Chronically enlarged tonsils | What does this mean for dentists?

Through: Jeffrey W. Horowitz, DMD, FAGD, D-ABDSM, D-ASBA

Chronically enlarged tonsils are a common condition, more common in children.

Chronically enlarged tonsils are associated with:

  • Frequent sore throat, ear and throat infection.
  • Enlarged adenoids and poor nasal breathing.
  • Poor nasal breathing leads to mouth breathing.
  • Mouth breathing changes the position of the tongue.
  • Poor tongue posture leads to poor maxillary arch growth.
  • Poor growth of the maxillary arch leads to a smaller nasal volume.
  • A smaller nasal volume leads to mandatory mouth breathing.
  • Mandatory mouth breathing leads to dentofacial discrepancies and malocclusion.
  • Common dental findings include the “3 C’s”, narrowing, cross bites and crowding.
  • Mouth breathing (unfiltered dry air) can cause further inflammation of tonsillar and pharyngeal tissues.
  • Chronically inflamed pharyngeal tissues can lead to snoring and lowered O2 levels!
  • Even small O2 changes can alter children’s sleep patterns and quality.
  • Poor sleep in children is associated with behavioral, emotional and growth disorders.

Chronically Enlarged Tonsils: Case Study

Let’s look at a case study of a patient I had with chronically enlarged tonsils to help you diagnose and treat future patients.

Patient information:

  • 8-year-old white woman presents for initial orthodontic evaluation
  • Mom says she was bullied for ‘buck teeth’ and wants to correct them.
  • Medical history positive for poor sleep, occasional snoring, mouth breathing, frequent sore throat.
  • The pediatrician noted: chronically enlarged tonsils but suggested that treatment was not necessary.
  • Dental/Perio examination negative for pathology.
  • Archform is narrow with high palatal vault.
  • Skeletal class II with anterior open bite and poor lip position.
  • Narrow nostrils, dark circles under the eyes.
  • Soft tissue examination positive for oropharyngeal inflammation/edema.
  • Grade 3 Tonsilar hypertrophy.
  • Low attachment of maxillary labial frenulum.
Picture of patients with chronically enlarged tonsils.

The patient’s tonsils and adenoids can also be seen on CBCT:

How to treat the patient with chronically enlarged tonsils?

Now that we have more knowledge behind us about our patient and their needs and concerns, what are our best treatment options?

Treatment options

  1. Tonsillectomy/adenoidectomy followed by myofuncional therapy
  2. Myofunctional therapy alone
  3. Orthodontic Arch Extension Followed by Myofunctional Therapy
  4. T&A with Arc Expansion and Myofunctional Therapy

Remark: All options include myofunctional therapy!

Treatment choice and results after 4 months

For our patient, we chose Phase 1 Aligner therapy with mandibular advancement (MA) followed by myofunctional therapy and frenectomy. Watch the growth and development after less than 4 months!


Recognition of the chronically enlarged tonsils along with a detailed history enabled us to find and address the medical condition behind aesthetic care.

As a result, we found a result that led to:

  • A confident young lady
  • Better school performance
  • Better behavior
  • Improved growth and health
  • A mom who can’t believe the dentist can have this kind of impact will NEVER leave my practice and tell ANYONE!

Next one: How to run a successful dental practice

photo by Markus Winkler

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