Leeway Space and the Resolution of

Crowding in the Mixed Dentmon

Anthony A. Gianelly
The leeway space provides adequate space to resolve crowding that is
present in the mixed dentition in the majority of individuals. This space can
be maintained by preserving arch length with a lingual arch as the primary
teeth begin to exfoliate, unless conditions such as the premature loss of a
primary canine require earlier intervention. A lip bumper can also be inserted after the eruption of the first premolars to preserve arch length.

Copyright 1995 by W.B. Saunders Company

rowding, which can be present in all classes

o f malocclusions, is p r o b a b l y the most
c o m m o n p r o b l e m r e s o l v e d by o r t h o d o n t i c
treatment. T o align a crowded dentition, space
is necessary. In the mixed dentition, one mechanism fbr gaining space for alignment is to
preserve the leeway space, which can be as
m u c h as 4.3 ram. ~ This g e n e r o u s space may be
one reason why crowding in the mixed dentition becomes less p r o n o u n c e d with the develo p m e n t o f the p e r m a n e n t dentition. For example, Moorrees and Chada indicated that 1 to 2
m m o f crowding is a characteristic feature in
individuals who d e m o n s t r a t e n o r m a l alignm e n t in the p e r m a n e n t dentition.
This observation raises a series o f interesting questions, such as what is the incidence of
crowding in the mixed dentition, and how often can the leeway space p r o v i d e a d e q u a t e
space to resolve this crowding? (Since lower
arch conditions dictate the strategy for maxillary arch treatment, only the changes in the
lower arch will be discussed.)
T o answer these questions, the mandibular
models o f t 00 patients in the mixed dentition
stage o f d e v e l o p m e n t were evaluated, in the
sample, crowding, which a v e r a g e d 4.5 ram,
was p r e s e n t in 85 o f the 100 individuals. ~

From the Department of Orthodontics, Boston University

School of Graduate Dentist~, Boston, MA.
Address correspondence to Anthony A. Gianelly, DMD, PhD,
MD, Professor and Chairman, Department of Orthodontics, Boston University School of Graduate Dentist~7, 100 E Newton St,
Boston, MA 02118.
Copyright 1995 by' W.B. Saunders Company
1073-8746/95/0103-000655.00/0

188

Crowding was d e f i n e d as a tooth-size/arch-size

discrepancy and was d e t e r m i n e d by c o m p a r i n g
the mesiodistal diameters o f the p r i m a r y and
p e r m a n e n t teeth to arch p e r i m e t e r . W h e n
teeth were absent, their size was estimated
from their antimere, when present, or f r o m
data provided by Moyers et al. 3
W h e n tile leeway space gain was included in
the analysis, only 23 o f the 100 individuals had
insufficient space for alignment. In actuality,
the leeway space represents the "E" space or
the difference between the mesio-distal (m-d)
diameter of the second p r i m a r y molar and the
second p r e m o l a r because the c o m b i n e d m-d
diameter of the primary canine and first molar
( 13.64 ram) is a p p r o x i m a t e l y equal to the combined m-d diameter (13.85 ram) o f the permanent canine and first premolar. :~ This simplifies the usual leeway space calculation.
Thus, with the inclusion o f the E space, 77
o f the 100 patients had a d e q u a t e space in the
arch to a c c o m m o d a t e an aligned dentition.
(The size of u n e r u p t e d p e r m a n e n t teeth was
derived from m-d d i a m e t e r ratios o f p r i m a r y
to c o r r e s p o n d i n g p e r m a n e n t teeth as d e f i n e d
by Moyers et al. :~)
In seven o f tile remaining 23 patients who
would still exhibit a space deficit even after the
inclusion of the E space, tile crowding did not
exceed 2 ram, indicating that 84 out o f 100
subjects would have no m o r e than 2 m m o f
crowding by simply maintaining the E space.
Developmentally, there are t h r e e signs that
are usually described to identify the potential
for crowding in the p e r m a n e n t dentition. 4 T h e
first is the lack o f interdental spaces in the pri-

Seminars in Orthodontics, Vol 1, No 3 (September), 1995: pp 188-194

Leeway Space and Crowding in the M&ed Dentition

189

mary dentition. This sign is not especially reliable since Baume showed that 9 of 16 individuals with no interdental spaces in the primary
dentition did not exhibit crowding in the permanent dentition. 5 The second sign is crowding of the permanent incisors in the mixed
dentition. The third sign is the premature loss
of a primary canine, presumably reflecting inadequate space for the eruption of the lateral
incisor. In crowded conditions, the erupting
lateral incisor "promotes" the resorption of the
root of the primary canine which then exfoliates.
In the group of 100 patients, the most severe crowding was most often associated with
the early loss of a primary canine.

Maintenance of the E Space

Two common appliances used to maintain the
E space are the lingual arch and the lip bumper.

Lingual Arch
Despite its widespread use, comparatively little
is known concerning the effect of lingual arch
placement on the dimensions of the lower
arch. In one of the few reported investigations
on this topic, Singer observed that both arch
length and arch width were increased slightly
by approximately 0.5 mm. 6 Although not a
clinically useful increase, this led him to state,
"It can be seen that the appellation 'passive lingual arch' is a misnomer. Certain basic dental
changes were noted with the use of this appliance. A portion of the effect may be construed
as active movement (distal repositioning of the
molars) although the reason remains obscure."
The results of Singer's study indicated that the
lingual arch should readily maintain the E
space.
Timing of lingual arch placement. The lingual
arch is used when a primary canine is lost prematurely, disrupting the integrity of the dental
arch (Fig 1). The opposite primary canine is
then removed for purposes of symmetry and a
lingual arch is inserted. The function of the
lingual arch at this stage is to prevent the lingual movement (uprighting) of the incisors
with consequent loss of arch length. For in-

Figure 1. (A) Models illustrating early loss of right

primary canine, the removal of the left primary canine, and a lingual arch in place to maintain arch
length. (B) Lingual arch in place as permanent teeth
erupt. Space is available for all teeth.
stance, in a review article on space closure following the early loss of primary teeth, Owen
indicated that most investigators found that
space closure in the lower arch is primarily due
to lingual m o v e m e n t of the Iower incisor
teeth. 7
This raises a question: Why not consider a
serial extraction protocol in patients who lose a
primary canine early, because exfoliation of
the canine represents a space deficit and the
most severe crowding was often noted in patients who lost a primary canine early? This
would avoid the routine insertion of a lingual
arch in these patients. An answer to this question is that the prediction of impending crowding in the permanent dentition is difficult.5'8
For example, Sampson and Richards 8 were
unable to predict incisor crowding from dental
arch parameters and pre-eruptive tooth positions because of unpredictable changes in dental arch width and depth. They advised that,
"Considering the great individual variation,
lack of reliable radiographic and dental arch

190

Anthony A. Gianelly

p a r a m e t e r s o f crowding, a n d the u n e x p e c t e d
tendency for m a n y initially c r o w d e d cases to at
least partially resolve the incisor and/or canine
crowding, e x t r e m e caution should be exercised
in deciding which patients will truly benefit
f r o m serial extraction or early space gaining
procedures."
A n o t h e r reason for not routinely e n d o r s i n g
serial e x t r a c t i o n p r o c e d u r e s w h e n c r o w d i n g
exists in the m i x e d dentition is the observation
by R i n g e n b e r g that there was no d i f f e r e n c e in
t r e a t m e n t results obtained in a g r o u p o f patients t r e a t e d by m e a n s o f serial e x t r a c t i o n
w h e n c o m p a r e d with patients whose t r e a t m e n t
involved conventional p r e m o l a r extractions, l
Active t r e a t m e n t in the serial extraction g r o u p
was a p p r o x i m a t e l y 6 m o n t h s shorter. This indicated that the extraction p r o c e d u r e can be
delayed with little consequence.
Accordingly, a r e c o m r n e n d e d strategy is to
maintain arch length until the first p r e m o l a r s
erupt. At that time, a decision c o n c e r n i n g extraction carl be m a d e with m o r e precision because most d e v e l o p m e n t a l changes will have
occurred, reducing the chance for error.
T h e r e are exceptions to this protocol. O n e is
the p r e s e n c e o f a dehiscence on the labial aspect o f a m a n d i b u l a r incisor tooth. Lingual
m o v e m e n t o f the incisor m i g h t he favorable
since lingual m o v e m e n t is associated with m o r e
p e r i o d o n t a l s u p p o r t ) ) A second exception is
w h e n e r u p t i n g teeth are forced to e r u p t in an
a r e a o f n o n - k e r a t i n i z e d gingiva. In this instance, the p e r i o d o n t a l s u p p o r t o f the tooth
m i g h t be c o m p r o m i s e d d u e to the lack o f keratinized tissue.
A lingual arch is also c o m m o n l y used when
the lateral incisors e r u p t lingual to tile central
incisors (Fig 2). T h e function o f the appliance
is to p r e v e n t loss o f arch length that could oc-

Figure 2. Pre- and post-lingual arch placement.

cur if the lateral incisors m o v e d lingually, followed by the central incisor teeth.

Lip Bumper
T h e lip b u m p e r is an effective appliance for
m a i n t a i n i n g and/or increasing arch length (Fig
3). Any increase in arch length generally reflects both distal m o v e m e n t o f the molars a n d
labial m o v e m e n t o f the incisors, l L.12 Also, most
o f the changes induced by lip b u m p e r treatm e n t occur within the first year. tt As an example, B e r g e r s o n n o t e d that a 1 m m increase
in arch length can routinely be achieved in as
little as 3 m o n t h s o f full-time lip b u m p e r use. 12
Arch width also increases with lip b u m p e r
t r e a t m e n t . 1:~ Cetlin and T e n H o e v e lt d e m o n strated a 2.5 m m increase in intercanine width
a n d a 4 m m gain in i n t e r p r e m o l a r width. T h e y
e m p h a s i z e d that this arch width increase is an
i m p o r t a n t m e c h a n i s m for gaining space for incisor alignment. O t h e r s have o b s e r v e d similar
increases in arch width. 13
Nevant et al l:~ indicated that the type o f lip
b u m p e r and the activation schedule can influence the changes in the m a n d i b u l a r arch obtained with lip b u m p e r therapy. T h e y n o t e d a
larger increases in arch length a n d width when
a lip b u m p e r with an acrylic shield was activated every 4 to 5 weeks when c o m p a r e d with
the changes o b s e r v e d with the use o f a t h i n n e r
lip b u m p e r which was activated every 2 to 3
months. T h u s , m o r e f r e q u e n t activation o f a
lip b u m p e r with a relatively thick labial shield
can e n h a n c e the changes in the dental arch.
T h e arch length and width changes p r o d u c e d
by the lip b u m p e r lead to an increase in arch
circumfi~rence which, in o n e study, a v e r a g e d
4.1 m m . II
Because both the length a n d width o f the
lower dental arch can be increased by b u m p e r
use, w h a t a r e r e a s o n a b l e o b j e c t i v e s o f lip
b u m p e r t r e a t m e n t ? T h i s is a difficult question
to answer because opinions differ c o n c e r n i n g
the stability o f e x p a n d e d m a n d i b u l a r dental
arches. Nance t6 believed that excessive labial
m o v e m e n t o f a n t e r i o r teeth leads to eventual
relapse a n d possible tissue d a m a g e : "to line u p
the teeth in an arch to n o r m a l contact point
relationships . . . is d o w n r i g h t easy p r o v i d e d
one ignores the relationships o f teeth to sup-

Leeway Space and Crowding in the Mixed Dentition

191

Figure 3. (A) Lip bumper in place. (B) Adequate space is present to align the teeth. Arch length was
increased by i mm.
porting bones." His view reiterates the wellknown extraction/non-extraction controversy
between E d w a r d Angle and Calvin Case.
Angle, as r e f e r e n c e d by Bernstein, represented the "new school" o f dentistry which
stressed that n o r m a l occlusion could exist only
when there was a full c o m p l e m e n t of" teeth. 17
Angle also believed that basal b o n e growth
could be induced by functional forces so that
teeth that were m o v e d to a new position would
be s u r r o u n d e d by n e w l y - f o r m e d basal bone.
T h u s , expansion was acceptable and extractions never indicated. In disagreement, Case,
who s u p p o r t e d the views o f the " r a t i o n a l
school," a r g u e d that "new bone c a n n o t be induced to grow b e y o n d its i n h e r e n t size and,
therefore, there are indications for extractions
in certain types o f malocclusions". ~8
One o f the m o r e compelling tales o f ortho d o n t i c f o l k l o r e is the c o n v e r s i o n o f D r
Charles T w e e d f r o m a "non-extractionist" to
an "extractionist." As he recalled, "I practiced
the philosophy of the full c o m p l e m e n t o f teeth
diligently for six years. At the end o f six and a
half years o f o r t h o d o n t i c practice, I called 70%
o f the patients I had treated and classified the
results into successes a n d failures. T o my
amazement, my successes were less than 20%
and my failures m o r e than 80%. ''m
T w e e d t h e n p e r f o r m e d a series o f trials
that, to this day, are unique. H e noted, "In the
beginning, two patients with similar occlusions
were selected, b o t h 13 years old. O n e was
treated with the r e t e n t i o n o f teeth and the
o t h e r had f o u r first premolars r e m o v e d b e f o r e
treatment. After treatment, the results were

most gratifying. Not so for the other, the control case . . . . T h e e x p e r i m e n t was r e p e a t e d ,
doubling the n u m b e r s and the results were
similar. ''2 Finally, a g r o u p o f patients presenting a discrepancy between the size o f teeth and
basal b o n e w e r e selected. T h e y were first
treated by retention o f all teeth. " T h e s e same
patients were r e t r e a t e d after the removal o f all
first premolars. T h e m a n d i b u l a r incisors were
positioned over basal bone. T h e changes in facial esthetics were r e m a r k a b l e and the cases are
now out o f retention and free f r o m any serious
relapse. ''19
T w e e d also stated that w h e n patients with
bimaxillary protrusions were treated by n o n
extraction procedures, "the cases were finished
with the m a n d i b u l a r incisors either tipped or
bodily displaced mesial f r o m their n o r m a l position. Facial aesthetics were bad and the dish a r m o n y o f facial lines increased in direct relation to the extent o f mesial displacement o f
the m a n d i b u l a r incisors f r o m their n o r m a l position. Years o f r e t e n t i o n were futile, and, as a
rule, collapse of the m a n d i b u l a r arch in the
incisor region o c c u r r e d . . . a n d i r r e p a r a b l e
d a m a g e to h a r d and soft investing tissues particularly in the incisal and p r e m o l a r areas, was
the usual a f t e r m a t h o f such treatment. ''19
This b r i e f review indicates that, historically,
the e x p a n d e d lower dental arch was perceived
to be unstable. Since there is confusion, o n e
a p p r o a c h to develop a s o u n d strategy might be
to evaluate comparative outcomes. For example, is the stability o f lower dental arches which
have been e x p a n d e d in the mixed dentition
equal to or greater than the stability o f dental

192

Anthony A. Gianelly

arches which have not been e x p a n d e d ? This

question has been addressed in one study. Little et al c o m p a r e d the stability o f m a n d i b u l a r
dental arches that were e x p a n d e d in the mixed
d e n t i t i o n stage o f d e v e l o p m e n t to resolve
crowding with the stability o f arches that were
not e x p a n d e d . 21 T h e y f o u n d that lower arches
that u n d e r w e n t an increase o f m o r e than 1 m m
in arch length (as m e a s u r e d f r o m one molar to
the mid point between the central incisors to
the o t h e r molar) e x p e r i e n c e d m o r e recrowding when c o m p a r e d with the recrowding noted
when arches were not e x p a n d e d . This observation led the authors to r e c o m m e n d a nonexpansion t r e a t m e n t protocol.
Is the transverse expansion noted with lip
b u m p e r t r e a t m e n t stable? Most emphasis has
been placed on the intercanine dimension because an increase in intercuspid width provides
m o r e space to c o r r e c t c r o w d i n g than o t h e r
transverse changes. Specifically, one estimate is
that 1 m m of intercanine expansion produces a
0.73 m m space that (:an be used t o t alignment,
whereas a 1 m m expansion at the level o f the
molars p r o d u c e s only a 0.25 m m increase in
space. 22
T h e vast majority o f investigators who assessed the long-term stability o f intercanine expansion indicated that expansion o f this zone is
i n h e r e n t l y unstable. 9~-3 in a relevant study
that e m p h a s i z e d stability o f n o n e x t r a c t i o n
t r e a t m e n t results, the intercanine width was increased slightly in t r e a t m e n t f r o m 25.4 m m to
26 ram. After retention, the intercanine width
contracted to 25 ram. Arch length was not increased in this sample. At the start of treatment, arch length was 60 mm, whereas immediately after treatment, it was 60.2 ram. After
retention, arch length was 58 mm, reflecting a
loss o f 2 ram. :~1
T h e inability to enlarge mandilmlar intercanine width p e r m a n e n t l y is probably one of the
most d o c u m e n t e d post t r e a t m e n t changes. Alt h o u g h most o f the i n f o r m a t i o n for this conclusion has been derived by evaluating records
o f patients who were not treated "early" in the
mixed dentition stage o f development, it places
the b u r d e n o f p r o o f to verify the stability of
e x p a n s i o n o f the i n t e r c a n i n e width in the
mixed d e n t i t i o n on those who p r o p o s e this
t r e a t m e n t plan.
T h e findings o f the a b o v e - m e n t i o n e d inves-

tigations indicates that the original arch dimensions are not easily changed. T h e r e f o r e , a
p r u d e n t goal of lip b u m p e r t h e r a p y may be to
gain no m o r e than 1 m m o f arch length and
little arch width, p r o d u c i n g only a 2 m m increase in arch perimeter. If this 2 m m increase
in arch p e r i m e t e r is applied to the 100 individuals previously described, space for alignment
would be available in 84 o f these individuals or
in 84% o f the study group.
Timing of lip bumper placement. T h e author's
p r e f e r e n c e is to insert a lip b u m p e r after the
e r u p t i o n o f the first premolars, particularly
since the primary goal o f b u m p e r placement is
to maintain the E space. I f a decision is m a d e to
increase arch length 1 ram, it can be readily
achieved as the second deciduous molars exfoliate and the second premolars erupt.
As discussed previously, one o f the indications for earlier intervention is the p r e m a t u r e
loss of a primary canine. T h e t r e a t m e n t entails
the removal o f the contralateral p r i m a r y canine and the p l a c e m e n t o f a lingual arch.
W h e n the first p r e m o l a r teeth are erupting, a
space analysis is p e r f o r m e d . I f space is adequate for alignment, the lingual arch is left in
place until all premolars have e r u p t e d . Any
necessary alignment is p e r f o r m e d at this time.
I f there is a space deficit which does not exceed
2 ram, the lingual arch is r e m o v e d when the
first premolars are e r u p t i n g and a lip b u m p e r
inserted. If the shortage o f space is g r e a t e r
than 2 mm, extraction t r e a t m e n t may be the
t r e a t m e n t o f choice unless skeleto-dental conditions contraindicate the extraction o f teeth.
In the study sample, only 16 o f the 100 patients evaluated had crowding in excess o f 2
in hi.

Some might argue that earlier intervention

could also p r o v i d e the space necessary for
these t 6 patients. For example, one strategy is
to e x p a n d the maxilla (RPE) to gain space in
the maxillary arch, and at the same time provoke spontaneous transverse expansion o f the
lower arch. :~9 Although there are too little data
to assess the merits o f this a p p r o a c h adequately, the results o f two studies are not optimistic. S a n d s t r o m et al 3~ e v a l u a t e d t h e
records o f 28 patients whose maxillae were exp a n d e d orthopedically and n o t e d a 2 m m increase in intercanine width which later contracted to only 1.1 ram. Adkins et a134 observed

Leeway Space and Crowding in the Mixed Dentition

that expansion of the lower arch following rapid

palatal expansion did not exceed 0.8 mm.
If "passive" expansion of the lower arch
proves inadequate, there is the possibility of
actively expanding the transverse dimension of
the arch with an appliance such as a Schwartz
plate. 35 As Burstone 36 indicated, the ability to
expand this apical base skeletally is limited
since there is no suture. Therefore any expansion is principally dental in nature. The available data are sparse and equivocal concerning
the ability to expand the lower arch with active
appliances such as the Schwartz plate. Lutz and
Poulton 37 expanded the transverse dimension
of 13 patients in the primary dentition stage of
development and compared the changes to
those observed in 12 control subjects. Expansion was accomplished with removable appliances in 1 1 patients and with fixed appliances
in the remaining two patients. After a threeyear retention period, the patients were followed for another three years. At this time, (6
years posttreatment) the intercanine dimension of the treated sample was not different
from the control group, indicating total relapse of the treatment gain. The findings of
this study are consistent with the many investigations, which concluded that expansion of
the intercanine dimension of the lower arch is
inherently unstable. 23-3
McInaney et al 3s used Crozat appliances to
expand the transverse dimension of the lower
arch in 5-year-old and 6-year-old patients and
retained the changes until all the primary teeth
exfoliated. The intercanine dimension was expanded approximately 5 ram. After retention
was discontinued, the arches remained stable.
In this study there were no control subjects
and data from other published sources were
used to represent the controls. As such, the
actual net e x p a n s i o n ( t r e a t m e n t c h a n g e /
growth change) was not reported. The net expansion would depend on the control sample
chosen for comparison. If the control sample
were comparable to the control group identified by Lutz and Poulton, in which the intercanine width increased 4 to 5 mm, s7 there
would be no net expansion. If, on the other
hand, the comparison involved the control
sample reported by Moorrees and Chada, 1 in
which the intercanine width increased only 2
or m o r e mm as the p e r m a n e n t incisors
erupted, a net gain a p p r o x i m a t i n g 2 mm

193

would be apparent. This lack of correlation between control groups may indicate that arch
width changes that occur in conditions with a
space deficit may be d i f f e r e n t f r o m the
changes noted when there is adequate space
for alignment.
Crowding can be easily resolved by nonextraction treatment procedures, if desired, in at
least 85% of all patients with modest treatment, which can be started in the late mixed
dentition. (One exception previously noted is
the early loss of a primary canine, which requires earlier intervention.) The fate of the
other 15% of the patients is debatable. Should
these be "extraction" type patients (assuming
there are no skeletal contraindications), or
should they be treated earlier, to pursue a nonextraction approach more aggressively? One
view, shared by the author, is that extractions
are the preferable route. A reason for this is
that long-term consequences of early intervention procedures, which are designed to avoid
extraction by producing active and/or passive
expansion of the anterior part of mandibular
dental arch (arch development), are not clear.
Often, the focus is lateral expansion of the intercanine dimension, because this procedure,
as indicated, can readily provide space for
alignment. In this context, arch development is
contrary to the vast majority of available data,
which document the instability of mandibular
intercanine expansion. 23-3 In addition, others
who have discussed and demonstrated posttreatment stability have emphasized that the
mandibular intercanine dimension should not
be expanded during treatment. 39"4
Thus, for those who prefer not to expand
the mandibular dental arch more than 1 mm, a
fundamental difference between extraction
and non-extraction resolution of crowding is
the timing of treatment. Four to five millimeters of incisor crowding in the mixed dentition
stage of development can usually be treated by
nonextraction procedures whose goals include
maintaining the E space. Extraction treatment
is most often necessary to correct 4 to 5 mm of
crowding in the permanent dentition.

References
1. MoorreesCFA,ChadaJM. Availablespace for incisors
during dental development.A growth study based on
physiologicage. Angle Orthod 1965;35:12-22.

194

Anthony ,4. Gia~'~elly

2. Arnold S: Analysis of leeway space in the mixed dentition. Thesis for certification. Boston, Boston University, 1991.
3. Movers RE, van der Linden FPGM, Riolo ML, et al.
Standards of Human OcclusaI Development. Monograph # 5 Craniofacial Growth Series. Ann Harbor,
MI: Center of Human Development, The University
of Michigan, 1976.
4. Gianellv AA. Diagnosis of incipient malocclusions. J
Am Dent Assoc 1969;79:658-661.
5. Baume L. Physiological tooth migration and its significance for the development of occlusion. Part III. The
biogenesis of the successional dentition. J Dent Res
1950;29:338-348.
6. Singer J. T h e effect of the passive lingual arch on the
lower denture. Angle Orthod 1974;44:146-155.
7. Owen DG. The incidence and nature of space closure
following the p r e m a t u r e extraction of deciduous
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