Orthodontics and Sleep Surgery by Drs. Nasim Mesgarzadeh and Stanley Y. C. Liu

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Orthodontics and Sleep Surgery   

An updated clinical perspective

by Drs. Nasim Mesgarzadeh and Stanley Y.C. Liu

Sleep-disordered breathing (SDB) is common, clinically significant, and often remains undiagnosed until substantial physiologic and psychological strain has developed. SDB includes the diagnoses of snoring, upper airway resistance syndrome, and obstructive sleep apnea (OSA). An updated international consensus statement estimates that OSA affects at least 1 in 9 people worldwide.1 The consequences extend beyond “poor sleep” and include cardiometabolic burden, impaired cognition, reduced quality of life, and developmental effects in children.2

For patients who cannot effectively manage SDB with nonsurgical therapy, including positive airway pressure (PAP), oral appliance, positional, and weight loss, sleep surgery becomes a consideration. As sleep surgery evolves, it is no longer defined by disparate procedures. Instead, it functions as part of a continuum of care that complements medical therapy, guided by physiologic and anatomic phenotyping, and patient-centered treatment sequencing.3–5

The current orthodontist’s role in sleep-disordered breathing has been formally considered in American Association of Orthodontists white papers.6,7 In this article, we invite orthodontists to understand the contemporary sleep-surgical thought process. We highlight how orthodontists already shape sleep-surgical outcomes, and why that deserves greater recognition.

Sleep surgery today
Sleep is a distinct physiologic state. Upper-airway behavior during sleep cannot be readily inferred from a chairside, awake exam. We must interpret studies in light of many other clues assessed during wakefulness. Reduction in neuromuscular tone, change in ventilatory control, and alteration of tissue compliance are not obvious in wakefulness.8 This is one reason modern sleep surgery emphasizes patient-reported outcome measures, dynamic airway assessment, and integrated planning.

In parallel, the therapeutic landscape has been broadened during the last two decades. Nasal procedures and naso-maxillary expansion strategies address nasal resistance. The classic uvulopalatopharyngoplasty has evolved toward approaches that largely preserve (rather than remove) palatal muscles. Hypoglossal nerve stimulation has shown success in well-selected candidates.5,9 Sleep surgery is now a phenotype-driven discipline, with interventions selected and sequenced to match patients within the context of other concurrent treatment modalities.3,4

Sleep surgery emerged through the work of clinicians who understood that upper airway muscle function cannot be separated from the supporting craniofacial structures. Dr. Nelson Powell and Dr. Robert Riley, both dentists who graduated from the University of California, San Francisco (UCSF), reunited as residents in otolaryngology (ENT) at Stanford University. This is where they met Dr. Christian Guilleminault, largely credited for starting the field of clinical sleep medicine, and the original Stanford Riley-Powell Sleep Surgery Approach came about. The surgeon author of this article followed the same tradition, as the field continues to demand fluency across medicine, dentistry, maxillofacial surgery, and otolaryngology. (Fig. 1)
Orthodontics and Sleep Surgery
Fig. 1: Dr. Nelson Powell (left) and Dr. Robert Riley (right), whose pioneering work established the original Stanford sleep surgery protocol.


The original Riley-Powell protocol organized treatment by levels and phases. Level defines the anatomic region, and phase defines the sequence. Phase 1 surgery was recommended after failure of medical treatments and targeted the soft palate and tongue. For those with persistent OSA after Phase 1, maxillomandibular osteotomy (MMO) would be advised. MMO eventually became better known as maxillomandibular advancement (MMA), as defined by its focus on improving sleep-disordered breathing. Better understanding of craniofacial and upper airway phenotypes helps identify patients for whom earlier skeletal surgery may offer greater benefit.4,10


The sleep-surgery algorithm as a longitudinal framework
Although OSA severity remains important for quantifying disease burden, treatment planning depends on a broader phenotype. That phenotype includes anatomy, physiology, comorbidities, tolerance for treatment burden, and the behavior of the airway during sleep.3,4,11,12 (Fig. 2)
Orthodontics and Sleep Surgery
Fig. 2: Complementary assessment of anatomy and physiology: Structural findings are typically obtained in wakefulness, while physiologic dysfunction is measured during sleep; both are required for precision planning.

Polysomnography (sleep study) quantifies physiologic burden but does not identify where collapse occurs. Conversely, airway examination—whether by awake nasopharyngoscopy (Fig. 3), nasal examination, imaging, or drug-induced sleep endoscopy (DISE)—does not measure physiologic severity.

DISE offers real-time visualization of multilevel obstruction under sedation, helping clinicians identify pattern-specific collapse and plan a targeted sequence. In rigorously performed DISE where EEG is placed, and dexmedetomidine protocols are used, there is the chance of seeing airway collapse during defined sleep staging.13

Finally, data are interpreted together: Physiology defines urgency and burden, while phenotyping directs what to treat and in what order.14,15

For orthodontists, the updated sleep surgery algorithm is best understood as a practical framework for how treatment is assessed and sequenced over time.3,10,12 It begins with whether PAP or oral appliance therapy is feasible and, if not, whether the limitation reflects true treatment failure or other anatomic factors such as nasal obstruction. Attention then turns to the pattern and levels of airway obstruction, including the palate or velum, lateral pharyngeal walls, tongue base, and epiglottis.

Within that framework, orthodontic records are highly informative. Findings such as transverse deficiency, vertical pattern, mandibular position, arch form, dentoalveolar compensation, and periodontal limitations can help define the structural context in which treatment decisions are made.

The updated sleep surgery protocol by Riley, Powell, and Liu also reflects the chronic nature of OSA: No one suddenly develops OSA, and treatment is rarely a single event. Risk factors accumulate over time, patients’ preferences change, and relapse can occur, especially across life stages that affect weight, airway muscle tone, or skeletal stability. This developmental framing is particularly relevant for teenagers and young adults, where improving facial skeletal development may reduce later disease burden.5,16 The algorithm is both an initial planning tool and a longitudinal decision framework. (Fig. 4)
Orthodontics and Sleep Surgery
Fig. 3a: Awake endoscopic airway evaluation in clinic. (right)
Orthodontics and Sleep Surgery
Fig. 3b:Drug-induced sleep endoscopy (DISE) enables dynamic assessment of upper airway collapse.

Orthodontics and Sleep Surgery
Fig. 4: Updated Stanford Riley-Powell-Liu sleep surgery algorithm for multilevel, phenotype-driven treatment selection and sequencing. Abbreviations: BMI, body mass index; CCC, complete concentric collapse of the velum on DISE; DISE, drug-induced sleep endoscopy; DOME, distraction osteogenesis maxillary expansion; GGA, genioglossus genioplasty advancement; NP, nasopharyngoscopy; OAT, oral appliance therapy; PAP, positive airway pressure; PE, physical examination; PSG, polysomnography; TB, tongue base; TORS, transoral robotic surgery; LPW, lateral pharyngeal wall collapse.

Skeletal surgery as an example of phenotype-driven planning
MMA exemplifies the structural logic of contemporary sleep-surgical planning. In appropriately selected patients, craniofacial structure may be a dominant driver of multilevel airway collapse, and skeletal advancement significantly improves airway stability, particularly through its effect on the velum and lateral pharyngeal walls.14 For that reason, skeletal intervention is sometimes prioritized earlier in the treatment sequence, whereas other phenotypes may benefit from different first steps or from combination therapy.

In borderline dentofacial cases, where the choice between orthodontic camouflage and orthognathic correction is not straightforward, SDB including OSA may justify stronger consideration of maxillomandibular advancement when it is the major phenotypic risk factor. (Fig. 5)
Orthodontics and Sleep Surgery
Fig. 5: Counterclockwise rotation of the maxillomandibular complex stabilizes the airway by both tension on upper airway dilator muscles, and increased space for muscle retraining and strengthening.

Where orthodontists fit in contemporary sleep-surgical care
Orthodontists matter in sleep-surgical care because their decisions shape the craniofacial structures that support the upper airway. As Enlow described, the airway functions as a “keystone for the face,” influencing the growth and stabilization of surrounding craniofacial structures.17 Orthodontic decisions affect transverse development, skeletal relationships, dentoalveolar compensation, and the feasibility and sequencing of later interventions, often in ways that directly influence what the sleep surgeon can plan and achieve.6,7,16

1. Craniofacial development and transverse foundation
Early attention to transverse development, vertical pattern, and craniofacial growth modification may reduce later sleep-breathing vulnerability in selected children and adolescents, particularly when coordinated with appropriate medical and surgical teams.17

Even when not delivered specifically as a sleep-breathing therapy, orthodontic treatment can still preserve future options by improving structural conditions on which later therapies depend.

2. Preserving options: Dentoalveolar compensation and surgical planning
Dentoalveolar compensation can conceal an underlying skeletal problem and reduce what remains surgically achievable later. When sleep-disordered breathing is part of the phenotype, dentoalveolar compensation should be documented carefully and altered with clear awareness of how future skeletal correction may affect bite, beauty, and breathing.

Transverse deficiencies, periodontal considerations, and arch form constraints may likewise influence whether expansion is feasible, how it may affect nasal resistance and tongue posture during sleep, and how stable the result is likely to be. (Fig. 6) The orthodontist’s role is to recognize these implications early enough to preserve flexibility in the interdisciplinary plan.

A child with a constricted maxilla and nasal obstruction who undergoes skeletal expansion is not simply receiving orthodontic treatment. In many growing patients, this may represent the only meaningful structural intervention available to support nasal breathing, since children are generally not candidates for septoplasty or nasal valve surgery. By expanding the maxilla, the orthodontist is acting on the principal skeletal lever available for nasal breathing at that stage of development.18
Orthodontics and Sleep Surgery
Fig. 6: Maxillary expansion (DOME) has shown to improve nasal breathing, decrease severity of OSA, and improve quality of sleep. Upper airway stability contributed by 1) slower airflow through the nasal passage, leading to less negative pressure that collapses the pharyngeal airway; 2) nasal breathing activates upper airway dilator muscles.

3. Presurgical orthodontics as phenotype-sensitive sequencing
Orthodontic preparation is often the longest phase of the surgical journey, and it may affect a patient’s breathing during treatment. Not all patients tolerate presurgical decompensation and orthodontic mechanics well. For selected patients, sequencing becomes clinically important, and a shortened presurgical phase or a surgery-first or surgery-early approach may improve tolerance and safety.

4. Communication in sleep-surgical collaboration
When orthodontists identify structural findings relevant to sleep-disordered breathing, a concise summary can improve interdisciplinary planning. The goal is to communicate the craniofacial and dentoalveolar context already evident in the orthodontic evaluation.

Relevant information may include skeletal classification, including whether the occlusion reflects true jaw position or dentoalveolar compensation, together with the transverse and vertical pattern; existing dentoalveolar compensation, such as compensatory incisor angulation or midline shifts that may mask underlying asymmetry; and periodontal considerations that could limit future decompensation or surgical planning.

Prior orthodontic treatment that may constrain future options is also important to communicate, including prior expansion, relapse after expansion, extractions, or camouflage treatment. Clinical features associated with sleep-disordered breathing should likewise be noted, such as mouth breathing, narrow palatal vault, posterior crossbite, lip incompetence, and patient- or family-reported snoring or witnessed apneas.

Shared early, this structural summary helps preserve options and supports more deliberate sequencing. Once orthodontic treatment has confined the patient to a narrower dentoalveolar envelope, the surgical plan may be forced to work within constraints that are already established.19

Conclusion
Contemporary sleep surgery should no longer be viewed as isolated procedures. Treatment selection and sequencing depend on integrated assessment of anatomy, physiology, multilevel patterns of collapse, skeletal versus soft-tissue contribution, and patient tolerance.

Orthodontists matter in this model because their decisions influence craniofacial support for the upper airway, preserve or constrain treatment options, and affect sequencing across surgical and nonsurgical care. Sharing relevant orthodontic considerations with surgical colleagues is part of the orthodontist’s role in interdisciplinary care.

That contribution is most valuable when it is integrated early, so clearer roles and better sequencing can significantly improve care for patients with sleep-disordered breathing. 

References

1. Chang JL, Goldberg AN, Alt JA, et al. International Consensus statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol. 2023;13(7):1061-1482.
2. American Association of Oral and Maxillofacial Surgeons. Position Paper: Evaluation and Management of Obstructive Sleep Apnea. American Association of Oral and Maxillofacial Surgeons; 2013. https://aaoms.org/wp-content/uploads/2024/03/osa_position_paper.pdf
3. Liu SYC, Powell NB, Riley RW. Algorithm for Multilevel Treatment, the Riley, Powell, and Liu Stanford Experience. In: Friedman M, Jacobowitz O, eds. Sleep Apnea and Snoring: Surgical and Non-Surgical Therapy. 2nd ed. Elsevier; 2020.
4. Liu SYC, Riley RW, Yu MS. Surgical algorithm for obstructive sleep apnea: An update. Clin Exp Otorhinolaryngol. 2020;13(3):215-224.
5. Liu SYC, Awad M, Riley R, Capasso R. The role of the revised Stanford protocol in today’s precision medicine. Sleep Med Clin. 2019;14(1):99-107.
6. Behrents RG, Shelgikar AV, Conley RS, et al. Obstructive sleep apnea and orthodontics: An American Association of Orthodontists White Paper. Am J Orthod Dentofacial Orthop. 2019;156(1):13-28.e1.
7. Palomo JM, Cohen-Levy J, Flores-Mir C, et al. Sleep-disordered breathing and orthodontics: An American Association of Orthodontists white paper update. Am J Orthod Dentofacial Orthop. 2026;169(4):419-427.
8. Dement WC, Vaughan CC. The Promise of Sleep: A Pioneer in Sleep Medicine Explores the Vital Connection Between Health, Happiness, and a Good Night’s Sleep. Dell; 2000.
9. Hong SO, Chen YF, Jung J, Kwon YD, Liu SYC. Hypoglossal nerve stimulation for treatment of obstructive sleep apnea (OSA): a primer for oral and maxillofacial surgeons. Maxillofac Plast Reconstr Surg. 2017;39(1):27.
10. Liu SYC, Schwartz K. Maxillofacial surgery in OSA. In: Obstructive Sleep Apnea. Springer International Publishing; 2023:487-510.
11. Liu SYC, Wayne Riley R, Pogrel A, Guilleminault C. Sleep surgery in the era of precision medicine. Atlas Oral Maxillofac Surg Clin North Am. 2019;27(1):1-5.
12. Liu SYC, Al-Sayed AA. Advancements and innovations in sleep surgery. In: Advancements and Innovations in OMFS, ENT, and Facial Plastic Surgery. Springer International Publishing; 2023:97-119.
13. Sleep (sedation) endoscopy (DISE) — Stanley Liu, MD, DDS, FACS. Stanley Liu, MD, DDS, FACS | Sleep Apnea Surgeon. Accessed April 13, 2026. https://www.drstanleyliu.com/drug-induced-sleep-endoscopy-dise
14. Liu SYC, Huon LK, Powell NB, et al. Lateral pharyngeal wall tension after maxillomandibular advancement for obstructive sleep apnea is a marker for surgical success: Observations from drug-induced sleep endoscopy. J Oral Maxillofac Surg. 2015;73(8):1575-1582.
15. Lan MC, Liu SYC, Lan MY, Huang YC, Huang TT, Hsu YB. Role of drug-induced sleep endoscopy in evaluation of positional vs non-positional OSA. J Otolaryngol Head Neck Surg. 2020;49(1):83.
16. Yoon A, Gozal D, Kushida C, et al. A roadmap of craniofacial growth modification for children with sleep-disordered breathing: a multidisciplinary proposal. Sleep. 2023;46(8). doi:10.1093/sleep/zsad095
17. Enlow DH. Essentials of Facial Growth. 2nd ed. Needham Press; 2008.
18. Calvo-Henriquez C, Martínez-Seijas P, Maniaci A, et al. Pediatric maxillary expansion to treat nasal obstruction. Acta Otorrinolaringol (Engl Ed). 2025;76(3):512220.
19. Ruoff CM, Guilleminault C. Orthodontics and sleep-disordered breathing. Sleep Breath. 2012;16(2):271-273.

Author Bios
Nasim Mesgarzadeh, DDS, PhD, MBA Nasim Mesgarzadeh, DDS, PhD, MBA, is an orthodontist with advanced fellowship training in craniofacial, surgical, and special care orthodontics. Her work focuses on the interface of orthodontics with sleep surgery, craniofacial surgery, translational research, and evolving models of healthcare development.
Stanley Y.C. Liu, MD, DDS, FACS Stanley Y.C. Liu, MD, DDS, FACS, is an oral and maxillofacial surgeon and ENT sleep surgeon. He serves as chair of oral and maxillofacial surgery at Nova Southeastern University and director of the NSU Breathe and Sleep Wellness Center. Internationally recognized for his scholarship and leadership in sleep surgery and sleep-disordered breathing, he has authored more than 120 peer-reviewed publications and book chapters.
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