What Are the Factors Associated with Longevity of Mandibular Advancement Oral Appliances?

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you very much for submitting your manuscript entitled “What Are the Factors Associated with Longevity of Mandibular Advancement Oral Appliances?” for review. The study addresses a clinically important and timely question, and I would like to commend you for the large dataset, the long observation period, and the careful statistical methodology, particularly the use of shared frailty analysis. The differentiation of failure types adds clarity and clinical value to your work.

The results are consistent and clinically relevant, with connector strength clearly emerging as the critical determinant of appliance survival. The findings regarding age and sex effects are also noteworthy, and the observation that apnea severity does not influence appliance longevity provides an interesting clinical perspective.

I do, however, see some areas where the manuscript could be further improved:

• The retrospective design and reliance on medical records should be acknowledged more prominently as a limitation, especially since factors such as occlusal patterns or parafunctional habits may also impact appliance durability.

• The discussion on connector failures could be expanded with more detailed consideration of material properties, possible reinforcement strategies, and potential directions for technical innovation.

• Since your conclusion emphasizes clinical decision-making, I would encourage you to provide more concrete guidance (for example, when a fixed or two-connector design should be preferred in younger male patients).

• Finally, expanding the discussion to consider generalisability across different populations and clinical settings would further strengthen the paper.

Overall, I believe this is a valuable and well-prepared manuscript. With minor revisions to expand the discussion and refine clinical recommendations, the work will make a meaningful contribution to the field.

Recommendation: Acceptance after minor revision.

Comments for author File: Comments.pdf

Author Response

We sincerely thank the reviewers for their valuable feedback and thoughtful suggestions regarding our manuscript. Below, we provide a detailed response to each point raised. All revisions have been made accordingly and are highlighted in red in the revised manuscript.

 

Comment1: The retrospective design and reliance on medical records should be acknowledged more prominently as a limitation, especially since factors such as occlusal patterns or parafunctional habits may also impact appliance durability.

Response1: Thank you for this important suggestion. We have added the following sentence to more clearly emphasize this limitation in the discussion section: In particular, occlusion patterns and parafunctional habits are likely to significantly impact appliance durability. The inability to accurately evaluate these factors must be acknowledged as a limitation inherent to the retrospective study design.

 

Comment2: The discussion on connector failures could be expanded with more detailed consideration of material properties, possible reinforcement strategies, and potential directions for technical innovation.

Response2: We appreciate this recommendation and have expanded the discussion accordingly. The following passage has been added: It is evident that the connectors used in MAOAs should be stronger than those made of HDPE, while still being soft enough to synchronize with muscle movement. Although polymeric materials are not strictly necessary, if metal is used, the risk of allergic reactions must be considered. Additionally, the connector’s adhesion to appliance components should be carefully evaluated. Further in vitro and in vivo studies are essential to validate these findings.

 

Comment3: Since your conclusion emphasizes clinical decision-making, I would encourage you to provide more concrete guidance (for example, when a fixed or two-connector design should be preferred in younger male patients).

Response3: Thank you for this valuable suggestion. We have added the following sentence to the conclusion to provide more practical clinical guidance: Given the results of this study, which showed no significant difference in survival rates between the two-connector type and the fixed type, and considering previous research highlighting the comfort of mobile MAOAs, it may be advisable to select the two-connector type from the outset for young male patients.

 

Comment4: Finally, expanding the discussion to consider generalisability across different populations and clinical settings would further strengthen the paper.

Response4: Thank you for highlighting this important aspect. We have included the following statement at the end of the discussion to address generalizability:

This study focused on individuals diagnosed with OSA by a respiratory medicine department. However, many people experience milder symptoms, such as snoring, that do not meet the diagnostic criteria for OSA. The fact that MAOAs, which offer therapeutic benefits, can be easily fabricated in dental clinics should be more widely publicized.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

I read with interest your article. I believe that this manuscript addresses animportant but underexplored question like the durability and survival of MAOs in patients with OSAS.

The paper is well written, with good Methods, proper results and an appropriate statistic approach. The citations seem appropriate.

However I have some aspects that i would like you to clarify before considering this article for publication. 

• The fact that parafunctional habits and bruxism were not considered due to lack of data should be better highlighted on the limitations. It could be useful also to consider other papers present in literature on the topic.
• The same observation can be also made on the materials: you used PETG thermoplastic and HDPE connectors; please add in the discussion a comparison of the strength data present in Literature, compared to other materials. 
• Also expand the conclusions regarding what should clinicians preferentially prescribe based on sex and age and whether should reinforcement strategies be systematically applied in selected cases. 

A few figures showing the breakage of the MAOs could also enrich the paper. 

 

Best Regards,

 

 

Comments on the Quality of English Language

The language is clear and appropriate.

Author Response

We sincerely thank the reviewers for their valuable feedback and thoughtful suggestions regarding our manuscript. Below, we provide a detailed response to each point raised. All revisions have been made accordingly and are highlighted in red in the revised manuscript.

Comment #1 We noticed that there are similarities of approximately 6% between your manuscript and the sources, the details are provided in the attached report. We kindly request that you reduce the repetition rate of each referenced source to below 3% and ensure that the overall repetition rate is lower than 25%.

Response #1 Thank you for bringing this to our attention. We have carefully revised the manuscript to reduce the similarity index. Each referenced source now falls below the 3% threshold, and the overall repetition rate is well under 25%.

 

Comment #2 Please ensure that the experimental details are provided in full and all the results are presented comprehensively. We kindly request that you thoroughly address the background and provide an overview of the research in the introduction section.

Response #2 All data will be submitted as supplementary material. Additionally, we have expanded the introduction to better outline the background and research objectives. The following sentence has been added:However, concerns remain that increasing the range of motion in MAOAs may compromise long-term durability, which should be evaluated through clinical studies with long-term follow-up involving a large cohort of MAOA patients.