The AAO have updated their recommendations on sleep-disordered breathing and orthodontics.
This post is by Martyn Cobourne. He published this on the excellent Evidence Based Orthodontics Facebook group. I was planning to write a post on this important update, but while I was out walking the dog, he beat me to it. He has done a great summary of the recommendations that the AAO group made.
Introduction
The American Association of Orthodontists published a white paper in 2019 on obstructive sleep apnea (OSA) and orthodontics, which provided an evidence-based, pragmatic guide for orthodontists on how best to manage these patients in an orthodontic environment. This new publication updates these guidelines, and we have summarised the main findings relevant to the management of children. The good news is that this article is Open Access:Â
Juan Martin Palomoa, Julia Cohen-Levy, Carlos Flores-Mirc,∙Rooz Khosravie, Mitchell Levine, Michael Pickard,Jackie Hittner, John Callahan, Steven M. Siegeli
AJO-DDO on line: DOI: 10.1016/j.ajodo.2026.01.014
These are the main findings of the group;
- Obstructive sleep apnea (OSA) is a severe form of sleep-disordered breathing (SDB), which represents a spectrum of conditions ranging from habitual snoring to severe OSA.
- Sleep-disordered breathing requires proper diagnosis by the relevant physician and certainly, any SDB-intervention should not be carried out in the absence of a formal diagnosis. Orthodontists can play an important role in early detection and risk assessment for SDB, and appropriate diagnostic referral when SDB is suspected. Polysomnography combined with clinical symptoms remains the gold standard for diagnosing OSA.
- There is currently no evidence of any orthodontic intervention capable of preventing the development of sleep- disordered breathing.
- SDB is a heterogeneous condition associated with a wide range of biological or pathophysiological mechanisms and a spectrum of associated clinical symptoms.
- In children, prepubertal OSA has a tendency to resolve naturally as the child transitions into adolescence; however, this does not always happen, and some children (males, overweight) can represent exceptions to this.
- The current meta-analysis finds either no direct causal relationship or is inconclusive regarding the relationship between SDB and craniofacial characteristics.
- ·SDB risk assessment by the orthodontist should involve a comprehensive history, examination and validated questionnaire. This should form the basis of any referral to a physician for definitive diagnosis.
- CBCT and cephalometric imaging of the upper airway has no diagnostic value for SDB assessment or diagnosis, and is not recommended for diagnosing OSA because of fundamental limitations.
- Using changes in upper airway dimensions to suggest the efficacy of orthodontic treatment is scientifically flawed. Increasing upper airway volume or dimensions does not necessarily signify functional improvement or effective management of OSA.
- The consensus evidence is that ankyloglossia does not contribute to OSA and routine frenectomy for SDB is not supported.
- Current evidence on the relationship between rapid maxillary expansion (RME) and paediatric OSA suggests a nuanced perspective. RME use for SDB management should be reserved for those patients where a clear orthodontic indication exists alongside a confirmed SDB diagnosis. There is no evidence to support prophylactic use of RME as a preventive measure for SDB over the lifespan.
- In terms of functional appliances, a critical perspective on the efficacy and limitations of such therapies for paediatric SDB should be maintained. There is no evidence to support prophylactic use of functional appliances as a preventive measure for SDB over the lifespan.
- There is no evidence to support a causal relationship between extractions and the development of SDB.
- Current evidence shows that distalising teeth does not inherently constrict the airway.
- There is insufficient evidence to support the routine use of myofunctional appliances for paediatric OSA.
- The management and treatment of children with Sleep Disorded Breathing should represent an interdisciplinary collaboration between medical and dental health care professionals. Orthodontists have the expertise to make significant contributions to the overall care of these children.
What did I think?
There have been controversies in orthodontics over the history of our specialty and in many respects, the role of the orthodontist in management of sleep disordered breathing is the 21st century controversy. Like most of these subjects, marginal and unsubstantiated views often dominate the narrative. These guidelines represent a pragmatic and balanced view based upon the best available evidence (and we would all agree that the current evidence base is lacking) written by a wide-ranging panel of experts. They are a very sensible set of recommendations and should be read by both generalists and specialists alike.
Orthodontists and other oral healthcare professionals are well-placed to play a role in the management of sleep-disordered breathing, but it must be evidence-based.
Just excellent! Thank you for the great summary!