The Role of Craniofacial Abnormalities and Orthodontic Interventions in Residual Obstructive Sleep Apnea after Adenotonsillectomy in Children: A Scoping Review.

Background: Obstructive sleep apnea (OSA) in children is often treated with adenotonsillectomy, yet residual or persistent OSA occurs in 20-75% of cases, particularly in children with craniofacial abnormalities. These structural features contribute to ongoing airway obstruction and highlight the need for phenotype-specific management. The objective of this scoping review was to map the evidence on craniofacial and dentofacial contributions to residual OSA and assess the potential role of orthodontic interventions, particularly rapid maxillary expansion (RME), within a multidisciplinary framework. Methods: This scoping review followed PRISMA-ScR guidelines and Joanna Briggs Institute methodology. A systematic search was conducted in PubMed, Web of Science, and Scopus from January 2010 to December 2025 using combinations of terms related to residual OSA, adenotonsillectomy, craniofacial abnormalities, and orthodontic interventions. Studies including children <18 years with residual/persistent OSA post-adenotonsillectomy were considered. Screening, selection, and data extraction were performed independently by two reviewers, with discrepancies resolved by discussion or a third reviewer. Data extracted included study design, sample size, craniofacial features, orthodontic interventions, outcomes (AHI, snoring, quality of life), and multidisciplinary management. Results: Six studies met the inclusion criteria. Craniofacial features such as high/narrow palate, maxillary constriction, retrognathia, and Class II tendencies were consistently associated with residual OSA, with prevalence up to 93%. Orthodontic interventions, particularly RME, reduced AHI by up to 70%, decreased snoring, and improved quality of life in children with transverse maxillary deficiency. Multidisciplinary approaches involving ENT, sleep specialists, and orthodontists were emphasized for optimal assessment and management. Conclusion: Craniofacial abnormalities are important but under-recognized contributors to persistent pediatric OSA post-adenotonsillectomy. Orthodontic treatments, especially RME, offer a valuable non-surgical adjunct in multidisciplinary care. Current evidence is limited by small sample sizes and few long-term trials. Future research should focus on high-quality, phenotype-driven studies to guide evidence-based management of residual OSA in children.