters were consistent with the typical results of Class II treatment achieved with different treatment approaches. The differences between T2 and T3 were small and did not reach statistical significance except for Go-Me and, 1-NA. Reliability analysis showed excellent repeatability, with ICC values of 0.90 or higher for all linear and angular measurements. Method error values ranged from 0.20 mm–0.40 mm for linear variables and 0.25°–0.50° for angular variables, indicating that tracing variability was within acceptable cephalometric limits. Airway dimensions were assessed at 11 levels (S0–S10) and shown in Table III. At the velopharyngeal level, statistically significant increases were found at S0 ( p = 0.002), with mean values rising from 13.46 mm (T1) to 14.85 mm (T3). Again at the velopharyngeal level, S3 also showed a significant change ( p = 0.002), with an initial increase at T2 followed by a decrease at T3. Within the oropharyngeal region (S6 and S8), significant increases were observed from T1 to T2 ( p < 0.05), and remained stable at T3. In the hypopharynx, S9 and S10 showed sustained improvements from T1 to T3 ( p < 0.001), and T2 to T3 changes were not significant. As demonstrated in Table IV, the AHI, the lowest and the mean oxygen saturation, the sleep efficiency (%), the arousal index, %REM sleep, and the ODI (Oxygen Desaturation Index) scores of the studied patients are presented before, after and at the follow-up visit. The percentages of REM sleep seemed to be stable from T1 to T2, but the increase from T2 to T3 was statistically significant. Median AHI decreased markedly from 2.3 events/hour at T1 to 0.5 at T2 (p < 0.05), indicating a significant improvement in sleep-disordered breathing. However, this improvement was partially reversed at T3, with AHI rising to 2.0 (p < 0.05). At the 7-year follow-up, AHI values increased relative to T2 (p < 0.05), reflecting a partial recurrence during adolescence, even though they remained below the clinically relevant threshold of 5 events/hour at T3. Evaluations of the PSQI score analysis are presented in Table V. The scale states that a total score of 5 or less indicates good sleep quality, while a score of 6 or more indicates poor sleep quality.[ 22 ] In light of this information, the present study demonstrates that at baseline (T1), sleep quality was not very poor, but an improvement in sleep quality was observed following treatment. Although a slight deterioration in PSQI occurred by 7 years, the change was not statistically significant and mean scores remained within the ‘good quality’ range. [ 22 ] Discussion The aetiological factors of apnea in children include craniofacial anomalies, which play a significant role in influencing the dimensions of the airway.[ 23 , 24 ] Early treatment of children with mandibular retrognathia and respiratory disorders is associated not only with correction of skeletal and dental problems, but also with an increase in pharyngeal airway dimensions and improvement in breathing. In the previous study as well, improvements were noted in mandibular position, overjet, and overbite, accompanied by decreased AHI scores, improved sleep quality, and reduced symptoms of sleep-disordered breathing during both night and day.[ 17 ] Despite the observed stability in skeletal parameters, AHI demonstrated a statistically significant increase from T2 to T3. Treatment was initiated when the patients were, on average, 11.64 ± 1.49 years old, and at the time of follow-up evaluations, all participants were in late adolescence or early adulthood. The mean AHI value of 2.0 observed at T3 falls within a diagnostic gray zone between pediatric and adult scoring criteria for obstructive sleep apnea. According to the American Academy of Pediatrics and supported by the AASM, an AHI greater than 1 event per hour is considered abnormal in individuals younger than 18 years, whereas adult diagnostic criteria define OSA at an AHI ≥ 5 events per hour. The applicability of pediatric versus adult thresholds in older adolescents remains debated, and clinical judgment is often recommended based on physiological maturity and symptomatology. Although the increase in AHI was statistically significant, it may not necessarily reflect a clinically meaningful deterioration, particularly given that most of the patients exhibited AHI values below the adult diagnostic threshold. Notably, these findings occurred in the absence of classical pediatric OSA risk factors such as obesity or adenotonsillar hypertrophy, suggesting the potential contribution of subclinical airway compromise or altered ventilatory control mechanisms during this developmental stage. In addition to changes in AHI, several polysomnographic parameters demonstrated unfavorable trends at long-term follow-up. Sleep efficiency showed a tendency to decrease, arousal-related indices increased, and a significant reduction in mean oxygen saturation values was observed at T3. Although minimum oxygen saturation values did not decline to clinically critical levels, the presence of these unfavorable changes underscores the heterogeneous and non-linear evolution of sleep-disordered breathing during adolescence. Taken together, these findings indicate that long-term outcomes following pediatric OSA treatment may involve concurrent improvements and deteriorations across different sleep domains, rather than a uniform trajectory of sustained improvement. In this study, a statistically significant increase in REM sleep percentage was observed at the T3 period. While this occurred concurrently with a rise in AHI, it is important to consider the context of the earlier sleep recordings. REM percentages were notably low during the T1 and T2 periods, which may reflect the first night effect —a common phenomenon in sleep laboratory settings where unfamiliar environments and sensor discomfort can suppress REM sleep during initial nights.[ 37 ] This interpretation is supported by normative data showing that REM sleep tends to increase with age and stabilizes across childhood and adolescence.[ 38 ] Although the current study did not directly assess treatment-related REM rebound, the increase in REM sleep observed at T3 may reflect a recovery of normal sleep architecture following earlier disruptions, possibly related to the first night effect or underlying sleep instability. A significant body of research has demonstrated the beneficial effects of mandibular advancement devices in children for the treatment of mandibular retrusion and associated OSA. [ 10 , 17 , 25 , 26 , 27 , 28 , 29 , 30 ] Moreover, in a study assessing the impact of different types of mandibular advancement appliances in children, all devices were found to be effective in promoting an increase in airway dimensions.[ 31 ] However, improvements seen after therapies [ 32 ] may not guarantee long-term resolution of SDB.[ 33 ] Therefore, assessing the long-term stability of mandibular advancement and airway gains remains crucial. A review of the literature indicates that while there are studies focused on improving sleep apnea in children through mandibular advancement and the stimulation of mandibular growth, the number of studies assessing the long-term effects of appliances used for this purpose in pediatric populations remains relatively scarce.[ 12 , 15 , 34 ] Some of these long term studies evaluate the effects of mandibular advancement devices on the airway using two-dimensional cephalometric radiographs or CBCT without evaluating the changes on polysomnographic measurements.[ 12 , 15 ] While craniofacial skeletal dimensions have been shown to be associated with childhood OSA—with many affected children exhibiting mandibular retrognathia and increased overjet—current understanding suggests that childhood OSA is a dynamic disorder influenced by both structural and neuromotor abnormalities, rather than by craniofacial morphology alone.[ 16 , 35 , 36 ] Accordingly, although craniofacial measurements may offer valuable insights into skeletal malocclusions such as mandibular retrognathia, and assist in detecting airway narrowing, PSG—the current gold standard for diagnosis—should not be neglected in the comprehensive assessment of the condition. In a long-term follow-up study,[ 32 ] PSG was used to evaluate the stability of treatment outcomes in children with OSA, and the results demonstrated sustained improvements over time. However, that study focused exclusively on children with isolated maxillary constriction, did not evaluate cases involving mandibular retrognathia, whereas the present study investigates patients who presented with mandibular retrognathia prior to treatment. The current study did not show significant changes during the follow-up period, suggesting potential maintenance of mandibular advancement over time. This supports findings by Han et al.[ 13 ] and Godt et al.,[ 12 ] who also reported long-term stability after growth-modifying treatments. These results suggest that early orthopedic correction of mandibular retrognathia may contribute to stable skeletal outcomes when applied during optimal growth periods. While adenotonsillectomy and watchful waiting are standard approaches for managing mild pediatric OSA,[ 42 ] the patients in this study did not exhibit significant adenotonsillar hypertrophy and were therefore not considered suitable candidates for surgical intervention. Treatment decisions were based on a comprehensive clinical assessment, and functional appliance therapy was chosen in accordance with individual patient characteristics, including the presence of mandibular retrognathia and absence of other identifiable upper airway obstructions. From a cephalometric perspective, the only parameter that demonstrated a statistically significant change at the T3 stage compared to earlier time points was the Go-Me distance, which reflects the length of the mandibular corpus. The observed increase in this distance between T2 and T3 may indicate a favorable shift in the position of the genioglossus muscle—attached to the menton—and, consequently, the hyoid bone. The pharyngeal airway analysis is consistent with the possibility of sustained airway dimensional changes.Significant and sustained increases in oropharyngeal and hypopharyngeal dimensions (particularly at S6, S8, S9, and S10) were observed, suggesting that the airway dimensions remained increased compared to baseline over the 7-year period. Interestingly, the velopharyngeal region (S0) demonstrated a gradual increase, whereas the hypopharyngeal level (S3) showed a decrease from T2 to T3, returning to near-baseline levels. This regional variation may reflect the differential response of soft tissues and neuromuscular control mechanisms in distinct anatomical zones of the airway. These findings are also consistent with those reported in previous studies.Temani et al.[ 39 ] and Yue et al.[ 40 ] also demonstrated short-term increases in oropharyngeal and hypopharyngeal airway dimensions following mandibular advancement. However, both studies lacked long-term follow-up data. The assessment of upper airway dimensions in the present study was based on lateral cephalometric radiographs, which represent a two-dimensional projection of a complex three-dimensional structure. This approach has inherent limitations, as it does not capture volumetric or dynamic airway changes. However, lateral cephalometry remains a widely used and standardized method for longitudinal evaluation of craniofacial and airway-related changes, particularly in pediatric populations, where minimizing radiation exposure is a key consideration. Importantly, all radiographs were obtained using the same device and protocol across all time points, allowing for reliable within-subject comparisons over time. Therefore, while absolute airway dimensions should be interpreted with caution, the observed longitudinal trends provide meaningful information regarding relative changes following treatment. The PSQI -a self report questionnaire- was used to assess sleep quality as perceived by the patients.[ 21 ] Between T1 and T2, an improvement in subjective sleep quality was observed in parallel with the objective improvement in apnea-related findings. However, between T2 and T3, despite a statistically significant increase in AHI, PSQI scores remained unchanged. This may be explained by the fact that the increase in AHI, while statistically significant, was not necessarily clinically significant, as the values still fell within the normal range for this age group. Similarly, as in the current study, the literature indicates that a significant correlation between AHI and PSQI is not consistently observed; individuals with sleep apnea—particularly those with mild to moderate severity—may still perceive their sleep quality as good.[ 41 ] Another finding at T3 was a significant decrease in mean oxygen saturation values (p = 0.002), which appears to parallel the increase in AHI. However, the absence of a significant change in minimum saturation values suggests that oxygen desaturation did not reach a clinically critical threshold, indicating that severe hypoxemia was likely avoided. In a longitudinal cephalometric study in which subjects presenting with Class I skeletal patterns and only minor orthodontic intervention were selected as a control group for Class II patients treated with activator-headgear therapy, sagittal pharyngeal airway dimensions demonstrated gradual increases during growth; however, the magnitude of these changes was generally limited and not uniformly distributed across all airway levels.[ 14 ] These findings suggest that physiologic growth alone results in modest, region-specific airway enlargement rather than marked or generalized expansion. In the present study, the absence of a matched untreated control group represents a limitation. In our view, an appropriate control group for patients with skeletal Class II malocclusion would ideally consist of untreated Class II individuals. However, withholding indicated orthopedic intervention in growing patients with mandibular retrognathia—particularly in the presence of functional impairment or OSA—raises ethical concerns. Therefore, while direct comparison with an untreated Class II cohort was not feasible, the findings should be interpreted with appropriate caution. Despite the relatively small sample size, the 7-year follow-up period represents an important strength of this investigation, as extended longitudinal data in pediatric OSA remain limited. Long-term observation allows evaluation of skeletal and airway adaptations over time. Nevertheless, larger prospective studies are required to confirm these findings and improve generalizability. From a clinical perspective, the results are consistent with the possibility that monoblock mandibular advancement therapy may play a role in skeletal and airway adaptation in selected children with mandibular retrognathia and OSA. However, variability in airway response and the mild increase in AHI observed during adolescence in some patients indicate that outcomes are not uniform and that long-term follow-up remains essential. These findings should therefore be considered within a multidisciplinary management framework, given that diagnosis, treatment planning, and follow-up of pediatric OSA require coordinated collaboration among orthodontic, pediatric pulmonology, and otorhinolaryngology specialists. Although cephalometric parameters are not routinely applied in otolaryngologic practice, they provide structural insight into craniofacial morphology and its relationship with upper airway configuration. When interpreted alongside polysomnographic findings, such measurements may contribute to a more comprehensive understanding of structural and functional adaptations associated with mandibular advancement therapy. In conclusion, this long-term follow-up study provides a descriptive evaluation of skeletal, airway, and sleep-related changes in children with mandibular retrognathia and obstructive sleep apnea treated with a monoblock appliance. Mandibular positioning appeared relatively stable over time, while airway dimensional changes followed heterogeneous patterns during the 7-year observation period. Although a mild but statistically significant increase in AHI was noted during adolescence, values remained below adult diagnostic thresholds in most patients, and subjective sleep quality did not deteriorate substantially. These observations underscore the dynamic and multifactorial nature of pediatric OSA and highlight the importance of sustained, individualized monitoring rather than assumptions of permanent resolution. Further multicenter longitudinal studies incorporating broader clinical and developmental parameters are warranted to clarify the long-term implications of orthopedic intervention in this population. Declarations Ethics Approval and Consent to Participate: Ethical approval was obtained from the Ethics Committee of Istanbul Medipol University (Approval No: 10840098-604.01.01-E.65336), and written informed consent was obtained from parents/legal guardians of all participants. Consent for Publication: Not applicable, as no identifiable images or personal data are included in this manuscript. Availability of Data and Materials: The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Competing Interest: The authors declare that they have no conflicts of interest. Funding: No funding was received for this research. Authors’ Contributions : S. K. A. contributed to conceptualization, methodology, formal analysis, data curation, original draft preparation, manuscript review and editing, visualization; E. K. contributed to formal analysis, data curation, manuscript review and editing, visualization, supervision, and project administration; R. E. contributed to manuscript review and editing, and supervision; H. K. contributed to conceptualization, methodology, formal analysis, manuscript review and editing, investigation and supervision; G. S. project administration, visualisation, manuscript review and editing; E. C. contributed to manuscript investigation, data curation, manuscript review and editing. References Carroll JL (2003) Obstructive sleep-disordered breathing in children: new controversies, new directions. 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Sleep Med 14:37–44 Idris G, Galland B, Robertson CJ, Gray A, Farella M (2018) Mandibular advancement appliances for sleep-disordered breathing in children: a randomized crossover clinical trial. J Dent 71:9–17 Zonato AI, Bittencourt LR, Martinho FL, Júnior JF, Gregório LC, Tufik S (2003) Association of systematic head and neck physical examination with severity of obstructive sleep apnea-hypopnea syndrome. Laryngoscope 113:973–980 Kushida CA, Efron B, Guilleminault C (1997) A predictive morphometric model for obstructive sleep apnea syndrome. Ann Intern Med 127:581–587 Verhulst SL, Schrauwen N, Haentjens D, Rooman RP, Van Gaal L, De Backer WA (2006) First-night effect for polysomnographic measures in children and adolescents with suspected sleep-disordered breathing. Arch Dis Child 91:233–237 Scholle S, Wiater A, Scholle HC, Lehmkuhl G (2011) Normative values of polysomnographic parameters in childhood and adolescence: a meta-analysis. Sleep Med 12:542–549 Temani P, Jain P, Rathee P, Temani R (2016) Volumetric changes in pharyngeal airway in Class II Division 1 patients treated with Forsus appliance: a CBCT study. Contemp Clin Dent 7:31–35 Yue Z, Yi Z, Liu X, Chen M, Yin S, Liu Q (2023) Comparison of Invisalign mandibular advancement and twin-block on upper airway and hyoid position in skeletal Class II children. BMC Oral Health 23:661 Grandner MA, Kripke DF, Yoon IY, Youngstedt SD (2006) Criterion validity of the Pittsburgh Sleep Quality Index. Sleep Biol Rhythms 4:129–139 Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J et al (2012) Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 130:e714–e755 Tables Table I. Summary of Cephalometric Landmarks and Definitions Abbreviation Definition 1 SNA (°) Angle between the lines from Sella to Nasion and from Nasion to Point A; represents the maxillary position relative to the cranial base. 2 SNB (°) Angle between the lines from Sella to Nasion and from Nasion to Point B; represents the mandibular position relative to the cranial base. 3 Go-Me (mm) Linear distance between Gonion and Menton; represents the length of the mandibular body. 4 ANS-PNS (mm) Linear distance from Anterior Nasal Spine to Posterior Nasal Spine; indicates maxillary length. 5 SN-GoMe (°) Angle between Sella–Nasion and Gonion–Menton lines; reflects the vertical growth pattern of the mandible. 6 1-SN (°) Angle between the long axisof the upper central incisor (U1i to U1a) and the Sella–Nasion line; indicates upper incisor inclination. 7 1-NA (mm) Linear distance from the most labial point of the upper incisor to the Nasion–Point A line; indicates upper incisor protrusion. 8 IMPA (°) Angle between the long axis of the lower incisor (L1i to L1a) and the mandibular plane (Go–Me); measures lower incisor inclination. 9 1-NB (mm) Linear distance from the most labial point of the lower incisor to the Nasion–Point B line; indicates lower incisor protrusion. 10 Overjet (mm) Horizontal distance between the upper and lower incisal edges; indicates sagittal incisor relationship. 11 Overbite (mm) Vertical overlap between the upper and lower incisal edges; indicates vertical incisor relationship. Table II. Comparison of cephalometric skeletal and dental parameters at T1 (pre-treatment), T2 (post-treatment), and T3 (7-year follow-up). T1 T2 T3 Test Statistic p SNA (°) 78,85 ± 3,89 78,23 ± 3,63 78,69 ± 3,64 1,778 0,191 x SNB (°) 71,54 ± 3,6 a 74,54 ± 3,73 b 74 ± 3,7 b 26,469 < 0,001 x Go-Me (mm) 55 (52 - 71) a 58 (55 - 74) b 60 (56 - 76) c 24,776 < 0,001 y ANS-PNS (mm) 48,46 ± 3,95 a 51,38 ± 3,45 b 51,77 ± 2,83 b 32,318 < 0,001 x SN-GoMe (°) 40,38 ± 5,85 40,77 ± 6,46 40,54 ± 7,02 0,166 0,750 x 1-SN (°) 108,54 ± 6,2 a 100,85 ± 7,74 b 104,46 ± 8,06 c 21,567 < 0,001 x 1-NA (mm) 6,08 ± 1,71 a 4 ± 1,47 b 4,62 ± 1,56 b 13,445 < 0,001x IMPA (°) 92,38 ± 6,97 a 96,08 ± 8,61 b 97,23 ± 7,35 b 8,591 0,002 x 1-NB (mm) 5 ± 1,83 5,77 ± 2,45 6 ± 2,38 1,906 0,171 x Overjet (mm) 8,5 (5,5 - 14) a 2,5 (2 - 4) b 3 (2 - 6) b 21,745 < 0,001 y Overbite (mm) 4 (2,5 - 5) a 2,5 (1,5 - 3,5) b 2 (1 - 3) b 20,043 < 0,001 y x Repeated measures ANOVA (used for normally distributed data); y Friedman Test (used for non-normally distributed data); a-c No significant difference between groups sharing the same letter Table III. Comparison of pharyngeal airway dimensions (S0–S10) at T1, T2, and T3. T1 T2 T3 Test Statistic p S0 13,46 ± 3,31 a 13,92 ± 3,93 a 14,85 ± 3,31 b 8,129 0,002 x S1 10,23 ± 3,72 10,69 ± 3,09 10,92 ± 3,01 2,066 0,149 x S2 8,69 ± 2,5 8,85 ± 2,38 8,69 ± 1,93 0,316 0,732 x S3 7,62 ± 2,26 ab 7,92 ± 2,33 a 7,38 ± 2,29 b 8,222 0,002 x S4 7,38 ± 1,94 7,69 ± 1,97 7,77 ± 2,17 1,054 0,339 x S5 7 (6 - 13) 7 (6 - 13) 7 (5 - 12) 1,167 0,558 y S6 7 (6 - 10) a 8 (7 - 11) b 8 (7 - 11) b 7,235 0,018 y S7 7,23 ± 1,09 7,38 ± 1,26 7,69 ± 1,75 1,240 0,297 x S8 6 (5 - 8) a 7 (6 - 9) b 7 (6 - 9) b 8,473 0,015 y S9 7,15 ± 1,95 a 8,08 ± 2,4 b 8,77 ± 1,59 b 15,857 < 0,001 x S10 10,15 ± 2,61 a 11,46 ± 1,98 b 12,15 ± 1,95 b 17,385 < 0,001 x x Repeated measures ANOVA (used for normally distributed data); y Friedman Test (used for non-normally distributed data); a-b No significant difference between groups sharing the same letter Table IV. Comparison of polysomnographic parameters at T1, T2, and T3. T1 T2 T3 Test Statistic p Stage 1 (%) 0,5 (0,2 - 1,7) 0,3 (0,1 - 70,1) 0,5 (0,1 - 1,2) 4,542 0,103 x Stage 2 (%) 57,5 (25,5 - 74,7) 65,2 (22,9 - 70) 59,2 (41,7 - 78,9) 0,275 0,872 x Stage 3,4 (%) 30,6 (17,6 - 74) 28 (0 - 75,4) 25,3 (14,1 - 47,1) 1,846 0,397 x REM (%) 5,82 ± 5,04 a 5,76 ± 3,83 a 12,48 ± 5,5 b 10,133 0,002 y AHI 2,3 (1 - 16,9) a 0,5 (0,2 - 1,8) b 2 (0,1 - 26) a 12,980 0,002 x Mean saturation (%) 97,46 ± 0,78 a 97,46 ± 0,97 a 96,23 ± 1,36 b 10,139 0,002 y Min. saturation (%) 92 (29 - 95) 92 (82 - 94) 89 (78 - 93) 3,040 0,219 x Sleep efficiency (%) 85,56 ± 8,29 88,15 ± 9,19 82,33 ± 11,96 1,808 0,190 y Arousal index 10,23 ± 7,69 13,49 ± 6,01 11,98 ± 7,57 0,533 0,594 y ODI 1,7 (0,6 - 5,9) 1,3 (0 - 3,1) 3 (0 - 18) 3,231 0,199 x x REM: Rapid eye movement, AHI: Apnea-Hypopnea Index, ODI: Oxygen Desaturation Index. Repeated measures ANOVA (used for normally distributed data); y Friedman Test (used for non-normally distributed data); a-b No significant difference between groups sharing the same letter, AHI: Apnea–Hypopnea Index Table V. Comparison of Pittsburgh Sleep Quality Index (PSQI) scores and components at T1, T2, and T3 T1 T2 T3 Test Statistic p Global Skor 5,23 ± 2,74 a 3,15 ± 2,15 b 3,85 ± 1,68 ab 6,943 0,005 x Subjective sleep quality 1 (0 - 3) 0 (0 - 2) 1 (0 - 2) 5,688 0,058 y Sleep latency 1 (0 - 2) 1 (0 - 2) 1 (0 - 1) 1,040 0,595 y Sleep disturbances 1 (0 - 3) 1 (0 - 1) 1 (0 - 1) 3,263 0,196 y Daytime dysfunction 1 (0 - 3) a 1 (0 - 3) b 1 (0 - 3) ab 7,032 0,030 y x Repeated measures ANOVA (used for normally distributed data); y Friedman Test (used for non-normally distributed data); a-b No significant difference between groups sharing the same letter Note: Sleep duration, habitual sleep efficiency, and use of sleep medication components within the PSQI were excluded from comparisons, as all observations for each time point were identical and scored as zero. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 03 Apr, 2026 Reviews received at journal 03 Apr, 2026 Reviews received at journal 03 Apr, 2026 Reviews received at journal 13 Mar, 2026 Reviews received at journal 09 Mar, 2026 Reviewers agreed at journal 25 Feb, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviewers invited by journal 18 Feb, 2026 Editor assigned by journal 17 Feb, 2026 Submission checks completed at journal 17 Feb, 2026 First submitted to journal 17 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8901194","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":593195896,"identity":"fdb545dd-84ad-4caa-a33a-c17e6506669e","order_by":0,"name":"Serife Kiran Aydil","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIie3RsWrDMBCA4TMGdTFkFTStX+GCIRlCyatIBJRFlIweMhgKztLQFyj0Fdyx25WAuqi7oR3cpVOGZOtgQmW82qZjB/3LIdAHhwTg8/3TKAURuRlUojlyCAggHCa2JSEKwIZAS9iAcaQZzF3+A4m3uy+iVI1n23eTVnUdzy7vkSCdyyzeVV0E7RsSWR2N7a0qZY6Tl0friF3JjF1gJ+EK9qc8jTjoaSkzDIpSIwX53pHuzeKnb6DXsyOjw3Qtaly05NxPoGSOZDriXE9BMJQtyfoJWgVERjlySLjMk2XxadYkzCrJmep5MRMeabNc8JGenH7q65vi4+65Om7mVw+h6V6sOwHDP+nz+Xy+4X4Bq8dmnCuonekAAAAASUVORK5CYII=","orcid":"","institution":"Istanbul University","correspondingAuthor":true,"prefix":"","firstName":"Serife","middleName":"Kiran","lastName":"Aydil","suffix":""},{"id":593195898,"identity":"f9b43868-22a8-48af-8971-c8e886853447","order_by":1,"name":"Esen Kiyan","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Esen","middleName":"","lastName":"Kiyan","suffix":""},{"id":593195899,"identity":"7c2a090b-008a-4e1f-b3fb-6a06a3de77d1","order_by":2,"name":"Refika Ersu","email":"","orcid":"","institution":"University of Ottawa","correspondingAuthor":false,"prefix":"","firstName":"Refika","middleName":"","lastName":"Ersu","suffix":""},{"id":593195903,"identity":"79b29a64-f14a-4299-bbf9-9cc37dd131a6","order_by":3,"name":"Hulya Kilicoglu","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Hulya","middleName":"","lastName":"Kilicoglu","suffix":""},{"id":593195905,"identity":"de68cbd7-16b9-4670-94d1-60fe051181c1","order_by":4,"name":"Gulsilay Sayar","email":"","orcid":"","institution":"Bahçeşehir University","correspondingAuthor":false,"prefix":"","firstName":"Gulsilay","middleName":"","lastName":"Sayar","suffix":""},{"id":593195908,"identity":"a97171ad-14d7-4a4e-b063-81223c7bf7e8","order_by":5,"name":"Eser Capan","email":"","orcid":"","institution":"private practice orthodontist","correspondingAuthor":false,"prefix":"","firstName":"Eser","middleName":"","lastName":"Capan","suffix":""}],"badges":[],"createdAt":"2026-02-17 12:41:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8901194/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8901194/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103178069,"identity":"3c5267ec-efb0-4538-9fc3-64ca0a7270ba","added_by":"auto","created_at":"2026-02-22 16:59:03","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":387569,"visible":true,"origin":"","legend":"\u003cp\u003eDesign and intraoral view of monoblock appliance\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8901194/v1/b742a3432a3587f106d5e582.jpeg"},{"id":103178070,"identity":"58704905-4a89-4090-bd68-adcddda8d261","added_by":"auto","created_at":"2026-02-22 16:59:03","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":215301,"visible":true,"origin":"","legend":"\u003cp\u003eCephalometric landmarks and reference lines used for skeletal and dental measurements. N, Nasion; S, Sella; ANS, anterior nasal spine; PNS, posterior nasal spine; Go, Gonion; Me, Menton; A, the deepest concavity of the anterior maxilla; B, the deepest concavity of the anterior mandible; U1a, apex of the upper central incisor root; U1i, incisal tip of the upper central incisor; L1a, apex of the lower central incisor root; L1i, incisal tip of the lower central incisor.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8901194/v1/3d75432f76a3fce282efc3b9.jpeg"},{"id":103178082,"identity":"3a84e675-6c94-4bf6-a397-bf1b35b71459","added_by":"auto","created_at":"2026-02-22 16:59:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1291510,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8901194/v1/e2d49b95-b43d-40c4-a0d4-c46c0b52b626.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long-Term Efficacy of Orthopedic Mandibular Advancement Therapy in Pediatric Obstructive Sleep Apnea: A 7-Year Follow-Up Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSleep-disordered breathing includes a spectrum of conditions from habitual snoring to obstructive sleep apnea (OSA), the most severe form, characterized by intermittent upper airway obstruction during sleep.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] OSA is associated with multiple factors such as adenotonsillar hypertrophy, reduced muscle tone, and craniofacial anomalies (e.g., transverse maxillary deficiency, mandibular retrognathia, micrognathia, macroglossia).[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] These anatomical deviations may reduce airway dimensions and contribute to OSA.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePediatric OSA is increasingly recognized as a multifactorial disorder in which skeletal, neuromuscular, and behavioral components interact to influence airway patency.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Given its multifactorial nature, the optimal treatment for OSA remains debated. While adenotonsillectomy remains the first-line treatment for pediatric OSA and is effective in many cases, concerns about long-term outcomes and recurrence in certain patient populations have prompted interest in alternative or adjunctive therapies. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSince abnormal mandibular and maxillary growth contributes significantly to pediatric OSA [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], orthodontic treatments targeting these issues\u0026mdash;such as rapid maxillary expansion [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], mandibular advancement appliances [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and maxillary protraction devices [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u0026mdash;have been explored.\u003c/p\u003e \u003cp\u003eSeveral studies have explored the long-term impact of these devices, particularly their ability to sustain mandibular advancement and cephalometric gains in airway dimensions in growing children.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] These changes appear to be stable over time and beneficial for sleep apnea. However, considering that OSA is influenced by not only skeletal parameters but also by neuromuscular, behavioral, and positional factors,[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] evaluating only craniofacial structures may not provide a comprehensive understanding of the disorder in the long term. However, to date, no study has examined the long-term effects of mandibular advancement therapy using both polysomnographic data and airway measurements in children. Therefore, this study aims to evaluate the long term (7 years) outcomes of children with mandibular retrognathia and OSA who were treated with a monoblock appliance, by assessing both polysomnographic and cephalometric variables.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study builds upon a previous investigation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] that included patients diagnosed with OSA via polysomnography (PSG) and aims to evaluate the long-term outcomes of that initial cohort. It was designed as a prospective longitudinal cohort study in which patients previously treated with a monoblock appliance were re-evaluated 7 years after treatment completion. Ethical approval for the present study was obtained from the Human Ethics Committee of Istanbul Medipol University, Istanbul, Turkey (Approval No: 10840098-604.01.01-E.65336).\u003c/p\u003e \u003cp\u003eThe initial cohort consisted of 16 consecutive pediatric patients with confirmed OSA (defined as an apnea\u0026ndash;hypopnea index [AHI]\u0026thinsp;\u0026ge;\u0026thinsp;1) and skeletal Class II malocclusion (SNB angle\u0026thinsp;\u0026lt;\u0026thinsp;78\u0026deg;). (17) Exclusion criteria included cleft lip and/or palate, obesity, cardiopulmonary diseases, syndromic conditions, dysmorphism, or other craniofacial anomalies. Orthopedic mandibular advancement was chosen for these patients because of their mandibular retrognathia and confirmed OSA after interdisciplinary evaluation. Each patient was treated with individualized custom-fabricated monoblock appliances (Fig. I). This functional orthopedic device is commonly used in orthodontics to achieve mandibular advancement in growing patients.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] The appliance was a single-piece appliance that covers the palatal and occlusal surfaces of the maxillary teeth, as well as the occlusal and palatolingual surfaces of the mandibular teeth. Patients were instructed to wear the appliance for a minimum of 17 hours per day. Functional orthopedic therapy was discontinued once a stable Class I molar relationship was achieved, which occurred within a period ranging from 6 to 10 months. All of the individuals were invited to participate in the present follow-up study. One patient declined to participate, and two were excluded due to obesity, based on reassessed body mass index (BMI) values. These three patients who were not included in the final follow-up sample did not differ substantially from the included participants in terms of baseline age, craniofacial characteristics, or initial AHI values. None of the patients had undergone adenotonsillectomy during the initial treatment or prior to the follow-up assessment. Consequently, the remaining 13 patients (81% of the initial group; 6 boys, 7 girls) were enrolled in this study. At treatment initiation, the mean age was 10.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.51 years. Following the active treatment phase, which lasted an average of 8.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29 months, the mean age was 11.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.49 years. The patients were re-evaluated 7 years after completion of monoblock therapy.\u003c/p\u003e \u003cp\u003eLateral cephalometric radiographs, PSG recordings, and Pittsburgh Sleep Quality Index (PSQI) assessments were conducted at three time points: pre-treatment (T1), post-treatment (T2), and at the 7-year follow-up (T3).The radiographic images were obtained under standardized conditions (62 kVp, 8 mA, 14.1 s) using the same device (Sirona Orthophos XG Plus DS/Ceph, Bensheim, Germany), with the patient in natural head position, teeth in maximum intercuspation, and lips relaxed. The radiographs were analyzed using NemoCeph Software (Nemotec, Madrid, Spain). All cephalometric tracings were conducted by the same orthodontist (E.C) to ensure consistency. The analysis was based on pharyngeal anteroposterior width, as well as sagittal and vertical skeletal parameters. Six linear and five angular cephalometric measurements were used in the study. These measurements, along with their definitions, are presented in Table I and illustrated in Fig. II.\u003c/p\u003e \u003cp\u003eUpper airway dimensions were analyzed using the method of Tsuiki et al.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Two reference planes were used for the analysis of lateral cephalometric radiographs: the S0 plane (line through anterior nasal spine and posterior nasal spine) and the N\u0026perp; plane (perpendicular to the S0 plane and passing through the Nasion point). The airway was segmented by drawing 11 parallel lines, numbered from S0 to S10, at equal intervals from the upper border of the velopharynx to the base of the epiglottis. The distances between the anterior and posterior pharyngeal walls were measured along each of these lines. The superior boundary of the velopharynx was defined by the backward extension of the S0 line, and the inferior boundary by a line drawn through the tip of the soft palate, parallel to S0. Similarly, the boundary between the oropharynx and hypopharynx was demarcated by a line passing through the tip of the epiglottis, also parallel to S0, while the inferior margin of the hypopharynx was defined by the backward extension of the S10 line. Accordingly, the S0\u0026ndash;S4 region was defined as the velopharynx, S4\u0026ndash;S8 as the oropharynx, and S8\u0026ndash;S10 as the hypopharynx.\u003c/p\u003e \u003cp\u003ePSG studies were performed in the Sleep Laboratory of the Department of Pulmonary Medicine, Istanbul University Faculty of Medicine, using the ALICE 5 system (Philips Respironics, USA). AASM (American Academy of Sleep Medicine) pediatric scoring was used, including EEG, EOG, EMG, oronasal airflow, oxygen saturation, respiratory effort, body position, and ECG.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePolysomnographic recordings were evaluated by pediatric pulmonology specialists, and management decisions were guided by interdisciplinary collaboration among orthodontists, pediatric pulmonologists, and otorhinolaryngologists.\u003c/p\u003e \u003cp\u003eOrthopedic mandibular advancement was selected as the treatment modality based on the presence of mandibular retrognathia and polysomnographically confirmed pediatric OSA, following interdisciplinary clinical evaluation.\u003c/p\u003e \u003cp\u003eFinally, the Pittsburgh Sleep Quality Index (PSQI) was used in the study. The PSQI is a 24-item questionnaire designed to assess changes in multiple dimensions of sleep over time. The instrument provides researchers and healthcare providers with a comprehensive assessment of an individual's sleep patterns, and can be used to inform treatment decisions and interventions for sleep disorders.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data were analysed using IBM SPSS v23. The normality of distribution was examined using the Shapiro-Wilk test. For the purpose of comparing dependent variables across time points, normally distributed quantitative data were analysed using Repeated Measures ANOVA. Post-hoc comparisons were conducted using the Bonferroni test. For the comparison of dependent variables between time points, non-normally distributed quantitative data were analysed using the Friedman test. Post-hoc comparisons were conducted using the Dunn test. Descriptive statistics for quantitative variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and median (minimum-maximum). The significance level was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. To evaluate measurement consistency, cephalometric radiographs was re-measured by the same examiner after a 2-week interval. Intra-observer reliability was assessed using intraclass correlation coefficients (ICC) and method error was calculated using Dahlberg\u0026rsquo;s formula.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 16 consecutive children completed monoblock appliance therapy, as previously described by Capan et al.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Of these, 13 patients (6 males) participated in the 7-year follow-up assessment. Following the completion of appliance therapy, patients were in the pre-peak or peak phases of skeletal development; by the reevaluation stage (T3), they had reached late adolescence or early adulthood.\u003c/p\u003e \u003cp\u003eThe cephalometric variables at the follow up (T3) visit compared with the pre- (T1) and post-treatment (T2) data are presented in Table II. The results for the skeletal (SNA, SNB, Go-Me, SN-GoMe, ANS-PNS) and dental (1-SN, 1-NA, IMPA, 1-NB, overjet, overbite) parameters were consistent with the typical results of Class II treatment achieved with different treatment approaches. The differences between T2 and T3 were small and did not reach statistical significance except for Go-Me and, 1-NA. Reliability analysis showed excellent repeatability, with ICC values of 0.90 or higher for all linear and angular measurements. Method error values ranged from 0.20 mm\u0026ndash;0.40 mm for linear variables and 0.25\u0026deg;\u0026ndash;0.50\u0026deg; for angular variables, indicating that tracing variability was within acceptable cephalometric limits.\u003c/p\u003e \u003cp\u003eAirway dimensions were assessed at 11 levels (S0\u0026ndash;S10) and shown in Table III. At the velopharyngeal level, statistically significant increases were found at S0 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), with mean values rising from 13.46 mm (T1) to 14.85 mm (T3). Again at the velopharyngeal level, S3 also showed a significant change (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), with an initial increase at T2 followed by a decrease at T3. Within the oropharyngeal region (S6 and S8), significant increases were observed from T1 to T2 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and remained stable at T3. In the hypopharynx, S9 and S10 showed sustained improvements from T1 to T3 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and T2 to T3 changes were not significant.\u003c/p\u003e \u003cp\u003eAs demonstrated in Table IV, the AHI, the lowest and the mean oxygen saturation, the sleep efficiency (%), the arousal index, %REM sleep, and the ODI (Oxygen Desaturation Index) scores of the studied patients are presented before, after and at the follow-up visit. The percentages of REM sleep seemed to be stable from T1 to T2, but the increase from T2 to T3 was statistically significant. Median AHI decreased markedly from 2.3 events/hour at T1 to 0.5 at T2 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating a significant improvement in sleep-disordered breathing. However, this improvement was partially reversed at T3, with AHI rising to 2.0 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). At the 7-year follow-up, AHI values increased relative to T2 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), reflecting a partial recurrence during adolescence, even though they remained below the clinically relevant threshold of 5 events/hour at T3.\u003c/p\u003e \u003cp\u003eEvaluations of the PSQI score analysis are presented in Table V. The scale states that a total score of 5 or less indicates good sleep quality, while a score of 6 or more indicates poor sleep quality.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] In light of this information, the present study demonstrates that at baseline (T1), sleep quality was not very poor, but an improvement in sleep quality was observed following treatment. Although a slight deterioration in PSQI occurred by 7 years, the change was not statistically significant and mean scores remained within the \u0026lsquo;good quality\u0026rsquo; range. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aetiological factors of apnea in children include craniofacial anomalies, which play a significant role in influencing the dimensions of the airway.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Early treatment of children with mandibular retrognathia and respiratory disorders is associated not only with correction of skeletal and dental problems, but also with an increase in pharyngeal airway dimensions and improvement in breathing. In the previous study as well, improvements were noted in mandibular position, overjet, and overbite, accompanied by decreased AHI scores, improved sleep quality, and reduced symptoms of sleep-disordered breathing during both night and day.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDespite the observed stability in skeletal parameters, AHI demonstrated a statistically significant increase from T2 to T3. Treatment was initiated when the patients were, on average, 11.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.49 years old, and at the time of follow-up evaluations, all participants were in late adolescence or early adulthood. The mean AHI value of 2.0 observed at T3 falls within a diagnostic gray zone between pediatric and adult scoring criteria for obstructive sleep apnea. According to the American Academy of Pediatrics and supported by the AASM, an AHI greater than 1 event per hour is considered abnormal in individuals younger than 18 years, whereas adult diagnostic criteria define OSA at an AHI\u0026thinsp;\u0026ge;\u0026thinsp;5 events per hour. The applicability of pediatric versus adult thresholds in older adolescents remains debated, and clinical judgment is often recommended based on physiological maturity and symptomatology. Although the increase in AHI was statistically significant, it may not necessarily reflect a clinically meaningful deterioration, particularly given that most of the patients exhibited AHI values below the adult diagnostic threshold. Notably, these findings occurred in the absence of classical pediatric OSA risk factors such as obesity or adenotonsillar hypertrophy, suggesting the potential contribution of subclinical airway compromise or altered ventilatory control mechanisms during this developmental stage.\u003c/p\u003e \u003cp\u003eIn addition to changes in AHI, several polysomnographic parameters demonstrated unfavorable trends at long-term follow-up. Sleep efficiency showed a tendency to decrease, arousal-related indices increased, and a significant reduction in mean oxygen saturation values was observed at T3. Although minimum oxygen saturation values did not decline to clinically critical levels, the presence of these unfavorable changes underscores the heterogeneous and non-linear evolution of sleep-disordered breathing during adolescence. Taken together, these findings indicate that long-term outcomes following pediatric OSA treatment may involve concurrent improvements and deteriorations across different sleep domains, rather than a uniform trajectory of sustained improvement.\u003c/p\u003e \u003cp\u003eIn this study, a statistically significant increase in REM sleep percentage was observed at the T3 period. While this occurred concurrently with a rise in AHI, it is important to consider the context of the earlier sleep recordings. REM percentages were notably low during the T1 and T2 periods, which may reflect the \u003cem\u003efirst night effect\u003c/em\u003e\u0026mdash;a common phenomenon in sleep laboratory settings where unfamiliar environments and sensor discomfort can suppress REM sleep during initial nights.[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] This interpretation is supported by normative data showing that REM sleep tends to increase with age and stabilizes across childhood and adolescence.[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Although the current study did not directly assess treatment-related REM rebound, the increase in REM sleep observed at T3 may reflect a recovery of normal sleep architecture following earlier disruptions, possibly related to the first night effect or underlying sleep instability.\u003c/p\u003e \u003cp\u003eA significant body of research has demonstrated the beneficial effects of mandibular advancement devices in children for the treatment of mandibular retrusion and associated OSA. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Moreover, in a study assessing the impact of different types of mandibular advancement appliances in children, all devices were found to be effective in promoting an increase in airway dimensions.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] However, improvements seen after therapies [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] may not guarantee long-term resolution of SDB.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] Therefore, assessing the long-term stability of mandibular advancement and airway gains remains crucial.\u003c/p\u003e \u003cp\u003eA review of the literature indicates that while there are studies focused on improving sleep apnea in children through mandibular advancement and the stimulation of mandibular growth, the number of studies assessing the long-term effects of appliances used for this purpose in pediatric populations remains relatively scarce.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] Some of these long term studies evaluate the effects of mandibular advancement devices on the airway using two-dimensional cephalometric radiographs or CBCT without evaluating the changes on polysomnographic measurements.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] While craniofacial skeletal dimensions have been shown to be associated with childhood OSA\u0026mdash;with many affected children exhibiting mandibular retrognathia and increased overjet\u0026mdash;current understanding suggests that childhood OSA is a dynamic disorder influenced by both structural and neuromotor abnormalities, rather than by craniofacial morphology alone.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] Accordingly, although craniofacial measurements may offer valuable insights into skeletal malocclusions such as mandibular retrognathia, and assist in detecting airway narrowing, PSG\u0026mdash;the current gold standard for diagnosis\u0026mdash;should not be neglected in the comprehensive assessment of the condition. In a long-term follow-up study,[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] PSG was used to evaluate the stability of treatment outcomes in children with OSA, and the results demonstrated sustained improvements over time. However, that study focused exclusively on children with isolated maxillary constriction, did not evaluate cases involving mandibular retrognathia, whereas the present study investigates patients who presented with mandibular retrognathia prior to treatment.\u003c/p\u003e \u003cp\u003eThe current study did not show significant changes during the follow-up period, suggesting potential maintenance of mandibular advancement over time. This supports findings by Han et al.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and Godt et al.,[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] who also reported long-term stability after growth-modifying treatments. These results suggest that early orthopedic correction of mandibular retrognathia may contribute to stable skeletal outcomes when applied during optimal growth periods.\u003c/p\u003e \u003cp\u003eWhile adenotonsillectomy and watchful waiting are standard approaches for managing mild pediatric OSA,[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] the patients in this study did not exhibit significant adenotonsillar hypertrophy and were therefore not considered suitable candidates for surgical intervention. Treatment decisions were based on a comprehensive clinical assessment, and functional appliance therapy was chosen in accordance with individual patient characteristics, including the presence of mandibular retrognathia and absence of other identifiable upper airway obstructions.\u003c/p\u003e \u003cp\u003eFrom a cephalometric perspective, the only parameter that demonstrated a statistically significant change at the T3 stage compared to earlier time points was the Go-Me distance, which reflects the length of the mandibular corpus. The observed increase in this distance between T2 and T3 may indicate a favorable shift in the position of the genioglossus muscle\u0026mdash;attached to the menton\u0026mdash;and, consequently, the hyoid bone.\u003c/p\u003e \u003cp\u003eThe pharyngeal airway analysis is consistent with the possibility of sustained airway dimensional changes.Significant and sustained increases in oropharyngeal and hypopharyngeal dimensions (particularly at S6, S8, S9, and S10) were observed, suggesting that the airway dimensions remained increased compared to baseline over the 7-year period. Interestingly, the velopharyngeal region (S0) demonstrated a gradual increase, whereas the hypopharyngeal level (S3) showed a decrease from T2 to T3, returning to near-baseline levels. This regional variation may reflect the differential response of soft tissues and neuromuscular control mechanisms in distinct anatomical zones of the airway. These findings are also consistent with those reported in previous studies.Temani et al.[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] and Yue et al.[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] also demonstrated short-term increases in oropharyngeal and hypopharyngeal airway dimensions following mandibular advancement. However, both studies lacked long-term follow-up data.\u003c/p\u003e \u003cp\u003eThe assessment of upper airway dimensions in the present study was based on lateral cephalometric radiographs, which represent a two-dimensional projection of a complex three-dimensional structure. This approach has inherent limitations, as it does not capture volumetric or dynamic airway changes. However, lateral cephalometry remains a widely used and standardized method for longitudinal evaluation of craniofacial and airway-related changes, particularly in pediatric populations, where minimizing radiation exposure is a key consideration. Importantly, all radiographs were obtained using the same device and protocol across all time points, allowing for reliable within-subject comparisons over time. Therefore, while absolute airway dimensions should be interpreted with caution, the observed longitudinal trends provide meaningful information regarding relative changes following treatment.\u003c/p\u003e \u003cp\u003eThe PSQI -a self report questionnaire- was used to assess sleep quality as perceived by the patients.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Between T1 and T2, an improvement in subjective sleep quality was observed in parallel with the objective improvement in apnea-related findings. However, between T2 and T3, despite a statistically significant increase in AHI, PSQI scores remained unchanged. This may be explained by the fact that the increase in AHI, while statistically significant, was not necessarily clinically significant, as the values still fell within the normal range for this age group. Similarly, as in the current study, the literature indicates that a significant correlation between AHI and PSQI is not consistently observed; individuals with sleep apnea\u0026mdash;particularly those with mild to moderate severity\u0026mdash;may still perceive their sleep quality as good.[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] Another finding at T3 was a significant decrease in mean oxygen saturation values (p\u0026thinsp;=\u0026thinsp;0.002), which appears to parallel the increase in AHI. However, the absence of a significant change in minimum saturation values suggests that oxygen desaturation did not reach a clinically critical threshold, indicating that severe hypoxemia was likely avoided.\u003c/p\u003e \u003cp\u003eIn a longitudinal cephalometric study in which subjects presenting with Class I skeletal patterns and only minor orthodontic intervention were selected as a control group for Class II patients treated with activator-headgear therapy, sagittal pharyngeal airway dimensions demonstrated gradual increases during growth; however, the magnitude of these changes was generally limited and not uniformly distributed across all airway levels.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] These findings suggest that physiologic growth alone results in modest, region-specific airway enlargement rather than marked or generalized expansion.\u003c/p\u003e \u003cp\u003eIn the present study, the absence of a matched untreated control group represents a limitation. In our view, an appropriate control group for patients with skeletal Class II malocclusion would ideally consist of untreated Class II individuals. However, withholding indicated orthopedic intervention in growing patients with mandibular retrognathia\u0026mdash;particularly in the presence of functional impairment or OSA\u0026mdash;raises ethical concerns. Therefore, while direct comparison with an untreated Class II cohort was not feasible, the findings should be interpreted with appropriate caution.\u003c/p\u003e \u003cp\u003eDespite the relatively small sample size, the 7-year follow-up period represents an important strength of this investigation, as extended longitudinal data in pediatric OSA remain limited. Long-term observation allows evaluation of skeletal and airway adaptations over time. Nevertheless, larger prospective studies are required to confirm these findings and improve generalizability.\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, the results are consistent with the possibility that monoblock mandibular advancement therapy may play a role in skeletal and airway adaptation in selected children with mandibular retrognathia and OSA. However, variability in airway response and the mild increase in AHI observed during adolescence in some patients indicate that outcomes are not uniform and that long-term follow-up remains essential. These findings should therefore be considered within a multidisciplinary management framework, given that diagnosis, treatment planning, and follow-up of pediatric OSA require coordinated collaboration among orthodontic, pediatric pulmonology, and otorhinolaryngology specialists.\u003c/p\u003e \u003cp\u003eAlthough cephalometric parameters are not routinely applied in otolaryngologic practice, they provide structural insight into craniofacial morphology and its relationship with upper airway configuration. When interpreted alongside polysomnographic findings, such measurements may contribute to a more comprehensive understanding of structural and functional adaptations associated with mandibular advancement therapy.\u003c/p\u003e \u003cp\u003eIn conclusion, this long-term follow-up study provides a descriptive evaluation of skeletal, airway, and sleep-related changes in children with mandibular retrognathia and obstructive sleep apnea treated with a monoblock appliance. Mandibular positioning appeared relatively stable over time, while airway dimensional changes followed heterogeneous patterns during the 7-year observation period. Although a mild but statistically significant increase in AHI was noted during adolescence, values remained below adult diagnostic thresholds in most patients, and subjective sleep quality did not deteriorate substantially. These observations underscore the dynamic and multifactorial nature of pediatric OSA and highlight the importance of sustained, individualized monitoring rather than assumptions of permanent resolution. Further multicenter longitudinal studies incorporating broader clinical and developmental parameters are warranted to clarify the long-term implications of orthopedic intervention in this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e Ethical approval was obtained from the Ethics Committee of Istanbul Medipol University (Approval No: 10840098-604.01.01-E.65336), and written informed consent was obtained from parents/legal guardians of all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable, as no identifiable images or personal data are included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u003c/strong\u003e The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest:\u003c/strong\u003e The authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding was received for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e S. K. A. contributed to conceptualization, methodology, formal analysis, data curation, original draft preparation, manuscript review and editing, visualization; E. K. contributed to formal analysis, data curation, manuscript review and editing, visualization, supervision, and project administration; R. E. contributed to manuscript review and editing, and supervision; H. K. contributed to conceptualization, methodology, formal analysis, manuscript review and editing, \u0026nbsp;investigation and supervision; \u0026nbsp;G. S. project administration, visualisation, manuscript review and editing; E. C. contributed to manuscript investigation, data curation, manuscript review and editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCarroll JL (2003) Obstructive sleep-disordered breathing in children: new controversies, new directions. 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Angle Orthod 72:43\u0026ndash;47\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGodt A, Koos B, Hagen H, G\u0026ouml;z G (2011) Changes in upper airway width associated with Class II treatments (headgear vs activator) and different growth patterns. Angle Orthod 81:440\u0026ndash;446\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan S, Choi YJ, Chung CJ, Kim JY, Kim KH (2014) Long-term pharyngeal airway changes after Bionator treatment in adolescents with skeletal Class II malocclusions. Korean J Orthod 44:13\u0026ndash;19\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026auml;nggi MP, Teuscher UM, Roos M, Peltom\u0026auml;ki TA (2008) Long-term changes in pharyngeal airway dimensions following activator-headgear and fixed-appliance treatment. Eur J Orthod 30:598\u0026ndash;605\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIwasaki T, Saitoh I, Takemoto Y, Inada E, Kanomi R, Hayasaki H (2012) Improvement of nasal airway ventilation after rapid maxillary expansion evaluated with computational fluid dynamics. Am J Orthod Dentofac Orthop 141:269\u0026ndash;278\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuilleminault C, Li KK, Khramtsov A, Pelayo R, Martinez S (2004) Sleep disordered breathing: surgical outcomes in prepubertal children. Laryngoscope 114:132\u0026ndash;137\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCapan E, Kılıcoglu H, Uzuncıbuk H (2024) Assessment of changes in behavior and quality of life after monoblock treatment in children with obstructive sleep apnea or primary snoring. Turk J Orthod 37:112\u0026ndash;121\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBishara SE, Ziaja RR (1989) Functional appliances: a review. Am J Orthod Dentofac Orthop 95:250\u0026ndash;258\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsuiki S, Lowe AA, Almeida FR, Fleetham JA (2004) Effects of an anteriorly titrated mandibular position on awake airway and obstructive sleep apnea severity. Am J Orthod Dentofac Orthop 125:548\u0026ndash;555\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerry RB, Budhiraja R, Gottlieb DJ et al (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM manual. J Clin Sleep Med 8:597\u0026ndash;619\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ (1989) The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 28:193\u0026ndash;213\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoi Y, Minowa M, Uchiyama M, Okawa M, Kim K, Shibui K (2000) Psychometric assessment of subjective sleep quality using the Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J). Psychiatry Res 97:165\u0026ndash;172\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKikuchi M (2005) Orthodontic treatment in children to prevent sleep-disordered breathing in adulthood. Sleep Breath 9:146\u0026ndash;158\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSolow B, Skov S, Ovesen J, Norup PW, Wildschi\u0026oslash;dtz G (1996) Airway dimensions and head posture in obstructive sleep apnoea. Eur J Orthod 18:571\u0026ndash;579\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang C, He H, Ngan P (2013) Effects of twin block appliance on obstructive sleep apnea in children: a preliminary study. Sleep Breath 17:1309\u0026ndash;1314\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSch\u0026uuml;tz TC, Dominguez GC, Hallinan MP, Cunha TC, Tufik S (2011) Class II correction improves nocturnal breathing in adolescents. Angle Orthod 81:222\u0026ndash;228\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVilla MP, Bernkopf E, Pagani J, Broia V, Montesano M, Ronchetti R (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 165:123\u0026ndash;127\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRemy F, Bonnaure P, Moisdon P, Burgart P, Godio-Raboutet Y, Thollon L (2021) Impact of simultaneous palatal expansion and mandibular advancement on respiratory status during sleep in children with OSAS. J Stomatol Oral Maxillofac Surg 122:235\u0026ndash;240\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZreaqat M, Hassan R, Samsudin AR, Alforaidi S (2023) Effects of twin-block appliance on upper airway parameters in OSA children with Class II malocclusion and mandibular retrognathia: a CBCT study. Eur J Pediatr 182:5501\u0026ndash;5510\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMastud CS, Deshmukh SV, Rahalkar J, Bharatwal M, Mane S, Mastud SP (2024) Evaluation of customized fixed intra-oral appliance with maxillary expansion and twin-block in pediatric obstructive sleep apnea patients. Sleep Med Res 15:113\u0026ndash;123\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElfouly D, Dumu E Jr, Madian AM, Eid FY (2024) The effect of different functional appliances on the sagittal pharyngeal airway dimension in skeletal Class II: a retrospective study. Sci Rep 14:19410\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePirelli P, Saponara M, Guilleminault C (2015) Rapid maxillary expansion for pediatric obstructive sleep apnea: a 12-year follow-up. Sleep Med 16:933\u0026ndash;935\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuilleminault C, Huang YS, Quo S, Monteyrol PJ, Lin CH (2013) Teenage sleep-disordered breathing: recurrence of syndrome. Sleep Med 14:37\u0026ndash;44\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIdris G, Galland B, Robertson CJ, Gray A, Farella M (2018) Mandibular advancement appliances for sleep-disordered breathing in children: a randomized crossover clinical trial. J Dent 71:9\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZonato AI, Bittencourt LR, Martinho FL, J\u0026uacute;nior JF, Greg\u0026oacute;rio LC, Tufik S (2003) Association of systematic head and neck physical examination with severity of obstructive sleep apnea-hypopnea syndrome. Laryngoscope 113:973\u0026ndash;980\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKushida CA, Efron B, Guilleminault C (1997) A predictive morphometric model for obstructive sleep apnea syndrome. Ann Intern Med 127:581\u0026ndash;587\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerhulst SL, Schrauwen N, Haentjens D, Rooman RP, Van Gaal L, De Backer WA (2006) First-night effect for polysomnographic measures in children and adolescents with suspected sleep-disordered breathing. Arch Dis Child 91:233\u0026ndash;237\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScholle S, Wiater A, Scholle HC, Lehmkuhl G (2011) Normative values of polysomnographic parameters in childhood and adolescence: a meta-analysis. Sleep Med 12:542\u0026ndash;549\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTemani P, Jain P, Rathee P, Temani R (2016) Volumetric changes in pharyngeal airway in Class II Division 1 patients treated with Forsus appliance: a CBCT study. Contemp Clin Dent 7:31\u0026ndash;35\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYue Z, Yi Z, Liu X, Chen M, Yin S, Liu Q (2023) Comparison of Invisalign mandibular advancement and twin-block on upper airway and hyoid position in skeletal Class II children. BMC Oral Health 23:661\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrandner MA, Kripke DF, Yoon IY, Youngstedt SD (2006) Criterion validity of the Pittsburgh Sleep Quality Index. Sleep Biol Rhythms 4:129\u0026ndash;139\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J et al (2012) Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 130:e714\u0026ndash;e755\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable I. Summary of Cephalometric Landmarks and Definitions\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSNA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eAngle between the lines from Sella to Nasion and from Nasion to Point A; represents the maxillary position relative to the cranial base.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSNB (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eAngle between the lines from Sella to Nasion and from Nasion to Point B; represents the mandibular position relative to the cranial base.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eGo-Me (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eLinear distance between Gonion and Menton; represents the length of the mandibular body.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eANS-PNS (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eLinear distance from Anterior Nasal Spine to Posterior Nasal Spine; indicates maxillary length.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSN-GoMe (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eAngle between Sella\u0026ndash;Nasion and Gonion\u0026ndash;Menton lines; reflects the vertical growth pattern of the mandible.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1-SN (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eAngle between the long axisof the upper central incisor (U1i to U1a) \u0026nbsp;and the Sella\u0026ndash;Nasion line; indicates upper incisor inclination.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1-NA (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eLinear distance from the most labial point of the upper incisor to the Nasion\u0026ndash;Point A line; indicates upper incisor protrusion.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eIMPA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eAngle between the long axis of the lower incisor (L1i to L1a) and the mandibular plane (Go\u0026ndash;Me); measures lower incisor inclination.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1-NB (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eLinear distance from the most labial point of the lower incisor to the Nasion\u0026ndash;Point B line; indicates lower incisor protrusion.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eOverjet (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eHorizontal distance between the upper and lower incisal edges; indicates sagittal incisor relationship.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eOverbite (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eVertical overlap between the upper and lower incisal edges; indicates vertical incisor relationship.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e Table II. Comparison of cephalometric skeletal and dental parameters at T1 (pre-treatment), T2 (post-treatment), and T3 (7-year follow-up).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" title=\" Bağımlı Veri Analizi Tablosu \" align=\"\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17px;\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18px;\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18px;\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17px;\"\u003e\n \u003cp\u003eTest Statistic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eSNA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e78,85 \u0026plusmn; 3,89\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e78,23 \u0026plusmn; 3,63\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e78,69 \u0026plusmn; 3,64\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1,778\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0,191\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eSNB (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e71,54 \u0026plusmn; 3,6 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e74,54 \u0026plusmn; 3,73 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e74 \u0026plusmn; 3,7 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e26,469\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026lt; 0,001\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eGo-Me (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e55 (52 - 71) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e58 (55 - 74) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e60 (56 - 76) \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e24,776\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026lt; 0,001\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eANS-PNS (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e48,46 \u0026plusmn; 3,95 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e51,38 \u0026plusmn; 3,45 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e51,77 \u0026plusmn; 2,83 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e32,318\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026lt; 0,001\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eSN-GoMe (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e40,38 \u0026plusmn; 5,85\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e40,77 \u0026plusmn; 6,46\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e40,54 \u0026plusmn; 7,02\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0,166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0,750\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1-SN (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e108,54 \u0026plusmn; 6,2 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e100,85 \u0026plusmn; 7,74 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e104,46 \u0026plusmn; 8,06 \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e21,567\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026lt; 0,001\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1-NA (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e6,08 \u0026plusmn; 1,71 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e4 \u0026plusmn; 1,47 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e4,62 \u0026plusmn; 1,56 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e13,445\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026lt; 0,001x\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eIMPA (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e92,38 \u0026plusmn; 6,97 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e96,08 \u0026plusmn; 8,61 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e97,23 \u0026plusmn; 7,35 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e8,591\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0,002\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1-NB (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e5 \u0026plusmn; 1,83\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e5,77 \u0026plusmn; 2,45\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e6 \u0026plusmn; 2,38\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1,906\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0,171\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eOverjet (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e8,5 (5,5 - 14) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e2,5 (2 - 4) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e3 (2 - 6) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e21,745\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026lt; 0,001\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eOverbite (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e4 (2,5 - 5) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e2,5 (1,5 - 3,5) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e2 (1 - 3) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e20,043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026lt; 0,001\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ex\u003c/sup\u003e Repeated measures ANOVA (used for normally distributed data); \u0026nbsp;\u003csup\u003ey\u003c/sup\u003e Friedman Test (used for non-normally distributed data); \u003csup\u003ea-c\u003c/sup\u003e No significant difference between groups sharing the same letter\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable III. Comparison of pharyngeal airway dimensions (S0\u0026ndash;S10) at T1, T2, and T3.\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" title=\" Bağımlı Veri Analizi Tablosu \" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eTest Statistic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e13,46 \u0026plusmn; 3,31 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e13,92 \u0026plusmn; 3,93 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e14,85 \u0026plusmn; 3,31 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e8,129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0,002\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e10,23 \u0026plusmn; 3,72\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e10,69 \u0026plusmn; 3,09\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e10,92 \u0026plusmn; 3,01\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2,066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0,149\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e8,69 \u0026plusmn; 2,5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e8,85 \u0026plusmn; 2,38\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e8,69 \u0026plusmn; 1,93\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0,316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0,732\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7,62 \u0026plusmn; 2,26 \u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7,92 \u0026plusmn; 2,33 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7,38 \u0026plusmn; 2,29 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e8,222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0,002\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7,38 \u0026plusmn; 1,94\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7,69 \u0026plusmn; 1,97\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7,77 \u0026plusmn; 2,17\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e1,054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0,339\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7 (6 - 13)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7 (6 - 13)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7 (5 - 12)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e1,167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0,558\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7 (6 - 10) \u003csup\u003ea\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e8 (7 - 11)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e8 (7 - 11) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e7,235\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0,018\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7,23 \u0026plusmn; 1,09\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7,38 \u0026plusmn; 1,26\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7,69 \u0026plusmn; 1,75\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e1,240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0,297\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e6 (5 - 8) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7 (6 - 9) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7 (6 - 9) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e8,473\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0,015\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e7,15 \u0026plusmn; 1,95 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e8,08 \u0026plusmn; 2,4 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e8,77 \u0026plusmn; 1,59 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e15,857\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026lt; 0,001\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eS10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e10,15 \u0026plusmn; 2,61 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e11,46 \u0026plusmn; 1,98 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e12,15 \u0026plusmn; 1,95 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e17,385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026lt; 0,001\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003csup\u003ex\u003c/sup\u003e Repeated measures ANOVA (used for normally distributed data); \u0026nbsp;\u003csup\u003ey\u003c/sup\u003e Friedman Test (used for non-normally distributed data); \u003csup\u003ea-b\u003c/sup\u003e No significant difference between groups sharing the same letter\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable IV. Comparison of polysomnographic parameters at T1, T2, and T3.\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" title=\" Bağımlı Veri Analizi Tablosu \" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17px;\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17px;\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003eTest Statistic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eStage 1 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0,5 (0,2 - 1,7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0,3 (0,1 - 70,1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0,5 (0,1 - 1,2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4,542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,103\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eStage 2 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e57,5 (25,5 - 74,7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e65,2 (22,9 - 70)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e59,2 (41,7 - 78,9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0,275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,872\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eStage 3,4 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e30,6 (17,6 - 74)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e28 (0 - 75,4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e25,3 (14,1 - 47,1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1,846\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,397\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eREM (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e5,82 \u0026plusmn; 5,04 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e5,76 \u0026plusmn; 3,83 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e12,48 \u0026plusmn; 5,5 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e10,133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,002\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eAHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e2,3 (1 - 16,9) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0,5 (0,2 - 1,8) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e2 (0,1 - 26) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e12,980\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,002\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eMean saturation (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e97,46 \u0026plusmn; 0,78 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e97,46 \u0026plusmn; 0,97 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e96,23 \u0026plusmn; 1,36 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e10,139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,002\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eMin. saturation (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e92 (29 - 95)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e92 (82 - 94)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e89 (78 - 93)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e3,040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,219\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eSleep efficiency (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e85,56 \u0026plusmn; 8,29\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e88,15 \u0026plusmn; 9,19\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e82,33 \u0026plusmn; 11,96\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1,808\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,190\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eArousal index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e10,23 \u0026plusmn; 7,69\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e13,49 \u0026plusmn; 6,01\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e11,98 \u0026plusmn; 7,57\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0,533\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,594\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eODI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1,7 (0,6 - 5,9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1,3 (0 - 3,1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e3 (0 - 18)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e3,231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,199\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003csup\u003ex\u003c/sup\u003e REM: Rapid eye movement, AHI: Apnea-Hypopnea Index, ODI: Oxygen Desaturation Index. Repeated measures ANOVA (used for normally distributed data); \u0026nbsp;\u003csup\u003ey\u003c/sup\u003e Friedman Test (used for non-normally distributed data); \u003csup\u003ea-b\u003c/sup\u003e No significant difference between groups sharing the same letter, AHI: Apnea\u0026ndash;Hypopnea Index\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable V. Comparison of Pittsburgh Sleep Quality Index (PSQI) scores and components at T1, T2, and T3\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" title=\" Bağımlı Veri Analizi Tablosu \" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003eTest Statistic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eGlobal Skor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e5,23 \u0026plusmn; 2,74 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3,15 \u0026plusmn; 2,15 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e3,85 \u0026plusmn; 1,68 \u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e6,943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,005\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eSubjective sleep quality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (0 - 3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0 (0 - 2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1 (0 - 2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e5,688\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,058\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eSleep latency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (0 - 2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (0 - 2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1 (0 - 1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1,040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,595\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eSleep disturbances\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (0 - 3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (0 - 1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1 (0 - 1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e3,263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,196\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eDaytime dysfunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (0 - 3) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;1 (0 - 3) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp; 1 (0 - 3) \u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e7,032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0,030\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003csup\u003ex\u003c/sup\u003e Repeated measures ANOVA (used for normally distributed data); \u0026nbsp;\u003csup\u003ey\u003c/sup\u003e Friedman Test (used for non-normally distributed data); \u003csup\u003ea-b\u003c/sup\u003e No significant difference between groups sharing the same letter\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003e Sleep duration, habitual sleep efficiency, and use of sleep medication components within the PSQI were excluded from comparisons, as all observations for each time point were identical and scored as zero.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pediatric OSA, mandibular retrognathia, functional appliance, long-term outcomes, sleep","lastPublishedDoi":"10.21203/rs.3.rs-8901194/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8901194/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eStudy Objectives:\u003c/h2\u003e \u003cp\u003eTo evaluate the long-term effects of monoblock mandibular advancement therapy on craniofacial morphology, upper airway dimensions, and sleep-related parameters in children with obstructive sleep apnea (OSA).\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThis prospective longitudinal cohort study included 13 children (mean age 10.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.51 years) with OSA and mandibular retrognathia treated with a monoblock appliance. Assessments were conducted at baseline (T1), post-treatment (T2), and 7 years after treatment (T3), including lateral cephalometric radiographs, polysomnography, and Pittsburgh Sleep Quality Index (PSQI) scores. Pharyngeal airway changes were analyzed using a standardized cephalometric protocol across 11 sagittal reference planes. Repeated measures ANOVA and nonparametric equivalents were applied for longitudinal comparisons.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eIncreases in oropharyngeal and hypopharyngeal airway dimensions (S6\u0026ndash;S10) observed after treatment were generally maintained over time. Skeletal parameters showed relative stability at follow-up. Although AHI decreased significantly after treatment, a moderate increase was noted at T3; however, values remained below the adult diagnostic threshold in most patients. PSQI scores improved initially and did not show significant long-term deterioration. An increase in REM sleep percentage at T3 may reflect normalization of sleep architecture following earlier first-night effects.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eMonoblock mandibular advancement therapy initiated during childhood may be associated with favorable and largely sustained changes in skeletal and airway parameters over a 7-year period. While partial recurrence of AHI was observed during adolescence, the overall pattern suggests a potential long-term benefit in selected patients, warranting further investigation in larger cohorts.\u003c/p\u003e","manuscriptTitle":"Long-Term Efficacy of Orthopedic Mandibular Advancement Therapy in Pediatric Obstructive Sleep Apnea: A 7-Year Follow-Up Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-22 16:58:55","doi":"10.21203/rs.3.rs-8901194/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-03T20:09:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T07:55:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T06:29:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-13T14:36:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-09T14:20:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291057131509240919167061099976036792243","date":"2026-02-25T13:31:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26989890732170205618387673578926145900","date":"2026-02-23T13:23:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312206907382027130280305029576108250129","date":"2026-02-20T12:35:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208109950297225129332553443964168179416","date":"2026-02-20T10:03:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-18T08:58:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-18T04:32:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-18T04:31:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Clinical Oral Investigations","date":"2026-02-17T12:23:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4c934dde-1e92-4b3b-aac0-7a873ffad0a6","owner":[],"postedDate":"February 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T06:08:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-22 16:58:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8901194","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8901194","identity":"rs-8901194","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}