Craniofacial and Malocclusion Characteristics Associated with Polysomnography-Confirmed Obstructive Sleep Apnea in Pediatric and Adolescent Patients: A Systematic Review

Obstructive Sleep Apnea (OSA) is a sleep-related breathing disorder estimated to affect 1–5% of children worldwide, with untreated cases associated with neurocognitive impairment, behavioral disorders, and long-term cardiovascular risks. Although adenotonsillar hypertrophy is the most common soft tissue etiology, dentofacial and craniofacial structures, particularly Class II malocclusion, transverse maxillary narrowing, and hyperdivergent vertical facial patterns, can independently narrow the pharyngeal airway. Whether this malocclusion is a predisposing factor for OSA or develops secondary to chronic mouth breathing is still debated. This review was conducted according to PRISMA 2020 guidelines. Eligible studies enrolled non-syndromic children under 16 years of age with PSG-confirmed OSA and reported malocclusion parameters via clinical/dental model examination or cephalometric analysis. Methodological quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool. Of the 386 records identified, seven studies (4,717 children; six countries; 2023–2026) met all eligibility criteria. Class II sagittal skeletal discrepancy was reported in six of seven studies and was significantly associated with the presence or severity of OSA in the majority of studies. Class II sagittal skeletal discrepancy and a hyperdivergent vertical facial pattern were the malocclusion phenotypes most consistently associated with PSG-confirmed pediatric OSA, supporting their use as clinical indicators for sleep referral during routine orthodontic examinations.