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Guideline on Management of the Developing

Dentition and Occlusion in Pediatric Dentistry
Originating Committee
Clinical Affairs Committee Developing Dentition Subcommittee
Review Council
Council on Clinical Affairs


1991, 1998, 2001, 2005, 2009, 2014

Purpose responsibility to recognize, diagnose, and manage or refer

The American Academy of Pediatric Dentistry (AAPD) recog- abnormalities in the developing dentition as dictated by the
nizes the importance of managing the developing dentition complexity of the problem and the individual clinicians train-
and occlusion and its effect on the well-being of infants, ing, knowledge, and experience.5
children, and adolescents. Management includes the recogni- Many factors can affect the management of the developing
tion, diagnosis, and appropriate treatment of dentofacial dental arches and minimize the overall success of any treat-
abnormalities. This guideline is intended to set forth objectives ment. The variables associated with the treatment of the
for management of the developing dentition and occlusion in developing dentition that will affect the degree to which
pediatric dentistry. treatment is successful include, but are not limited to:
1. Chronological/mental/emotional age of the patient
Methods and the patients ability to understand and cooperate

This revision is based upon a new PubMed search using the
following parameters: Terms: tooth ankylosis, Class II maloc-
in the treatment.
2. Intensity, frequency, and duration of an oral habit.
clusion, Class III malocclusion, interceptive orthodontic treat- 3. Parental support for the treatment.
ment, evidence-based, dental crowding, ectopic eruption, dental 4. Compliance with clinicians instructions.
impaction, obstruction sleep apnea syndrome (OSAS), occlusal 5. Craniofacial configuration.
development, craniofacial development, craniofacial growth, 6. Craniofacial growth.
airway, facial growth, oligodontia, oral habits, occlusal wear 7. Concomitant systemic disease or condition.
and dental erosion, anterior crossbite, posterior crossbite, space 8. Accuracy of diagnosis.
maintenance, third molar development, and tooth size/arch 9. Appropriateness of treatment.
length discrepancy; Fields: all; Limits: within the last 10 years, 10. Timing of treatment.
humans, English, and birth through age 18. Papers for review A thorough clinical examination, appropriate pretreatment
were chosen from these searches and from references within records, differential diagnosis, sequential treatment plan, and
selected articles. When data did not appear sufficient or were progress records are necessary to manage any condition affect-
inconclusive, recommendations were based upon expert and/or ing the developing dentition.
consensus opinion by experienced researchers and clinicians. Clinical examination should include:
1. Facial analysis to:
Background a. identify adverse transverse growth patterns inclu-
Guidance of eruption and development of the primary, mixed, ding asymmetries (maxillary and mandibular);
and permanent dentitions is an integral component of com- b. identify adverse vertical growth patterns;
prehensive oral health care for all pediatric dental patients. c. identify adverse sagittal (anteroposterior) growth
Such guidance should contribute to the development of a patterns and dental anteroposterior (AP) occlusal
permanent dentition that is in a stable, functional, and esthe- disharmonies; and
tically acceptable occlusion and normal subsequent dentofacial d. assess esthetics and identify orthopedic and
development. Early diagnosis and successful treatment of orthodontic interventions that may improve
developing malocclusions can have both short-term and long- esthetics and resultant self-image and emotional
term benefits while achieving the goals of occlusal harmony development.
and function and dentofacial esthetics.1-4 Dentists have the


REFERENCE MANUAL V 37 / NO 6 15 / 16

2. Intraoral examination to: A differential diagnosis and diagnostic summary are com-
a. assess overall oral health status; and pleted to:
b. determine the functional status of the patients 1. Establish the relative contributions of the soft tissue
occlusion. and dental and skeletal structures to the patients
3. Functional analysis to: malocclusion.
a. determine functional factors associated with the 2. Prioritize problems in terms of relative severity.
malocclusion; 3. Detect favorable and unfavorable interactions that may
b. detect deleterious habits; and result from treatment options for each problem area.
c. detect temporomandibular joint dysfunction, 4. Establish short-term and long-term objectives.
which may require additional diagnostic pro- 5. Summarize the prognosis of treatment for achieving
cedures. stability, function, and esthetics.
Diagnostic records may be needed to assist in the evalua- A sequential treatment plan will:
tion of the patients condition and for documentation pur- 1. Establish timing priorities for each phase of therapy.
poses. Prudent judgment is exercised to decide the appropriate 2. Establish proper sequence of treatments to achieve
records required for diagnosis of the clinical condition.6 short-term and long-term objectives.
Diagnostic orthodontic records fall into three major catego- 3. Assess treatment progress and update the biomechan-
ries of evaluation: (1) health of the teeth and oral structures, ical protocol accordingly on a regular basis.
(2) alignment and occlusal relationships of the teeth, and (3)
facial and jaw proportions which includes both cephalometric Stages of development of occlusion
radiographs and facial photographs. Digital images, including General considerations and principles of management: The
cone-beam computed tomographic images (CBCT), are stages of occlusal development include:
supplementing and/or replacing film as records, especially in 1. Primary dentition: Beginning in infancy with the
cases of impacted teeth.6 eruption of the first tooth, usually about six months of
Diagnostic records may include: age, and complete from approximately three to six
1. Extraoral and intraoral photographs to: years of age when all primary teeth are erupted.
a. supplement clinical findings with oriented facial 2. Mixed dentition: From approximately age six to 13,
and intraoral photographs; and primary and permanent teeth are present in the
b. establish a database for documenting facial mouth.
changes during treatment. 3. Adolescent dentition: All primary teeth have exfoli-
2. Diagnostic dental casts to: ated, second permanent molars may be erupted or
a. assess the occlusal relationship; erupting, and third molars have not erupted.
b. determine arch length requirements for intraarch 4. Adult dentition: All permanent teeth are present and
tooth size relationships; eruptive growth is complete.7-10
c. determine arch length requirements for interarch These stages may further be divided and referenced as
tooth size relationships; and early and late (eg, early primary, late primary, early mixed,
d. determine location and extent of arch asymmetry. late mixed).7-10
3. Intraoral and panoramic radiographs to: Evaluation and treatment of occlusal and skeletal dishar-
a. establish dental age; monies may be initiated at various stages of dental arch
b. assess eruption problems; development, depending on the problems, growth, parental
c. estimate the size and presence of unerupted teeth; involvement, risks and benefits of treatment and of deferring
and treatment.5
d. identify dental anomalies/pathology. Historically, orthodontic treatment was provided mainly for
4. Lateral and AP cephalograms to: adolescents. Interest continues to be expressed in the concept
a. produce a comprehensive cephalometric analysis of interceptive (early) treatment as well as in adult treatment.
of the relative dental and skeletal components in Treatment and timing options for the growing patient, espe-
the anteroposterior, vertical, and transverse di- cially in the mixed dentition and early permanent dentition,
mensions; have increased and continue to be evaluated by the research
b. establish a baseline growth record for longitudinal community. 9,11,12 Many clinicians seek to modify skeletal,
assessment of growth and displacement of the muscular, and dentoalveolar abnormalities before the eruption
jaws; and of the full permanent dentition.7
c. determine dental maturity relataive to skeletal A thorough knowledge of craniofacial growth and develop-
maturity and chronological age. ment of the dentition, as well as orthodontic treatment, must
5. Other diagnostic views (eg, magnetic resonance ima- be used in diagnosing and reviewing possible interceptive
ging, CBCT) for hard and soft tissue imaging as treatment options before recommendations are made to par-
indicated by history and clinical examination. ents.9 Treatment is beneficial for many children, but may not
be indicated for every patient with a developing malocclusion.



Treatment considerations: The developing dentition should tion and space, and parents should be informed of
be monitored throughout eruption. This monitoring at regular the dentists observations.
clinical examinations should include, but not be limited to, 5. Early adult dentition stage: Third molars should be
diagnosis of missing, supernumerary, developmentally de- evaluated. If orthodontic diagnosis has not been
fective, and fused or geminated teeth; ectopic eruption; space accomplished, recommendations should be made as
and tooth loss secondary to caries and periodontal and pulpal necessary.
health of the teeth. Treatment objectives: At each stage, the objectives of
Radiographic examination, when necessary13 and feasible, intervention/treatment include managing adverse growth,
should accompany clinical examination. Diagnosis of anomalies correcting dental and skeletal disharmonies, improving esthet-
of primary or permanent tooth development and eruption ics of the smile and the accompanying positive effects on
should be made to inform the patients parent and to plan and self-image, and improving the occlusion.
recommend appropriate intervention. This evaluation is on- 1. Primary dentition stage: Habits and crossbites should
going throughout the developing dentition, at all stages.6-10 be diagnosed and, if predicted not likely to be self-
1. Primary dentition stage: Anomalies of primary teeth correcting, they should be addressed as early as feasible
and eruption may not be evident/diagnosable prior to facilitate normal occlusal relationships. Parents
to eruption, due to the childs not presenting for should be informed about findings of adverse growth
dental examination or to a radiographic examination and developing malocclusions. Interventions/
not being possible in a young child. Evaluation, treatment can be recommended if diagnosis can be
however, should be accomplished when feasible. The made, treatment is appropriate and possible, and
objectives of evaluation include identification of: parents are supportive and desire to have treatment
a. all anomalies of tooth number and size (as done.
previously noted); 2. Early-to-mid mixed dentition stage: Treatment con-
b. anterior and posterior crossbites; sideration should address: (a) habits; (b) arch length
c. presence of habits along with their dental and shortage; (c) intervention for crowded incisors; (d)
skeletal sequelae; and intervention for ectopic teeth; (e) holding of leeway
d. airway problems. space; (f ) crossbites; (g) surgical needs; and (h) adverse
Radiographs are taken with appropriate clinical indi- skeletal growth. Intervention for ectopic teeth may
cators or based upon risk assessment/history. include extractions of primary teeth and space
2. Early mixed dentition stage: The objectives of evalu- maintenance/regaining to aid eruption of succeda-
ation continue as noted for the primary dentition neous teeth and reduce the risk of need for permanent
stage. Palpation for unerupted teeth should be part of tooth extraction or surgical bracket placement for
every examination. Panoramic, occlusal, and peria- orthodontic traction. Treatment should take
pical radiographs, as indicated at the time of eruption advantage of high rates of growth and should be
of the lower incisors and first permanent molars, aimed at prevention of adverse dental relationships
provide diagnostic information concerning: and skeletal growth.
a. unerupted teeth; 3. Mid-to-late mixed dentition stage: Intervention for
b. missing, supernumerary, fused, and geminated treatment of skeletal disharmonies and crowding
teeth; may be instituted at this stage.
c. tooth size and shape (eg, peg or small lateral 4. Adolescent dentition stage: In full permanent denti-
incisors); tion, final orthodontic diagnosis and treatment can
d. positions (eg, ectopic first permanent molars); provide the most functional and esthetic occlusion.
e. developing skeletal discrepancies; and 5. Early adult dentition stage: Third molar position or
f. periodontal health. space can be evaluated and, if indicated, the tooth/
Space analysis can be used to evaluate arch length/ teeth removed. Full orthodontic treatment should be
crowding at the time of incisor eruption. recommended if needed.
3. Mid-to-late mixed dentition stage: The objectives
of the evaluations remain consistent with the prior Recommendations
stages, with an emphasis on evaluation for ectopic Oral habits
tooth positions, especially canines, bicuspids, and sec- General considerations and principles of management: The
ond permanent molars. habits of nonnutritive sucking, bruxing, tongue thrust swallow
4. Adolescent dentition stage: If not instituted earlier, and abnormal tongue position, self-injurious/self-mutilating
orthodontic diagnosis and treatment should be behavior, and OSAS are discussed in this guideline.
planned for Class I crowded, Class II, and Class III Oral habits may apply forces to the teeth and dentoal-
malocclusions as well as posterior and anterior cross- veolar structures. The relationship between oral habits and
bites. Third molars should be monitored as to posi- unfavorable dental and facial development is associational


REFERENCE MANUAL V 37 / NO 6 15 / 16

rather than cause and effect.14-16 Habits of sufficient frequency, lip- and tongue-biting habits may be associated with profound
duration, and intensity may be associated with dentoalveolar neurodisability due to severe brain damage.31 Management
or skeletal deformations such as increased overjet, reduced options include monitoring the lesion, odontoplasty, providing
overbite, posterior crossbite, or long facial height. The duration a bite-opening appliance, or extracting the teeth.31
of force is more important than its magnitude; the resting Research on the relationship between malocclusion and
pressure from the lips, cheeks, and tongue has the greatest mouth breathing suggests that impaired nasal respiration may
impact on tooth position, as these forces are maintained most contribute to the development of increased facial height,
of the time.17,18 anterior open bite, increased overjet, and narrow palate, but it
Nonnutritive sucking behaviors are considered normal in is not the sole or even the major cause of these conditions.32
infants and young children. Prolonged nonnutritive sucking OSAS may be associated with narrow maxilla, crossbite,
habits have been associated with decreased maxillary arch low tongue position, vertical growth, and open bite. History
width, increased overjet, decreased overbite, anterior open bite, associated with OSAS may include snoring, observed apnea,
and posterior crossbite.15,17,18 As preliminary evidence indicates restless sleep, daytime neurobehavioral abnormalities or sleepi-
that some changes resulting from sucking habits persist past ness, and bedwetting. Physical findings may include growth
the cessation of the habit, it has been suggested that early abnormalities, signs of nasal obstruction, adenoidal facies, and/
dental visits provide parents with anticipatory guidance to or enlarged tonsils.32-34
help their children stop sucking habits by age 36 months or The identification of an abnormal habit and the assessment
younger. 15,17,18 of its potential immediate and long-term effects on the
Bruxism, defined as the habitual nonfunctional and force- craniofacial complex and dentition should be made as early as
ful contact between occlusal surfaces, can occur while awake possible. The dentist should evaluate habit frequency, dura-
or asleep. The etiology is multifactorial and has been reported tion, and intensity in all patients with habits. Intervention to
to include central factors (eg, emotional stress,19 parasomnias,20 terminate the habit should be initiated if indicated.16
traumatic brain injury,21 neurologic disabilities22) and mor- Patients and their parents should be provided with infor-
phologic factors (eg, malocclusion 23, muscle recruitment 24). mation regarding consequences of a habit. Parents may play
The occlusal wear that may result from bruxism is important a negative role in the correction of an oral habit as nagging
to differentiate from other forms of occlusal loss of enamel or punishment may result in an increase in habit behaviors;
(eg, erosion caused by diet or gastroesophageal reflux).25 Re- change in the home environment may be necessary before a
ported complications of bruxism include dental attrition, habit can be overcome.15
headaches, temporomandibular dysfunction, and soreness of Treatment considerations: Management of an oral habit is
the masticatory muscles.19 Evidence indicates that juvenile indicated whenever the habit is associated with unfavorable
bruxism is self-limiting and does not persist in adults.26 The dentofacial development or adverse effects on child health or
spectrum of bruxism management ranges from patient/parent when there is a reasonable indication that the oral habit will
education, occlusal splints, and psychological techniques to result in unfavorable sequelae in the developing permanent
medications.19,21,27,28 dentition. Any treatment must be appropriate for the childs
Tongue thrusting, an abnormal tongue position and devia- development, comprehension, and ability to cooperate. Habit
tion from the normal swallowing pattern, may be associated treatment modalities include patient/parent counseling, be-
with anterior open bite, abnormal speech, and anterior pro- havior modification techniques, myofunctional therapy,
trusion of the maxillary incisors.16 There is no evidence that appliance therapy, or referral to other providers including, but
intermittent short-duration pressures, created when the tongue not limited to, orthodontists, psychologists, myofunctional
and lips contact the teeth during swallowing or chewing, have therapists, or otolaryngologists. Use of an appliance to manage
significant impact on tooth position.16,17 If the resting tongue oral habits is indicated only when the child wants to stop the
posture is forward of the normal position, incisor displacement habit and would benefit from a reminder.16
is likely, but if resting tongue posture is normal, a tongue Treatment objectives: Treatment is directed toward decreasing
thrust swallow has no clinical significance.17 or eliminating the habit and minimizing potential deleterious
Self-injurious or self-mutilating behavior (ie, repetitive acts effects on the dentofacial complex.
that result in physical damage to the individual) is extremely
rare in the normal child.29 Such behavior, however, has been Disturbances in number
associated with developmental delay or disabilities, psychiatric Congenitally missing teeth
disorders, traumatic brain injuries, and some syndromes. 29,30 General considerations and principles of management: Hypo-
The spectrum of treatment options for developmentally dontia, the congenital absence of one or more permanent
disabled individuals includes pharmacologic management, teeth, has a prevalence of 3.5 to 6.5 percent.35 Excluding third
behavior modification, and physical restraint.31 Reported dental molars, the most frequently missing permanent tooth is the
treatment modalities include, among others, lip-bumper and mandibular second premolar followed by the maxillary
occlusal bite appliances, protective padding, and extractions.29 lateral incisor.35 In the primary dentition, hypodontia occurs
Some habits, such as lip-licking and lip-pulling, are relatively less (0.1 percent to 0.9 percent prevalence) and almost always
benign in relation to an effect on the dentition.29 More severe affects the maxillary incisors and first primary molars.36 The



chance of familial occurrence of one or two congenitally 90 percent of all supernumeraries occur in the maxilla, with
missing teeth is to be differentiated from missing lateral half in the anterior area and almost all in the palatal position.44
incisors in cleft lip/palate37 and multiple missing teeth (six or A supernumerary primary tooth is followed by a supernu-
more) due to ectodermal dysplasia or other syndromes38 as the merary permanent tooth in one third of the cases.46 Supernu-
treatment usually differs. A congenitally missing tooth should merary teeth are classified according to their form and
be suspected in patients with cleft lip/palate, certain syn- location.44,47
dromes, and a familial pattern of missing teeth. In addition, During the early mixed dentition, 79 to 91 percent of ante-
patients with asymmetric eruption sequence, over-retained rior permanent supernumerary teeth are unerupted.40,45 While
primary teeth, or ankylosis of a primary mandibular second more erupt with age, only 25 percent of all mesiodens (a
molar may have a congenitally missing tooth.37,39,40 permanent supernumerary incisor located at the midline)
Treatment considerations: With congenitally missing perma- erupt spontaneously.44 Mesiodens can prevent or cause ectopic
nent maxillary incisor(s) or mandibular second premolar(s), eruption of a central incisor. Less frequently, a mesiodens can
the decision to extract the primary tooth and close the space cause dilaceration or resorption of the permanent incisors
orthodontically versus opening the space orthodontically and root. Dentigerous cyst formation involving the mesiodens, in
placing a prosthesis or implant depends on many factors. For addition to eruption into the nasal cavity, has been reported.44
maxillary laterals, the dentist may move the maxillary canine If there is an asymmetric eruption pattern of the maxillary
mesially and use the canine as a lateral incisor or create space incisors, delayed eruption, an overretained primary incisor, or
for a future lateral prosthesis or implant.16,41 ectopic eruption of an incisor, a supernumerary can be sus-
Factors that influence the decision are: (1) patient age; (2) pected.36,37,45 Panoramic, occlusal, and periapical radiographs
canine shape; (3) canine position; (4) childs occlusion and all can reveal a supernumerary, but the best way to locate the
amount of crowding; (5) bite depth; and (6) quality and quan- supernumerary is two periapical or occlusal films reviewed
tity of bone in the edentulous area.41 Early extraction of the by the parallax rule.44
primary canine and/or lateral may be needed. 41 Opening Treatment considerations: Management and treatment of hy-
space for a prosthesis or implant requires less tooth movement, perdontia differs if the tooth is primary or permanent. Primary
but the space needs to be maintained with an interim pros- supernumerary teeth normally are accommodated into the
thesis, especially if an implant is planned. 38,41 Moving the arch and usually erupt and exfoliate without complications.46
canine into the lateral position produces little facial change, Extraction of an unerupted supernumerary tooth during the
but the resultant tooth size discrepancy often does not allow a primary dentition usually is not done to allow it to erupt;
canine guided occlusion.40,41 surgical extraction of unerupted supernumerary teeth can
For a congenitally missing premolar, the primary molar displace or damage the permanent incisor.44 Removal of a
either may be maintained or extracted with subsequent place- mesiodens or other permanent supernumerary incisor results
ment of a prosthesis or orthodontically closing the space.41-43 in eruption of the permanent adjacent normal incisor in 75
Maintaining the primary second molar may cause occlusal percent of the cases.44 Extraction of an unerupted supernu-
problems due to its larger mesiodistal diameter, compared to merary during the early mixed dentition allows for a normal
the second premolar. 41 Reducing the width of the second eruptive force and eruption of the adjacent normal permanent
primary molar is a consideration, but root resorption and sub- incisor.44,45 Later removal of the mesiodens reduces the likeli-
sequent exfoliation may occur.16,41 In crowded arches or with hood that the adjacent normal permanent incisor will erupt on
multiple missing premolars, extraction of the primary molar(s) its own, especially if the apex is completed.44 Inverted conical
can be considered, especially in mild Class III cases.16,41,42 For supernumeraries can be harder to remove if removal is delayed,
a single missing premolar, if maintaining the primary molar is as they can migrate deeper into the jaw.45 After removal of the
not possible, placement of a prosthesis or implant should be supernumerary, clinical and radiographic follow-up is indicated
considered.16,42 Preserving the primary tooth may be indicated in six months to determine if the normal incisor is erupting. If
in certain cases. However, maintaining a submerged ankylosed there is no eruption after six to 12 months and sufficient space
tooth may increase likelihood of alveolar defect which can exists, surgical exposure and orthodontic extrusion is needed.44,48
compromise later implant success.42,43 Consideration for extrac- Treatment objectives: Removal of supernumerary teeth should
tion and space maintenance may be indicated.42,43 Consultation facilitate eruption of permanent teeth and encourage normal
with an orthodontist and/or prosthodontist may be considered. alignment. In cases where normal alignment or spontaneous
Treatment objectives: Treatment is directed toward an esthe- eruption does not occur, further orthodontic treatment is
tically pleasing occlusion that functions well for the patient. indicated.

Supernumerary teeth (primary, permanent, and mesiodens) Localized disturbances in eruption

General considerations and principles of management: Super- Ectopic eruption
numerary teeth, or hyperdontia, can occur in the primary General considerations and principles of management: Ec-
or permanent dentition but are five times more common in topic eruption (EE) of permanent first molars occurs due to
the permanent.44 Prevalence is reported in the primary and the molars abnormal mesioangular eruption path, resulting in
mixed dentitions from 0.52 to 2 percent.44,45 Between 80 and an impaction at the distal prominence of the primary second


REFERENCE MANUAL V 37 / NO 6 15 / 16

molars crown.49,50 EE can be suspected if asymmetric erup- assist in the eruption of the cuspids. This need can be deter-
tion is observed or if the mesial marginal ridge is noted to be mined from a panoramic radiograph.63,64 Bonded orthodontic
under the distal prominence of the second primary molar.49,50 treatment normally is required to create space or align the ca-
EE of permanent molars can be diagnosed from bitewing or nine. Long-term periodontal health of impacted canines after
panoramic radiographs in the early mixed dentition.49,50 This orthodontic treatment is similar to nonimpacted canines.65
condition occurs in up to three percent of the population,49 Treatment of ectopically erupting incisors depends on the
but is more common in children with cleft lip and palate.50,51 etiology. Extraction of necrotic or over-retained pulpally-
The maxillary canine appears in an impacted position in 1.5 - 2 treated primary incisors is indicated in the early mixed denti-
percent of the population,52 while maxillary incisors can erupt tion.53 Removal of supernumerary incisors in the early mixed
ectopically or be impacted from supernumerary teeth in up to dentition will lessen ectopic eruption of an adjacent permanent
two percent of the population.47 Incisors also can have altered incisor. 44 After incisor eruption, orthodontic treatment
eruption due to pulp necrosis (following trauma or caries) or involving removable or banded therapy may be needed.
pulpal treatment of the primary incisor.53 Treatment objectives: Management of ectopically erupting
EE of permanent molars is classified into two types. There molars, canines, and incisors should result in improved
are those that self-correct and others that remain impacted. eruptive positioning of the tooth. In cases where normal
Sixty-six percent of EE permanent molars self-correct by age alignment does not occur, subsequent comprehensive ortho-
seven.40,50 A permanent molar that presents with part of its dontic treatment may be necessary to achieve appropriate
occlusal surface clinically visible and part under the distal of arch form and intercuspation.
the primary second molar usually does not self-correct and is
the impacted type.49,50 After the age of seven, definitive treat- Ankylosis
ment is indicated to manage and/or avoid early loss of the General considerations and principles of management:
primary second molar and space loss.49,50 Ankylosis is a condition in which the cementum of a tooths
Maxillary canine impaction should be suspected when the root fuses directly to the surrounding bone. The periodontal
canine bulge is not palpable, asymmetric canine eruption is ligament is replaced with osseous tissue, rendering the tooth
evident, or peg shaped lateral incisors are present.52,54 Panoramic immobile to eruptive change. Ankylosis can occur in the
radiographs may demonstrate that the canine has an abnormal primary and permanent dentitions, with the most common
inclination and/or overlaps the lateral incisor root. EE of per- incidence involving primary molars. The incidence is reported
manent incisors can be suspected after trauma to primary to be between seven and 14 percent in the primary denti-
incisors, with pulpally-treated primary incisors, with asymme- tion.66 In the permanent dentition, ankylosis occurs most
tric eruption, or if a supernumerary incisor is diagnosed.52,54 frequently following luxation injuries.67
Treatment considerations: Treatment depends on how severe Ankylosis is common in anterior teeth following trauma
the impaction appears clinically and radiographically. For and is referred to as replacement resorption. Periodontal
mildly impacted first permanent molars, where little of the ligament cells are destroyed and the cells of the alveolar bone
tooth is impacted under the primary second molar, elastic perform most of the healing. Over time, normal bony activ-
or metal orthodontic separators can be placed to wedge the ity results in the replacement of root structure with osseous
permanent first molar distally.15,49 For more severe impactions, tissue.66 Ankylosis can occur rapidly or gradually over time,
distal tipping of the permanent molar is required.49 Tipping in some cases as long as five years post trauma. It also may be
action can be accomplished with brass wires, removable appli- transient if only a small bony bridge forms then is resorbed
ances using springs, fixed appliances such as sectional wires with subsequent osteoclastic activity.68
with open coil springs, sling shot-type appliances,55 a Halter- Ankylosis can be verified by clinical and radiographic
man appliance,56 or surgical uprighting.57 means. Submergence of the tooth is the primary recognizable
Early diagnosis and treatment of impacted maxillary canines sign, but the diagnosis also can be made through percussion
can lessen the severity of the impaction and may stimulate and palpation. Radiographic examination also may reveal the
eruption of the canine. Extraction of the primary canine is loss of the periodontal ligament and bony bridging.
indicated when the canine bulge cannot be palpated in the Treatment considerations: With ankylosis of a primary molar,
alveolar process and there is radiographic overlapping of the exfoliation usually occurs normally. Extraction is recommended
canine with the formed root of the lateral during the mixed if prolonged retention of the primary molar is noted. If a
dentition.52,58,59 The use of rapid maxillary expansion in the severe marginal ridge discrepancy develops, extraction should
early mixed dentition has been shown to increase the rate of be considered to prevent the adjacent teeth from tipping and
eruption of palatally displaced maxillary cuspids. 60,61 When producing space loss.3 Replacement resorption of permanent
the impacted canine is diagnosed at a later age (11 to 16), if teeth usually results in the loss of the involved tooth.66
the canine is not horizontal, extraction of the primary canine Mildly to moderately ankylosed primary molars without
lessens the severity of the permanent canine impaction and 75 permanent successors may be retained and restored to func-
percent will erupt.62 Extraction of the first primary molar also tion in arches without crowding. Extraction of these molars
has been reported to allow eruption of first bicuspids and to can assist in resolving crowded arches in complex orthodontic



cases.69 Surgical luxation of ankylosed permanent teeth with traction and space/arch length maintenance with
forced eruption has been described as an alternative to pre- holding arches. Extraction of primary or permanent
mature extraction.70 teeth with the aim of alleviating crowding should not
Treatment objectives: Treatment of ankylosis should result in be undertaken without a comprehensive space anal-
the continuing normal development of the permanent denti- ysis and a short and long term orthodontic treat-
tion. In the case of replacement resorption of a permanent ment plan.
tooth, appropriate prosthetic replacement should be planned. 2. Orthodontic alignment of permanent teeth as soon
as erupted and feasible, expansion and correction of
Tooth size/arch length discrepancy and crowding arch length as early as feasible.
General considerations and principles of management: Arch 3. Utilizing holding arches in the mixed dentition until
length discrepancies include inadequate arch length and all permanent bicuspids and canines have erupted.
crowding of the dental arches, excess arch length and spacing, 4. Maintaining patients original arch form.81
and tooth size discrepancy, often referred to as a Bolton dis-
crepancy.71 These arch length discrepancies may be found in Additional treatment modalities may include, but are not
conjunction with complicating and other etiological factors limited to: (1) interproximal reduction; (2) restorative bond-
including missing teeth, supernumerary teeth, and fused or ing; (3) veneers; (4) crowns; (5) implants; and (6) orthognathic
geminated teeth. Inadequate arch length with resulting incisor surgery.
crowding is a common occurrence with various negative Treatment objectives: Well-timed intervention can:
sequelae and is particularly common in the early mixed denti- 1. Prevent crowded incisors.
tion.72-75 Studies of arch length in todays children compared 2. Increase long-term stability of incisor positions.
to their parents and grandparents of 50 years ago indicate 3. Decrease ectopic eruption and impaction of perma-
less arch length, more frequent incisor crowding, and stable nent canines.
tooth sizes.76-78 This implies that the problem of incisor 4. Reduce orthodontic treatment time and sequelae.
crowding and ultimate arch length discrepancies may be 5. Improve gingival health and overall dental health.72,83,84
increasing in numbers of patients and in amount of arch
length shortage.76,77,79 Space maintenance
Arch length and especially crowding must be considered in General considerations and principles of management: The
the context of the esthetic, dental, skeletal, and soft tissue premature loss of primary teeth due to caries, trauma, ecto-
relationships. Mandibular incisors have a high relapse rate in pic eruption, or other causes may lead to undesirable tooth
rotations and crowding. 72,74 Growth of the aging skeleton movements of primary and/or permanent teeth including loss
causes further crowding and incisor rotations. 80 Functional of arch length. Arch length deficiency can produce or increase
contacts are diminished where rotations of incisors, canines, the severity of malocclusions with crowding, rotations, ectopic
and bicuspids exist.81 Occlusal harmony and temporomandi- eruption, crossbite, excessive overjet, excessive overbite, and un-
bular joint health are impacted negatively by less functional favorable molar relationships.85 Whenever possible, restoration
contacts.81 of carious primary teeth should be attempted to avoid maloc-
Initial assessment may be done in early mixed dentition, clusions that could result from their extraction.86 The use of
when mandibular incisors begin to erupt. 72 Evaluation of space maintainers to reduce the prevalence and severity of
available space and consideration of making space for perma- malocclusion following premature loss of primary teeth is
nent incisors to erupt may be done initially utilizing appro- recommended.16,87,88 Space maintenance may be a consideration
priate radiographs to ascertain the presence of permanent in the primary dentition after early loss of a maxillary incisor
successors. Comprehensive diagnostic analysis is suggested, with when the child has an active digit habit. An intense habit may
evaluation of maxillary and mandibular skeletal relationships, reduce the space for the erupting permanent incisor.
direction and pattern of growth, facial profile, facial width, Adverse effects associated with space maintainers include:
muscle balance, and dental and occlusal findings including (1) dislodged, broken, and lost appliances; (2) plaque accumu-
tooth positions, arch length analysis, and leeway space. lation; (3) caries; (4) damage or interference with successor
Derotation of teeth just after emergence in the mouth im- eruption; (5) undesirable tooth movement; (6) inhibition of al-
plies correction before the transseptal fiber arrangement has veolar growth; (7) soft tissue impingement; and (8) pain.85,89-94
been established.72,81 It has been shown that the transseptal Premature loss of a primary tooth of any type, especially in
fibers do not develop until the cementoenamel junction of crowded dentitions, has the potential to cause loss of space
erupting teeth pass the bony border of the alveolar process.81 available for the succeeding permanent tooth, but there is a lack
Long-term stability of aligned incisors may be increased.82 of consensus regarding the effectiveness of space maintainers
Treatment considerations: Treatment considerations may in- in preventing or reducing the severity of malocclusion.85,90,91,95-99
clude, but are not limited to: Treatment considerations: It is prudent to consider space main-
1. Gaining space for permanent incisors to erupt and tenance when primary teeth are lost prematurely. Factors to
become straight naturally through primary canine ex- consider include: (1) specific tooth lost; (2) time elapsed since


REFERENCE MANUAL V 37 / NO 6 15 / 16

tooth loss; (3) pre-existing occlusion; (4) favorable space analy- clude: dentofacial development, age at time of tooth loss, tooth
sis; (5) presence and root development of permanent successor; that has been lost, space available, and space needed.1,85,87
(6) amount of alveolar bone covering permanent successor; Treatment objectives: The goal of space regaining intervention
(7) patients health status; (8) patients cooperative ability; (9) is the recovery of lost arch width and perimeter and/or im-
active oral habits; and (10) oral hygiene.16,85 proved eruptive position of succedaneous teeth. Space regained
The literature pertaining to the use of space maintainers should be maintained until adjacent permanent teeth have
specific to the loss of a particular primary tooth type include erupted completely and/or until a subsequent comprehensive
expert opinion, case reports, and details of appliance de- orthodontic treatment plan is initiated.
sign.16,87,88 Treatment modalities may include, but are not
limited to: Crossbites (dental, functional, and skeletal)
1. Fixed appliances (eg, band and loop, crown and loop, General considerations and principles of management: Cross-
passive lingual arch, distal shoe, Nance appliance, bites are defined as any abnormal buccal-lingual relation
transpalatal arch). between opposing incisors, molars, or premolars in centric
2. Removable appliances (eg, partial dentures, Hawley relation.103-105 If the mid-lines undergo a compensatory or
appliance).16,87,88 habitual shift when the teeth occlude in crossbite, this is
The placement and retention of space maintaining appliances termed a functional shift.101 A crossbite can be of dental or
requires ongoing compliant patient behavior. Follow-up of skeletal origin or a combination of both.101
patients with space maintainers is necessary to assess integrity A simple anterior crossbite is of dental origin if the molar
of cement and to evaluate and clean the abutment teeth.93 occlusion is Class I and the malocclusion is the result of an
The appliance should function until the succedaneous teeth abnormal axial inclination of maxillary anterior teeth. This
have erupted into the arch. condition should be differentiated from a Class III skeletal
Treatment objectives: The goal of space maintenance is to malocclusion where the crossbite is the result of the basal bone
prevent loss of arch length, width, and perimeter by main- position.104 Posterior crossbites may be the result of bilateral or
taining the relative position of the existing dentition.16,87 unilateral lingual position of the maxillary teeth relative to the
The AAPD recognizes the need for controlled randomized mandibular posterior teeth due to tipping or alveolar discre-
clinical trials to determine efficacy of space maintainers as well pancy, or a combination. Most often, unilateral posterior
as analysis of costs and side effects of treatment crossbites are the manifestation of a bilateral crossbite with a
functional mandibular shift.105 Dental crossbites may be the
Space regaining result of tipping or rotation of a tooth or teeth. In this case,
General considerations and principles of management: Some the condition is localized and does not involve the basal bone.
of the more common causes of space loss within an arch are In contrast, skeletal crossbites involve disharmony of the
(1) primary teeth with interproximal caries; (2) ectopically craniofacial skeleton.105,106 Aberrations in bony growth may
erupting teeth; (3) alteration in the sequence of eruption; give rise to crossbites in two ways:
(4) ankylosis of a primary molar; (5) dental impaction; (6) 1. Adverse transverse growth of the maxilla and
transposition of teeth; (7) loss of primary molars without mandible.
proper space management; (8) congenitally missing teeth; (9) 2. Disharmonious or adverse growth in the sagittal (AP)
abnormal resorption of primary molar roots; (10) premature length of the maxilla and mandible.103,107
and delayed eruption of permanent teeth; and (11) abnormal Such growth aberrations can be due to inherited growth
dental morphology.16,85,88,100,101 Therefore, loss of space in the patterns, trauma, or functional disturbances that alter normal
dental arch that interferes with the desired eruption of the growth.105-107
permanent teeth may require evaluation. Treatment considerations: Crossbites should be considered in
The degree to which space is affected varies according to the context of the patients total treatment needs. Anterior
the arch, site in the arch, and time elapsed since tooth loss.102 crossbite correction can: (1) reduce dental attrition; (2) improve
The quantity and incidence of space loss are dependent upon dental esthetics; (3) redirect skeletal growth; (4) improve the
which adjacent teeth are present in the dental arch and their tooth-to-alveolus relationship; and (5) increase arch perim-
status.16,85 The amount of crowding or spacing in the dental eter.106 If enough space is available, a simple anterior crossbite
arch will determine the consequence of space loss.1,101 can be aligned as soon as the condition is noted. Treatment
Treatment considerations: Space can be maintained or regained options include acrylic incline planes, acrylic retainers with
with removable or fixed appliances.85,87 Some examples of fixed lingual springs, or fixed appliances with springs. If space is
space regaining appliances are active holding arches, pendulum needed, an expansion appliance also is an option. 103 Poste-
appliances, and Jones jig. Examples of removable space regain- rior crossbite correction can accomplish the same objectives
ing appliances are Hawley appliance with springs, lip bumper, and can improve the eruptive position of the succedaneous
and headgear.87 If space regaining is planned, a comprehensive teeth. Early correction of unilateral posterior crossbites has
analysis should be completed prior to any treatment decisions. been shown to improve functional conditions significantly and
Some factors that should be considered in the analysis in- largely eliminate morphological and positional asymmetries of
the mandible.108,109 Functional shifts should be eliminated as



soon as possible with early correction107 to avoid asymmetric Treatment considerations: Factors to consider when planning
growth.105 Treatment can be completed with: orthodontic intervention for Class II malocclusion are: (1) fa-
1. Equilibration. cial growth pattern; (2) amount of AP discrepancy; (3) patient
2. Appliance therapy (fixed or removable). age; (4) projected patient compliance; (5) space analysis; (6)
3. Extractions. anchorage requirements; and (7) patient and parent desires.
4. A combination of these treatment modalities to cor- Treatment modalities include: (1) extraoral appliances
rect the alveolar constriction.110 headgear; (2) functional appliances; (3) fixed appliances; (4)
Skeletal expansion with fixed or removable palatal ex- tooth extraction and interarch elastics; and (5) orthodontics
panders can be utilized until midline suture fusion occurs.101,104 with orthognathic surgery.101
Treatment decisions depend on the: Treatment objectives: Treatment of a developing Class II mal-
1. Amount and type of movement (tipping vs. bodily occlusion should result in an improved overbite, overjet, and
movement, rotation, or dental vs. orthopedic move- intercuspation of posterior teeth and an esthetic appearance
ment). and profile compatible with the patients skeletal morphology.
2. Space available.
3. AP, transverse, and vertical skeletal relationships. Class III malocclusion
4. Growth status. General considerations and principles of management: Class
5. Patient cooperation. III malocclusion (mesio-occlusion) involves a mesial relation-
Patients with crossbites and concomitant Class III skeletal ship of the mandible to the maxilla or mandibular teeth to
patterns and/or skeletal asymmetry should receive comprehen- maxillary teeth. This relationship may result from dental
sive treatment as covered in the Class III malocclusion section. factors (malposition of the teeth in the arches), skeletal factors
Treatment objectives: Treatment of a crossbite should result (asymmetry, mandibular prognathism, and/or maxillary
in improved intramaxillary alignment and an acceptable inter- retrognathism), anterior functional shift of the mandible, or a
arch occlusion and function.108 combination of these factors.126
The etiology of Class III malocclusions can be hereditary,
Class II malocclusion environmental, or both. Hereditary factors can include clefts
General considerations and principles of management: Class of the alveolus and palate as well as other craniofacial ano-
II malocclusion (distocclusion) may be unilateral or bilat- malies that are part of a genetic syndrome. 127,128 Some
eral and involves a distal relationship of the mandible to the environmental factors are trauma, oral/digital habits, caries,
maxilla or the mandibular teeth to maxillary teeth. This rela- and early childhood OSAS.129
tionship may result from dental (malposition of the teeth in Treatment considerations: Treatment of Class III malocclu-
the arches), skeletal (mandibular retrusion and/or maxillary sions is indicated to provide psychosocial benefits for the
protrusion), or a combination of dental and skeletal factors.6 child patient by reducing or eliminating facial disfigurement
Results of randomized clinical trials indicate that Class II and to reduce the severity of malocclusion by promoting com-
malocclusion can be corrected effectively with either a single pensating growth.130 Interceptive Class III treatment has been
or two-phase regimen.111-114 Growth-modifying effects in some proposed for years and has been advocated as a necessary tool
studies did not show an influence on the Class II skeletal in contemporary orthodontics.131-136 Factors to consider when
pattern,113,115,116 while other studies dispute these findings.117,118 planning orthodontic intervention for Class III malocclusion
There is substantial variation in treatment response to growth are: (1) facial growth pattern; (2) amount of AP discrepancy;
modification treatments (headgear or functional appliance) (3) patient age; (4) projected patient compliance; (5) space
and no reliable predictors for favorable growth response have analysis; (6) anchorage headgear; (7) functional appliances;
been found.111,117 Some reports state interceptive treatment (8) fixed appliances; (9) tooth extraction; (10) interarch elastics;
does not reduce the need for either premolar extractions or and (11) orthodontics with orthognathic surgery.137
orthognathic surgery,112,113 while others disagree with these Treatment objectives: Interceptive Class III treatment may
findings.119 Two-phase treatment results in significantly longer provide a more favorable environment for growth and may
treatment time.107,112,120 improve occlusion, function, and esthetics.138 Although inter-
Clinicians may decide to provide interceptive treatment ceptive treatment can minimize the malocclusion and poten-
based on other factors.112,117 Evidence suggests that, for some tially eliminate future orthognathic surgery, this is not always
children, interceptive Class II treatment may improve self- possible. Typically, Class III patients tend to grow longer and
esteem and decreases negative social experiences, although more unpredictably and, therefore, surgery combined with
the improvement may not be different longterm.121,122 Incisor orthodontics is the best alternative to achieve a satisfactory
injury is associated with overjet greater than three millime- result for some patients.101
ters.123 Further, when injury is more severe than simple enamel Treatment of a Class III malocclusion in a growing patient
fractures, increased overjet and prognathic position of the should result in improved overbite, overjet, and intercuspation
maxilla are more strongly associated.124 Some studies indicate of posterior teeth and an esthetic appearance and profile com-
interceptive treatment for Class II malocclusions can be initi- patible with the patients skeletal morphology.
ated, depending upon patient cooperation and management.125


REFERENCE MANUAL V 37 / NO 6 15 / 16

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