Non-Cochrane · intervention · PM42101711
Efficacy of the twin-block appliance for pediatric obstructive sleep apnea: an updated systematic review and meta-analysis.
Zhou Xu, Wang Feifei, Fan Maolin, et al. · Sleep & breathing = Schlaf & Atmung · 2026 · PubMed · doi:10.1007/s11325-026-03670-7
Findings
Population Children and adolescents (<18 years) with obstructive sleep apnea or sleep-disordered breathing
12 findings
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Leave-one-out analysis omitting Zreaqat 2025 | MD -5.72 [-8.69, -2.75] GRADE not reported 6 studies |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Leave-one-out analysis omitting Zhang 2013 | MD -4.63 [-6.54, -2.72] GRADE not reported 6 studies |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Primary analysis as printed in Figure 3 forest plot | MD -5.55 [-8.07, -3.04] GRADE not reported 7 studies · 397 participants |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Leave-one-out analysis omitting Yu 2020 (TB only) | MD -6.07 [-8.81, -3.32] GRADE not reported 6 studies |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Sensitivity analysis excluding two lowest quality studies (Guan 2010, Lu 2014), as reported in text | MD -7.14 [-9.93, -4.35] GRADE not reported 5 studies |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Leave-one-out analysis omitting Idris 2018 | MD -6.24 [-8.70, -3.77] GRADE not reported 6 studies |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Sensitivity analysis excluding Guan 2010 and Lu 2014, common effect model as printed in Figure 4A | MD (common effect) -3.97 [-4.33, -3.62] GRADE not reported 5 studies · 305 participants |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Primary analysis as reported in abstract and text | MD -6.68 [-8.76, -4.60] GRADE not reported 7 studies · 219 participants |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Leave-one-out analysis omitting Gao 2020 | MD -5.12 [-7.94, -2.30] GRADE not reported 6 studies |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Sensitivity analysis excluding Guan 2010 and Lu 2014, random effects as printed in Figure 4A | MD -5.57 [-9.25, -1.88] GRADE not reported 5 studies · 305 participants |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Leave-one-out analysis omitting Guan 2010 | MD -5.49 [-8.48, -2.50] GRADE not reported 6 studies |
| Twin-Block or modified Twin-Block appliance | Control group (no treatment, placebo or other treatment) or pre-post treatment comparison | Change in Apnea-Hypopnea Index (AHI, events/hour) Leave-one-out analysis omitting Lu 2014 | MD -5.63 [-8.63, -2.63] GRADE not reported 6 studies |
Included primary studies 5
Open in Studies| Study | Year | Also included by | Outcomes it informs here | Trial data |
|---|---|---|---|---|
| Guan 2010 matched by author and year (probable) | NR | this review only | not stated | not extracted yet |
| Idris 2018 Mandibular advancement appliances for sleep-disordered breathing in children: A randomized crossover clinical trial. PMID:29357293 | 2018 | this review only | not stated | not extracted yet |
| Radwan 2023 Effect of functional appliances on sleep-disordered breathing in Class II division 1 malocclusion children: Randomized controlled trial. PMID:37522361 | 2024 | this review only | not stated | not extracted yet |
| Zhang 2013 Effects of twin block appliance on obstructive sleep apnea in children: a preliminary study. PMID:23558604 | 2013 | this review only | not stated | not extracted yet |
| Zreaqat 2025 Effects of twin-block appliance on quality of life in OSA children with class 2 malocclusion and mandibular retrognathia. PMID:40586105 | 2025 | this review only | not stated | not extracted yet |
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Children and adolescents (<18 years) with obstructive sleep apnea or sleep-disordered breathing | Children with OSA (8 studies, 259 patients) |
| Intervention | Twin-Block or modified Twin-Block appliance | Twin-Block appliance (n=259) |
| Comparison | Control group (placebo, no treatment, or another active treatment) or pre-post treatment design | Control or pre-post comparison |
| Outcomes | Change in Apnea-Hypopnea Index (primary), Oxygen Desaturation Index, pharyngeal airway dimensions | AHI change (7 studies, n=219); oropharyngeal airway volume (1 RCT, not poolable) |
| Study designs | RCTs, non-randomized controlled trials and case series | 2 RCTs, 1 non-randomized controlled trial, 5 case series (n=8) |
| Timing | Not specified | Not specified |
AMSTAR 2 items
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | Yes | yes |
| 2Protocol established before the reviewcritical | Partial Yes | Partial Yes | yes |
| 3Choice of study designs explained | No | No | yes |
| 4Comprehensive literature searchcritical | Partial Yes | Partial Yes | yes |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | Yes | Yes | yes |
| 7List of excluded studies with reasonscritical | No | No | yes |
| 8Included studies described in detail | Partial Yes | Partial Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | RCT: Yes · NRSI: Yes | NRSI: Yes · RCT: Yes | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: Yes · NRSI: No | NRSI: No · RCT: No | no |
| 12Impact of risk of bias on the pooled results | Yes | Yes | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | No | No | yes |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | Critically Low | Critically Low | yes |