Objectives <p>To evaluate the effects of different subtypes of tonsillar hypertrophy on dentofacial and craniofacial development in children during the mixed dentition stage, and to preliminarily explore associated craniofacial growth trends.</p> Methods <p>A total of 275 children in the mixed dentition stage were retrospectively recruited from two hospitals between August 2023 and July 2024. Tonsillar hypertrophy was assessed using the Brodsky and Baroni methods, and patients were categorized by airway obstruction type: mild (Group A), transverse (Group B), anteroposterior (Group C), or combined (Group D). Anterior occlusion, sagittal skeletal classification, and lateral cephalometric parameters (Jarabak analysis) were recorded and compared across groups.</p> Results <p>Groups C and D were found to have significantly higher rates of anterior crossbite (16.67% and 21.77%) and skeletal Class III malocclusion (30.95% and 34.01%) compared to Groups A (0.00%, 2.78%) and B (0.00%, 6.00%) (<i>p</i> &lt; 0.05). Subgroup D2 (severe combined obstruction) demonstrated the most pronounced skeletal Class III features, as evidenced by a higher mean SNB angle (78.75° ± 3.92), a lower ANB angle (− 0.03° ± 3.65), and pronounced mandibular prognathism. Both dental and skeletal compensatory changes were most evident in the combined obstruction group, indicating a significant degree of craniofacial imbalance (<i>p</i> &lt; 0.05).</p> Conclusions <p>Anteroposterior tonsillar hypertrophy is strongly associated with anterior crossbite and skeletal Class III development, primarily through mandibular advancement and rotational growth adaptations. Transverse obstruction has minimal skeletal impact, whereas combined obstruction of multiple directions exacerbates dentoskeletal compensation. These findings highlight the directional influence of upper airway obstruction on craniofacial morphology in growing children and underscore the importance of early interdisciplinary evaluation.</p>