SPECIAL ARTICLE
Obstructive sleep apnea and early
orthodontic intervention: How early
is early?
Sanjivan Kandasamya,b,c
St Louis, Mo, and Nedlands and Midland, Western Australia, Australia
I
t appears that the debate regarding the role of the
orthodontist in assessing and managing patients
with obstructive sleep apnea (OSA) has become
more controversial and contentious, especially after
the recent American Association of Orthodontists
(AAO) conference in Chicago in May 2023.
The controversy revolves around the key issue of early
orthodontic intervention for OSA in pediatric patients.
Some speakers highlighted the need for early orthopedic
maxillary expansion, early myofunctional therapy, and
growth modification to improve OSA signs and
symptoms or to prevent their occurrence later in young
patients as early as 3 years old.1
In November 2017, the AAO identified that there was
a need to address the growing controversy regarding the
role of orthodontists with patients with OSA. As a result,
a panel of dental and medical experts convened to create
a document to serve as an evidence-based guide for cli-
nicians. In May 2019, the AAO released this document as
a White Paper, which today still serves as a reasonable
guide for clinicians to follow around the world.2 A
more expanded clinical perspective on this topic was
later published by Kandasamy in 2019.3
Despite multiple publications in our literature pro-
posing a conservative approach, more recently, there
has been increasing advocacy for early orthodontic
intervention for OSA by certain groups and/or self-
appointed experts. Early intervention treatments range
a
Center for Advanced Dental Education, Saint Louis University, St Louis, Mo.
b
Dental School, The University of Western Australia, Nedlands, Western Australia,
Australia.
c
Private practice, West Australian Orthodontics, Midland, Western Australia,
Australia.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Sanjivan Kandasamy, West Australian Orthodontics,
Suite 9A, 401 Great Eastern Highway, Midland, 6056 Western Australia,
Australia; e-mail, sanj@kandasamy.com.au.
Submitted, August 2023; revised and accepted, December 2023.
0889-5406
Ó 2023 by the American Association of Orthodontists. This is an open access
article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
https://doi.org/10.1016/j.ajodo.2023.12.005
from promoting nasal breathing, postural correction,
midface advancement, slow or rapid maxillary expan-
sion, unlocking deep overbites and growing mandibles,
adenotonsillectomy, and myofunctional therapy in chil-
dren as young as 2-3 years old.1 As a result of this latest
controversy, I was asked to put into perspective the cur-
rent state of OSA and early orthodontic intervention.
The consequences of OSA in any age group are real,
and this definitely needs proper attention, assessment,
and appropriate patient-specific management. OSA in
the pediatric population has been shown to lead to
cognitive and social impairment, behavioral and mood
disturbances, impaired growth, and obesity.4 It also
has been reported to cause cardiovascular complica-
tions, initially starting as increased blood pressure.4
When left untreated in children, OSA may progress
into adulthood, increasing the risk of diabetes, coronary
artery disease, congestive heart failure, myocardial
infarction, hypertension, cardiac arrhythmia, and
stroke.2,5 The prevalence of OSA in the general pediatric
population ranges from 1.2%-5.7%.4 While there may
be health risks associated with untreated OSA in chil-
dren, there is little substantiated evidence to suggest
that expansion and growth modification will mitigate
these risks. Accordingly, where is the benefit in recom-
mending parents to bring their children in for treatment
as early as 2-3 years of age?
The treatments that are mostly talked about are
maxillary expansion and orthopedic advancement/
growth of the maxilla and/or mandible to increase
airway space to prevent or cure childhood OSA. Interest-
ingly, these early treatment modalities also conveniently
happen to be financially lucrative to anyone keen on
embracing this newfound means of income, self-
promotion, and practice growth. This is perhaps the
real reason why it has become so popular today despite
the lack of data to support such treatments for OSA.
Have we not seen this before with self-ligating brackets,
temporomandibular disorders, third molar extractions,
maxillary expansion, and functional appliances, to
name a few? Is it really ethical to financially benefit
1
2 Kandasamy
from the unsupported so-called benefits of expansion
and growth modification for OSA while masquerading
as a clinician primarily concerned about the short- and
long-term mental and systemic health consequences of
childhood OSA?
Some orthopedic maxillary expansion studies have
shown a significant improvement in the apnea-
hypopnea index scores in children with sleep apnea after
rapid maxillary expansion.6,7 As a result, these authors
have advocated rapid maxillary expansion before adeno-
tonsillectomy in children, as this may reduce the need for
adenotonsillectomy after expansion in a large propor-
tion of patients. According to the inclusion criteria, it
would appear that maxillary expansion might have
been carried out in many patients without the presence
of a posterior crossbite in those studies. Instead, expan-
sion was prescribed because of the presence of a high
palatal vault and narrow maxillary arch related to the
contraction of the maxilla at its base.6,7 What does ap-
pearing to be narrow even mean? Narrow to the naked
eye or some generic intermolar width? Furthermore,
the amount of expansion varied, and little to no atten-
tion was paid to the skeletal and dental malocclusion,
including the vertical facial patterns of the subjects.
Thus, if there is no bilateral or unilateral posterior cross-
bite, any expansion will result in creating a buccal scissor
bite relationship or overexpansion of the posterior
maxillary teeth. This will result in unnecessary extrusion
of the overexpanded maxillary posterior teeth and
lingual tipping of the opposing mandibular posterior
teeth in the long term, as well as all the unwanted bite
opening and dentoalveolar compensations, including
asymmetries. To avoid this, the clinician will need to
then transversely expand the mandibular posterior teeth,
which we know is limiting and unstable if not retained
on the long term, to accommodate the newly overex-
panded maxillary arch. How is it even justifiable or
even practical from a patient management perspective
to carry out all of these procedures at the age of 2-3
years and then have this expansion maintained over
many years in a large cohort of children when we cannot
predict which children will actually develop OSA in later
years?
As a result of this controversy regarding early expan-
sion and/or growth modification for OSA, there has been
a call for better research, including randomized
controlled trials, to investigate these incredible claims.
Carrying out these studies will take a significant amount
of time, collaboration, and financial aid. Considering the
invasiveness and cost of the proposed procedures, how
many children are going to be subjected to treatments
that ultimately may not make any difference to their
breathing and sleeping lives in the long term?
- 2023  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics
In addition, do we not already know enough about
our inability to grow mandibles? Interestingly, an excep-
tionally small mandible associated with Pierre Robin
syndrome is commonly referred to as the key example
of why a small mandible obstructs the posterior airway.
As a result of this extreme syndromic example, many
self-recognized experts have extrapolated that all the
less-than-normally-sized mandibles now need to be
grown to increase the posterior airway space. Random-
ized controlled trials carried out almost 20 years ago
have shown us that the mandible is going to grow to
where it is going to grow.8-14 Despite the significant
amount of information in the literature supporting not
exposing children to acrylic poisoning and/or
subjecting children to forward mandibular posturing
early in life to grow mandibles, functional appliance
therapy is still a common practice around the world.
Can we not see the same thing happening here again
with OSA in children? Do all people with retruded
mandibles suffer from OSA? No, it is more complicated
than that.
Furthermore, has anyone not seen the practicality
associated with orthodontically assessing and treating
a child for OSA as young as 2-3 years? Are these children
coughing and gasping for air in bed every night that they
need orthodontic intervention at 2-3 years of age? If
these children are in such a state, no amount of ortho-
dontic intervention is going to help or cure their OSA
signs and symptoms. In fact, they will require medical
attention immediately. Would it not be better, and
more in line with the AAO White Paper’s guidelines,
for such treatments to be carried out when these children
are much older? Even if we do wait for those more
appropriate age groups to receive the treatments being
discussed here, we know that orthodontic intervention
such as expansion and growth modification for OSA is
not definitive, and there is no long-term data to support
these treatment modalities as being effective for OSA.
Thus, should we be subjecting very young children to
any of this? Should we be using these treatment modal-
ities like vaccinations to prevent young children from
developing OSA? The answer is clearly no.
Currently, the AAO recommends that children be
screened by an orthodontist around 7 years old for any
dental and skeletal issues. What does this new version
of early orthodontic OSA assessment and management
actually require orthodontists to do? Should orthodon-
tists now start assessing children as young as 2 years
old? If so, what are they supposed to be assessing, and
how? Are they meant to assess a child’s respiratory func-
tion, issues with snoring frequency, difficulty with
breathing during sleep, mouth breathing, observed ap-
neas, daytime sleepiness, and irritability? If they crudely
Kandasamy
identify any sleep issues chairside, are they expected to
assume then that the presence of various anatomic phe-
nomena such as a maxillary transverse discrepancy, a
smaller than “normal” mandible, a retruded maxilla,
abnormal tongue posture, chewing or swallowing, or a
long face is the cause? In contrast, the literature shows
that OSA occurs as a complex interplay between
anatomic and nonanatomic factors. It is not appropriate
to simply look at a specific craniofacial morphologic
characteristic and assume someone exhibits or will later
develop OSA. It is more complicated than this.
It is accepted today that orthodontists should screen
for any obvious OSA signs and symptoms. This makes
sense. If an orthodontist detects a problem, then making
the necessary referral to the appropriate medical practi-
tioner would be indicated. However, what if we do not?
Is there a childhood OSA health crisis requiring orthodon-
tic intervention unbeknownst to the medical specialty,
such that it is now the orthodontist’s responsibility to
get children in and treat them as early as 2-3 years old?
There is not enough evidence currently to even
consider following this new line of thinking about early
interventions. In addition, there is certainly little to no
quality evidence when it comes to advocating nasal vs
mouth breathing, postural correction, and myofunc-
tional therapy routinely for OSA in children as young
as 3 years old. The burden of responsibility should lie
on the shoulders of those people both within and outside
of our specialty, advocating a shift in our specialty’s re-
sponsibilities and this type of management. We cannot
misinform the public and scare families into believing
that their children will develop all these conditions
from a morphologic problem that they potentially may
not have. Furthermore, we do not want our patients to
believe that these early treatments are capable of effec-
tively managing these problems when the evidence
clearly does not even support this.
If our colleagues want to play medical doctor, then
they should consider going to medical school. If our col-
leagues want to carry out orthodontic treatment to treat
medical problems on the basis of anecdotal claims and
beliefs unsubstantiated by the evidence, such as expan-
sion and growth modification at all costs, then this is not
only unethical but grossly misleading to the public. To
expect a significant paradigm shift in the way patients
are to be treated requires more than hands-on experi-
ence, biased limited research, and basic rationalism.
Our expectations as a specialty collectively need to be
raised, and the way we interpret new information needs
to be more rigorous and critical. Our specialty, our
patients, and our future deserve better.
American Journal of Orthodontics and Dentofacial Orthopedics
3
AUTHOR CREDIT STATEMENT
Sanjivan Kandasamy contributed to conceptualiza-
tion, data curation, formal analysis, investigation, vali-
dation, visualization, original draft preparation, and
manuscript review and editing.
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