Kazmierski Progress in Orthodontics (2024) 25:21 Progress in Orthodontics

https://doi.org/10.1186/s40510-024-00524-4

REVIEW Open Access

Obstructive sleep apnea: What

is an orthodontist’s role?
Robert H. Kazmierski1*   

Abstract
Background The American Association of Orthodontists white paper on obstructive sleep apnea and orthodontics
remains the most authoritative statement on the topic. This was produced in 2019 due to increasing orthodontic
interest in obstructive sleep apnea (OSA) and the lack of formal guidelines for orthodontists. Since the white paper’s
release, advocacy for contrarian ideas and practices remain. Orthodontists are sometimes acting as primary care
providers for OSA. Procedures appropriate only for screening are sometimes being used for diagnosis. The side effects
of effective treatments such as mandibular advancement devices need further consideration. Also, research has clari-
fied the effectiveness and ineffectiveness of treatments such as palatal expansion.
Results Part of an orthodontist’s role is screening for OSA. The correct action when this is suspected remains referral
to the appropriate physician specialist for diagnosis and treatment or coordination of treatment. Orthodontists may
participate in the treatment of patients with OSA as a member of a multi-disciplinary team. Effective orthodontic
treatments may include orthognathic surgery with maxillomandibular advancement and mandibular advancement
devices. The negative effects of the latter make this a choice of last resort. Current research indicates that OSA alone
is not sufficient indication for palatal expansion.
Conclusions Orthodontists should appropriately screen for obstructive sleep apnea. This may be done as part of our
health histories, our clinical examination, and review of radiographs taken for purposes other than the diagnosis
and screening for OSA. Orthodontic treatment for OSA can be helpful and effective. However, this may be done
only after referral to the appropriate physician specialist, as part of a multi-disciplinary team, with consideration
of the likely effectiveness of treatment, and after all likely and potential negative consequences have been considered
and thoroughly discussed with the patient.
Keywords Obstructive sleep apnea, Orthognathic surgery, Maxillomandibular advancement, Mandibular
advancement devices, Palatal expansion

Introduction of established guidelines specific to orthodontic prac-

The American Association of Orthodontists (AAO) white tice [1]. However, since its publication, there persists a
paper on obstructive sleep apnea (OSA) and orthodon- prevalence of advocacy for divergent ideas and practices.
tics stands as the definitive statement on this subject Some orthodontists have assumed roles akin to primary
[1]. Released in 2019, it was prompted by the growing care providers for OSA, occasionally employing proce-
interest among orthodontists in OSA and the absence dures meant for screening purposes for diagnosis. Fur-
thermore, while effective treatments like mandibular
*Correspondence: advancement devices MADs have shown promise, their
Robert H. Kazmierski potential side effects warrant further exploration [2].
[email protected] Additionally, recent research has shed light on both the
1
Solo Private Orthodontic Practice, 110 Marter Ave., Suite 404,
Moorestown, NJ 08057, USA potential efficacy and the limitations of treatments such
as palatal expansion for OSA [3–5].

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Kazmierski Progress in Orthodontics (2024) 25:21 Page 2 of 6

Consequently, this commentary seeks to delve into the definitive diagnosis [14]. Overall, the primary screen-
appropriate delineation of an orthodontist’s role in OSA ing tools for OSA in orthodontic settings include radio-
treatment. This role can be anchored in three fundamen- graphs, medical history assessment, and standardized
tal principles: questionnaires like the STOP-BANG for adults and the
Pediatric Sleep questionnaire for children [15]. Addi-
First principle: do no harm tionally, the Modified Mallampati assessment for the
Obstructive sleep apnea (OSA) is a prevalent disorder palatine tonsils contributes to the screening [16].
associated with an increased risk of serious cardiovas- It’s important to acknowledge the evolving relevance
cular conditions such as coronary artery disease, heart of these screening tools in orthodontic research and
attack, and heart failure [6]. If left inadequately managed, their role in advancing OSA research. However, their
OSA can even lead to premature death [6]. As orthodon- limitations and the need for rigorous validation under-
tists, venturing into life-or-death scenarios is unfamiliar score the importance of exercising caution and con-
terrain for us. Therefore, when OSA is suspected or diag- sidering complementary diagnostic modalities when
nosed, careful considerations must be made. assessing patients for OSA. Unfortunately, much of the
The primary healthcare provider most qualified to relevant orthodontic research assessing the efficacy
diagnose and guide the management of OSA patients of appliance systems in improving airway and breath-
is the physician specializing in sleep medicine, com- ing fails to incorporate definitive diagnosis of airway
monly known as a sleep specialist [7]. The diagnosis and issues using polysomnography (PSG) before treatment
management of OSA fall distinctly outside the scope of or symptom assessment post-treatment. This raises sig-
orthodontics. Without the guidance of a sleep specialist, nificant concerns regarding the effectiveness of these
orthodontists risk violating the principle of "do no harm." appliances in curing obstructive sleep apnea (OSA) or
This does not imply that orthodontists are precluded any airway-related issues.
from screening for OSA. Orthodontists can indeed con- For example, it may seem intuitive that an expander
duct screening assessments for OSA; however, their role could increase airway dimensions as observed in CBCT
is strictly delineated by the directives and recommenda- scans or lateral cephalograms [17]. However, it cannot
tions provided by sleep specialists [1]. Also, orthodontists be definitively concluded that this treatment modality
bear the responsibility of ensuring that any management contributes to OSA treatment success utilizing meas-
provided under the guidance of a sleep specialist is effi- urements of dimensional changes alone. The crucial
cacious, that patients are fully informed about potential question arises: what impact does the change in air-
side effects, and that alternative treatment options have way volume have on OSA treatment if the patient did
been thoroughly explored. not initially have OSA, or if research fails to establish a
Polysomnography (PSG) stands as the gold standard definitive difference in pre- and post-treatment apnea–
for diagnosing obstructive sleep apnea (OSA), providing hypopnea index (AHI)?
a direct measure of apneic and hypopnea events over a The use of PSG appears necessary to validate treat-
specified period, known as the apnea–hypopnea index ment with orthodontic appliances for airway improve-
(AHI) [8]. Its validity has been endorsed by the American ment in OSA patients. The additional requirement
Academy of Pediatrics, particularly for children and ado- of having a control group seems critical in pediat-
lescents exhibiting snoring or OSA symptoms [9]. PSG ric patients, as their developing hard and soft tissues
offers a noninvasive means of assessment [10]. undergo constant change. With pediatric patients,
In contrast, orthodontic records are not considered observing the effects of an orthodontic treatment pro-
definitive diagnostic tools for OSA. They are viewed as tocol may frequently provide no value without a com-
indirect and less precise, primarily suitable for initial parison to a control group. A control group would
screening rather than a definitive diagnosis. For instance, elucidate whether claimed airway improvements are
cone beam computed tomography (CBCT) images, attributable to treatment rather than natural growth. A
although sometimes used to assess airway dimensions, third time point sufficiently past treatment completion
lack reliability and consistency in airway analysis [11]. seems necessary with pediatric patients as well. Even
Despite their potential utility in certain clinical scenar- if a post treatment difference is achieved, growth may
ios, limitations such as static imagery, inability to evalu- result in the control group catching up. This would nul-
ate airway function, and radiation risks undermine their lify any initial difference from treatment.
diagnostic value [12, 13]. In summary, for more robust and valid airway clini-
Similarly, lateral cephalograms, providing 2D rep- cal and research practices, PSG assessment before
resentations of 3D structures, are less effective than and after treatment is essential to ascertain treatment
CBCT in OSA screening and are unsuitable for efficacy.
Kazmierski Progress in Orthodontics (2024) 25:21 Page 3 of 6

Second principle: soft tissue changes do not necessarily it can be argued that increasing the palatal width and
follow hard tissue changes nasopharyngeal airway space may not necessarily affect
The principle that soft tissue changes do not necessarily the collapsibility of the pharyngeal airway or the neuro-
follow hard tissue changes is significant, particularly in muscular tone during sleep, both of which could be caus-
the context of viewing obstructive sleep apnea (OSA) pri- ative factors in a patient’s OSA [26]. It’s important to note
marily as a soft tissue or neuromuscular issue rather than that the nasopharynx is not directly connected to the
a hard tissue problem [18]. The presence of hypoxemia non-collapsible trachea; rather, the collapsible pharyn-
serves as a critical factor in distinguishing between these geal airway lies between these two structures. Therefore,
etiologies, with constant hypoxemia indicating a narrow- palatal expansion and the resulting increase in naso-
ing in the hard tissue boundaries of the airway [19]. pharyngeal space may not directly impact the collapsibil-
Given that most orthodontic treatments focus on ity of the pharyngeal airway. Research on the effects of
adjusting hard tissues, there’s often an expectation that expansion on the collapsibility of the pharyngeal airway
neuromuscular tissues will adapt accordingly. However, space is lacking. Moreover, improvement in the patency
it’s important to acknowledge that the adaptation of soft of the nasal airway does not necessarily translate to an
tissues to these changes can sometimes be unpredict- improvement in the patient’s AHI. Consequently, few
able. Hence, it’s crucial to understand which hard tissue studies have investigated the long-term changes in AHI
changes might have a predictable effect on the relevant post-expansion. Any post-palatal expansion long-term
neuromuscular tissues. change in AHI should be viewed as a fortunate outcome
For example, surgical maxillomandibular advance- rather than a predictable one, as it is often short-term
ment (MMA) appears to yield the most reliable and and non-predictable.
predictable outcomes in terms of soft tissue adaptation For pediatric patients, the situation is considerably less
for OSA patients [20]. A recent meta-analysis assessing ambiguous. Research conducted on pediatric patients
the apnea–hypopnea index (AHI) post-MMA surgery with OSA has indicated that watchful waiting has an
reported promising results, with 85% of patients con- equivalent effect on any change in the apnea–hypopnea
sidered surgical successes and 38.5% completely cured index (AHI) as palatal expansion [5]. It appears that stud-
of OSA [21]. These findings underscore the potential of ies utilizing polysomnography to assess AHI in pediatric
maxillomandibular advancement surgery as a viable cure patients do not endorse the use of palatal expansion for
for OSA. the treatment or prevention of OSA [27]. Instead, the use
In contrast, mandibular advancement devices (MAD) of palatal expanders is advocated solely for orthodontic
aim to advance the mandible non-surgically by stretch- clinical purposes [27].
ing ligaments and musculature around the jaws. While Within this second principle and preceding this point,
MADs may offer benefits in terms of airway improve- orthodontic treatments for OSA vary in their success
ment, their effectiveness may not be as reliable or rates, ranging from highly successful to occasionally suc-
predictable as surgical interventions like MMA [22]. cessful within specific parameters and circumstances.
Therefore, mandibular advancement devices (MADs) Regrettably, some treatments that are known to be inef-
might offer improvement in airway problems by con- fective need to be addressed. Among these is the mis-
stantly increasing airway diameter and maintaining soft conception regarding the influence of orthodontic
tissue displacement. However, it’s important to note that extractions on the airway. To put it plainly, there is no
the adaptation of soft tissues to mandibular jaw displace- scientific evidence available to support the notion that a
ment is not guaranteed. Also, long-term use of MADs cause-and-effect relationship exists between orthodontic
has been associated with various malocclusions and their extractions and OSA [28]. Since orthodontic extractions
efficacy in reducing the apnea–hypopnea index (AHI) in do not cause OSA, it logically follows that opening prior
adults is reported to be moderate over the long term [22]. extraction spaces is not a legitimate treatment for OSA
Hence, caution must be exercised when prescribing these either. Similarly, there is no scientific evidence support-
appliances as a treatment for OSA, and patients should ing the effectiveness of treatments to increase "tongue
be informed of the potential risks involved. space" for the treatment of OSA.
Regarding palatal expansion, it is logical to assume that Overall, we must acknowledge that logical deductions
it might increase the nasopharyngeal airway space and can become invalid when contradicted by valid research
consequently decrease nasal airway resistance. However, evidence. Many concepts may initially seem plausible
the available evidence supporting this is only short-term, but are ultimately proven false when subjected to rigor-
equivocal, and of low quality [23, 24]. While a recent ous research scrutiny. An analogy can be drawn between
meta-analysis has shown a statistically significant reduc- the avoidance of orthodontic extractions to prevent OSA,
tion in nasal resistance following palatal expansion [25], treatments to increase "tongue space" for the treatment of
Kazmierski Progress in Orthodontics (2024) 25:21 Page 4 of 6

OSA, and the historical medical practice of bloodletting which can further compromise dental health and stability
to treat various ailments. Due to misplaced trust in per- [31].
sonal clinical experiences, numerous success stories, and In my own clinical experience, I have observed cases
detailed theoretical explanations, bloodletting remained where MAD appliances have caused significant dental
a medically accepted practice for over 2,000 years. It was changes, including flaring of mandibular incisors and
only through research demonstrating its lack of ben- associated lingual alveolar bone atrophy, ultimately lead-
efit that the practice was ultimately discontinued. Simi- ing to tooth loss. Once these changes occur, orthodontic
larly, in orthodontics, we must prioritize evidence-based correction may be challenging or even impossible, high-
approaches over anecdotal experiences or theoretical lighting the irreversible nature of the damage caused by
explanations. Valid research should serve as the guiding MADs.
principle in determining the most effective treatments Titration of the mandibular advancement in man-
for OSA and other conditions. dibular advancement devices (MADs) has been used to
minimize the impact of orthodontic forces [32]. Morning
occlusal guides are sometimes used to reverse the effects
Third principle: selection of treatment with least of MAD wear as well [33]. However, long-term damage
undesirable side effects, acceptable to patients may still occur, highlighting the importance of careful
Indeed, the selection of treatment for obstructive sleep monitoring and consideration of alternative treatments.
apnea (OSA) involves a delicate balance considering vari- As orthodontists, it’s essential to exercise caution when
ous factors unique to each patient and situation. While considering MADs as a treatment for OSA, emphasizing
positive pressure appliances (PPA) and weight loss are the potential risks and limitations to patients. Long-term
commonly recommended for adult patients [29], ade- use of MADs should be avoided, and alternative treat-
notonsillectomy is often favored for pediatric patients ment options should be explored whenever possible to
over two years old [30]. However, when dental interven- minimize the risk of adverse dental outcomes.
tions come into play, maxillomandibular advancement In cases where negative side effects of MADs become
(MMA) emerges as a successful option [21], albeit with evident, transitioning to continuous positive airway pres-
limited acceptability due to its surgical nature. Mandib- sure (CPAP) therapy or considering maxillomandibu-
ular advancement devices (MAD) offer a non-surgical lar advancement (MMA) surgery may be necessary to
alternative, but their long-term efficacy relies on con- address the issues effectively. Given the eventual dental
sistent nightly wear. This and their dental side effects effects, it is concerning that some patients may choose
can make them less desirable for some patients [31]. It’s MADs without being adequately informed of the poten-
crucial to acknowledge that while MADs can provide tial risks and limitations. During my clinical experience,
ongoing symptom relief, they are not a definitive cure for I have sadly encountered patients seeking orthodontic
OSA. solutions for the negative outcomes of MADs who were
There would seem little risk of side effects when MADs unaware of these possibilities and had not received com-
are used temporarily as a substitute for CPAP, particu- prehensive guidance from a physician specializing in
larly during travel, or as part of a surgery-first treatment sleep medicine or their orthodontists. This underscores
plan while awaiting MMA. However, when they are the importance of thorough patient education and shared
worn indefinitely as a definitive treatment, mandibular decision-making when considering treatment options for
advancement devices (MAD) exert significant ongoing OSA. Patients should be fully informed of the potential
forces on the teeth, potentially leading to unintended benefits and risks associated with each treatment modal-
side effects and worsening of the occlusion [31]. While ity, allowing them to make informed decisions about
these appliances may have some corrective effect in cases their care in collaboration with healthcare providers spe-
of class II malocclusion, their prolonged use can result cializing in sleep medicine.
in detrimental effects on the periodontium and dental It is important to recognize that while mandibu-
occlusion [31]. It’s crucial to recognize that while MADs lar advancement devices (MADs) may pose risks and
may offer temporary relief for obstructive sleep apnea potential harms, there are situations where they can be
(OSA), their continued use as a long-term solution poses a viable and appropriate treatment option for patients
risks to the health of the joint and dentition. Prolonged with obstructive sleep apnea (OSA). Despite their draw-
use of MADs can lead to anterior flaring of the mandibu- backs, MADs may be the best available choice for cer-
lar incisors, resulting in class III malocclusions and other tain individuals who are not suitable candidates for other
occlusal abnormalities [31]. Additionally, MADs can con- treatments or who are unable to tolerate alternative
tribute to conditions such as anterior edge-to-edge rela- interventions. For instance, in cases where a patient’s
tionships, posterior open bites, and anterior open bites, health is at risk due to untreated OSA and they cannot
Kazmierski Progress in Orthodontics (2024) 25:21 Page 5 of 6

undergo or tolerate other treatment modalities, using a OSA condition while minimizing risks and optimizing
MAD may be justified. In such circumstances, the poten- outcomes.
tial benefits of MAD therapy may outweigh the risks and
Abbreviations
limitations. Ultimately, the decision to use a MAD should AHI Apnea–hypopnea index
be made on a case-by-case basis, considering the individ- CBCT Cone beam computed tomography
ual patient’s medical history, preferences, and treatment CPAP Continuous positive airway pressure
CPR Cardiopulmonary resuscitation
goals. It is crucial for healthcare providers to thoroughly MAD Mandibular advancement devices
discuss the potential benefits, risks, and alternatives with MMA Maxillomandibular advancement
patients, empowering them to make informed decisions OSA Obstructive sleep apnea
PBCSM Physician board-certified in sleep medicine
about their care in collaboration with their healthcare PPA Positive pressure appliances
team. PSG Polysomnography
Every treatment option carries its own set of benefits SARME Surgically assisted rapid maxillary expansion
and limitations, and the optimal choice depends on the Acknowledgements
patient’s preferences, medical history, and willingness Not Applicable.
to undergo certain procedures. As orthodontists, we
Author contributions
must carefully weigh these factors to provide personal- Robert Kazmierski (RK) is the sole author. RK has read and approved the final
ized treatment plans that prioritize both effectiveness manuscript.
and patient acceptance. Upon evaluating the spectrum of
Funding
treatments for obstructive sleep apnea (OSA), a distinct Not Applicable.
trend emerges. When arranged in descending order of
preference, orthodontic interventions consistently rank Availability of data and materials
Not Applicable.
lower on the list. While maxillomandibular advancement
(MMA) surgery proves effective, its association with
Declarations
orthognathic surgery often deters patients from opting
for this approach. In contrast, mandibular advancement Ethical approval and consent to participate
devices (MADs) demonstrate efficacy for many patients. Not Applicable.
However, their eventual adverse effects relegate them to a Consent for publication
last-resort status. The remaining orthodontic treatments Not Applicable.
for OSA either lack sufficient reliability or are contra-
Competing interests
dicted by robust research findings. The author declares that they have no competing interests.
This pattern underscores the importance of a discern-
ing approach to treatment selection. By prioritizing
Received: 5 March 2024 Accepted: 10 May 2024
interventions with the optimal balance of effectiveness
and tolerability, healthcare providers can guide patients
toward solutions that offer the greatest benefit with the
fewest drawbacks.
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