The Orthodontist in Pediatric Sleep-Disordered Breathing: A Systematic Review and Clinical Practice Framework

Pediatric sleep-disordered breathing (SDB), including obstructive sleep apnea (OSA), is common and clinically consequential, and its craniofacial associations bring affected children into frequent contact with orthodontists. Whether and how orthodontists should participate in care is contested, with marketing claims sometimes outpacing evidence. We conducted a systematic review of pediatric orthodontic interventions for SDB and synthesized current professional guidance into a clinical practice framework. We conducted a systematic PubMed/MEDLINE search from January 1, 2001, to May 20, 2026, using terms for pediatric SDB and orthodontic intervention. We applied English-language and pediatric age filters. The review was not prospectively registered, and no protocol was published. Controlled studies reporting objective respiratory outcomes formed the primary evidence base, while uncontrolled pre-post studies were considered supportive. We assessed risk of bias using RoB 2 (parallel and crossover trials) and the National Heart, Lung, and Blood Institute (NHLBI) Before-After Quality Assessment Tool for uncontrolled pre-post studies. We summarized evidence certainty using a GRADE-informed approach. We included 16 reports representing 15 unique studies: seven controlled reports and nine uncontrolled pre-post reports from eight cohorts. Controlled studies comparing mandibular advancement or functional appliances with untreated or sham controls reported reductions in the apnea-hypopnea index in the treated groups. Controlled evidence for maxillary expansion was weaker and less consistent: in the only included trial with an untreated concurrent control, the apnea-hypopnea index fell comparably in treated and untreated children with no significant between-group difference, and two trials found maxillary expansion no better than, or inferior to, adenotonsillectomy. Studies were small and clinically heterogeneous, and complete variance data were not uniformly available. Quantitative pooling was therefore inappropriate and was not performed; findings are reported as a structured narrative synthesis. Across outcomes, certainty of evidence was low to very low, limited by risk of bias, imprecision, indirectness, and confounding by spontaneous resolution. Selected orthodontic interventions may improve respiratory indices in appropriately diagnosed children. Still, the evidence remains weak and does not establish equivalence with established physician-directed therapies or support orthodontic treatment to prevent future SDB. Consistent with American Association of Orthodontists (AAO) and American Academy of Pediatric Dentistry (AAPD) recommendations and, where applicable, informed by American Academy of Dental Sleep Medicine (AADSM)/American Academy of Sleep Medicine (AASM) dental sleep medicine guidance and American Academy of Orofacial Pain (AAOP) perspectives on interdisciplinary management, the orthodontist's evidence-based role is to identify at-risk children, conduct appropriate risk screening, and facilitate referral within an interdisciplinary, physician-led pathway. Physicians establish the diagnosis and direct medical management; polysomnography remains the diagnostic reference standard; and craniofacial imaging should not be used as a standalone screening or diagnostic test for pediatric SDB. This systematic review presents a guideline-anchored clinical decision framework to operationalize this role.