non-extraction approach Ronald A. Bell, DDS, MEd, and Andrew Sonis, DMD Mandibular incisor crowding in the mixed dentition is one of the most common problems presenting to the orthodontist. Asymmetry of alignment, premature loss of primary canine(s), and disruption in arch integrity are all early benchmarks of a tooth size/arch length discrepancy in the transitional dentition that can occur independent of any skeletal discrepancy. Space supervision and guidance of eruption refer to treatment interventions during the early to mid- mixed dentition periods that inuence the eruption patterns and positioning of the permanent teeth during their transition. Generally considered applicable to individuals with adequate overall arch dimensions to accommodate a normal complement of permanent teeth with an acceptable esthetic and functioning occlusion, guidance of eruption involves the implementation of directed interventions to optimize the eruption and alignment patterns of the permanent teeth as part of a non-extraction protocol. (Semin Orthod 2014; 20:1635.) & 2014 Elsevier Inc. All rights reserved. T he concept of an early phase of treatment intervention with guidance of eruption procedures to correct mandibular incisor crowding is not a new one. Space supervision, guidance of eruption, pre-orthodontic guidance, and interceptive orthodontics are all terms that have been used to refer to the treatment of crowding dis- crepancies presenting during the early to mid- mixed dentition (Nance, 1947 1 ; Popovich, 1962 2 ; Hotz, 1970 3 ; Ackerman and Proft, 1980 4 ; Moyer, 1988 5 ). While considerable debate has ensued as to the proper terminology, the denitions are far less important than the concepts of intervention. The authors have elected to utilize Hotzs 3 term guidance of eruption in referring to treatment procedures that inuence the eruption patterns and positioning of the permanent teeth during the transition from the primary dentition through the mixed dentition. The effective- ness of preserving leeway space with a lingual arch to resolve mandibular crowding was reported by Nance 1 in a presentation to the Southern Society of Orthodontics in 1946 and in an article in the American Journal of Ortho- dontics in 1947. Nance describes a series of cases dating back to 1934 that were successfully treated with passive lingual arches in the mixed dentition. A similar approach to preserving arch length was described by Hotz 3 in 1970 and later by Singer 6 in 1974. These opinion articles and case series were later substantiated in clinical studies by Wagers, 7 Arnold, 8 Gianelly, 9 DeBaets and Chiarini, 10 Dugoni et al., 11 Gianelly, 12,13 Rebellato et al., 14 Brennan and Gianelly, 15 Villalobos, 16 Gianelly, 17 and Bell. 18 Despite these positive reports, opponents of early intervention have argued that a second phase of therapy is frequently necessary, resulting in both increased length of treatment time and cost. While this opinion is frequently mentioned in the literature, there is scant research to substantiate such a conclusion. Wagers 7 reported in a survey of 100 patients undergoing mixed dentition treatment a 0.2-month difference in treatment & 2014 Elsevier Inc. All rights reserved. 1073-8746/12/1801-$30.00/0 http://dx.doi.org/10.1053/j.sodo.2013.12.003 Department of Pediatric Dentistry and Orthodontics, James B. Edwards College of Dental Medicine, Medical University of South Carolina, Charleston, SC; Children 0 s Hospital Boston, Boston, MA; Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA. Address correspondence to Ronald A. Bell, DDS, MEd, Depart- ment of Pediatric Dentistry and OrthodonticsJames B. Edwards College of Dental Medicine, Medical University of South Carolina, 30 Bee St MSC126, Charleston, SC 29425. E-mail: bellr@musc.edu 16 Seminars in Orthodontics, Vol 20, No 1 (March), 2014: pp 1635 time over those patients treated in the permanent dentition (21.6 months vs. 21.4 months). Popowich et al. 19 reported very similar results of patients treated in the mixed dentition with average treatment durations of 20.25 months in non- extraction Class I cases. The short-term and long-term dental health benets of early mandibular incisor alignment also remain unclear and unsubstantiated. Empirically, one would think that well-aligned teeth are easier to clean and thus less prone to plaque-mediated dental disease, namely caries and periodontal disease. Yet clinical studies fail to consistently demonstrate a causal relationship. A 2007 review by Burden 20 entitled Oral Health- Related Benets of Orthodontic Treatment in this same publication concluded that ortho- dontists today could not claim to prevent caries by orthodontic intervention and that orthodontic treatment confers neither harm nor benet in terms of long-term periodontal health. A more recent systematic review of the literature by Hafez et al. 21 arrived at this same conclusion. If not for overall dental health benets and with questions regarding multiple-phase ef- ciency, then why treats crowding in the mixed dentition? Proponents of early treatment argue long-term lower incisor positional stability is better in patients treated during this period. The study by Dugoni et al. 11 is often cited as evidence supporting such early guidance intervention. However, while the abstract of this study shows impressive results with 19 of 25 (76%) patients showing clinically satisfactory lower anterior alignment 10 years post-retention, a close review of the study suggests the reader may be misled by the abstract. Although it is unclear as to how patients were selected for the study and while no patients were stated to receive lower Edgewise treatment, it is clear the patients received more than just a passive lingual arch to maintain leeway space. Quoting the article, In most cases the lingual arch was removed and a lower xed canine-to-canine retainer was placed for a period of time. In addition, 16 (64%) patients had circumferential berotomies and 18 (72%) had interproximal enamel stripping. In contrast, while the classic 10-year post-retention follow-up study of rst premolar extraction cases by Little et al. 22 found satisfactory incisor alignment to be less than 30%, no circumferential berotomies were per- formed on any of the patients, and presumably none had interproximal enamel stripping. Con- sequently, to suggest that incisor alignment exhi- bited better long-term stability in the Dugoni et al. 11 study compared to the rst premolar extraction cases reported by Little et al. 22 may be somewhat misleading. Unfortunately, in another study by Little et al. 23 that examined post-rete- ntion stability in non-extraction cases treated in the mixed dentition that involved an increase in lower arch length, patients treated with lee- way space preservation were specically exclu- ded from the study. The study results involving mixed dentition arch dimensional expansion did demonstrate an instability and high relapse potential even when small amounts of expansion were utilized to resolve incisor crowding. Con- sequently, it is unclear whether one can con- clude resolution of lower crowding via leeway space preservation is any more stable than either premolar extractions or mixed dentition arch expansion. In addition to relapse of incisor alignment, some of the recurrence in crowding is likely related to normal physiologic changes as those observed in untreated individuals. The results of the Belfast longitudinal studies 24,25 showed a mean decrease in crowding of about 1 mmbetween 7 and 11 years of age; the crowding increased an average of 2.3 mm from 13 to 18 years. Given the information available suggesting post-treatment lower incisor stability is likely comparable with any of these approaches, the clinician might again askwhy bother with early treatment? In an essay entitled Timing of early treatment: An overview, Proft 26 suggested the indications for considering early treatment basically involve two issuesthe effectiveness and the efciency of treatment. The authors of the present article would argue that two guidance of eruption concepts meet these effectiveness and efciency requirements: the utilization of E-space just prior to exfoliation of the mandibular second primary molar and the sequential utilization of leeway space for the relief of mixed dentition lower incisor crowding. An understanding of normative eruption pat- terns and arch dimensional changes in relation to the primary to mixed dentition transitional stages is imperative in understanding the rationale for the various treatment approaches that will be discussed under the general concept of guidance of eruption. Space supervision and guidance of eruption 17 Normative transitional dimensional changes and anticipatory guidance Recognition of an impending tooth sizearch length discrepancy is often rst evident in the primary dentition. The signicance of spacing in the primary dentition (both generalized and primate spaces) and its relationship to potential crowding of the permanent incisors is well illus- trated by the longitudinal study by Leighton, 27 the work of Baume, 2830 and the work of Moorees and co-workers. 3134 Observing 200 children during the transition from full primary dentition to permanent dentition, Leighton 27 noted a direct relationship between the amount of spacing in the primary dentition and subsequent crowding of the permanent incisors. Specically, those children having 6 mm or more of spacing in the primary dentition had well-aligned perma- nent incisors, while approximately two-thirds of those with no spacing experienced signicant crowding of the permanent incisors. Baume 29 also observed a similar relationship, where 44% of subjects lacking interdental spacing in the primary dentition exhibited signicant crowd- ing in the permanent dentition while those with generalized primary spacing transitioned into normally aligned lower permanent incisors. The retrospective assessment of adolescents with well-aligned permanent dentitions by Moo- rees and Chadha 32 showed that the individuals expressed generalized spacing in the primary dentition at 5 years of age. There is also some historical evidence that impending malalignment of permanent incisors may be seen radiographi- cally well prior to their eruption. 35 Thus, the clinician seeing children in the primary dentition can inform parents of potential crowding con- cerns based on clinical observations supported by timely radiographs. On eruption of the lower lateral permanent incisors, there is a normative increase in lower intercanine arch width of 23 mm, with a range from 0 to 5 mm. 29,32 After lower permanent incisor transition is complete by 8 years of age, the normative amount of lower incisor crowding in the mid-mixed dentition approximates an in- cisor liability of about 1.52 mm, with a standard deviation of 1 mm. 37,38 These dimensional parameters indicating lower incisor crowding of 14 mm are expressed in the vast majority of children at 89 years of age after permanent lower incisor eruption is complete. Studies of transitional arch dimensional changes further document that no future increase in lower intercanine width will occur after the incisor eruption is complete. 29,32,36,39 These ndings suggest that normative transverse arch dimen- sional changes do not compensate for the relief of any malalignment that might be present in the mid-mixed dentition as the intercanine width is established by 8 years of age (Fig. 1). Relative to arch length changes, studies assessing dimen- sional changes occurring over the course of the transitional dentition show arch length decre- ases on average of about 23 mm per lower quadrant. 14,33,34,39,40 A slight decrease of about 1 mm, as the rst permanent molars erupt and close any available posterior primary dentition spaces (i.e., early mesial shift), is mostly offset by more forward incisor positioning during the incisor transition. The arch length is generally stable over the course of the mid- to late-mixed dentition, but shows a signicant average decrease of 23 mm as the nal buccal segment transition occurs with the exfoliation of the second primary molar and late mesial shift of the permanent rst molars (Fig. 2). Concurrently with the late transition period and subsequently into the adolescent years, an additional decrease in arch length may be associated with uprighting of the lower incisors as the overbite and overjet are dened. 14 The lack of width increase in the lower anterior segment after lower lateral incisors have erupted and the decrease in arch length concurrent with buccal segment transition and incisor uprighting combine to result in a notable decrease in mandibular arch perimeter as the mixed dentition transitions into the young permanent occlusion. This arch perimeter decrease is on the order of 46 mm in the lower arch during this period and helps explain why mixed dentition incisor crowding either remains the same or typically worsens more during the transition to the full permanent den- tition. As noted, the majority of lower arch peri- meter reduction occurs as the second primary molars exfoliate, and the residual space secon- dary to the size differential between this tooth and the succedaneous second premolar (i.e., E-space) is eliminated due to late mesial shift adjustments of the rst molars. Prior to this, minimal arch length change and the increase in arch width during incisor eruption actually Bell and Sonis 18 produce an increased arch perimeter through the majority of the mid-mixed dentition. The arch perimeter changes in the mixed to adoles- cent dentition period are illustrated in Fig. 3 After the lower permanent incisors have erupted and intercanine width changes have been realized in terms of anterior space dimen- sions, any crowding of the incisors should be considered an established dimensional reality with no self-improvement anticipated through future growth changes. 41 Since arch circumfer- ence decreases anterior to the rst permanent molars during normal development and with space loss often complicating alignment when arch integrity has been disrupted by premature loss of primary molars, 42 it is often desirable to supervise the eruption sequence and positioning of the permanent teeth during the transitional occlusion. The review of normative arch dimen- sional changes revealed that extra space is actu- ally available within the overall arch prior to the transition of the buccal dentition as represen- ted by the size difference between the primary canines and molars vs. the permanent canines and premolars. 1 This leeway space represents a 1.7-mm space on average in each lower qua- drant (overall 3.4 mm) and provides some potential for the relief of lower incisor crowding. Gianelly, 9 in a study of 100 mixed dentition children presenting for orthodontic needs, reported that 85 patients showed lower incisor crowding on an average of 4.4 mm, a level of crowding notably greater than the normative average of about 2 mm. Gianelly 9 calculated via space analysis that leeway space would provide adequate room to accommodate an aligned dentition in 72% of the cases presenting with incisor crowding. It is important to note that leeway space is most directly related to the size difference between second primary molars and the successor second premolars. This E-space approximates to 23 mm in compara- tive widths, and these are the last teeth to nor- mally transition in the lower buccal segment eru- ption sequence. 43 Thus, the control of leeway/ E-space through space supervision and guidance Figure 1. Dimensional changes show an average increase in lower intercanine width of 23 mm (range of 0 5 mm) during incisor transition, with no other increases in the lower intercanine width noted after the lower lateral incisors have fully erupted by 8 years of age. The normative nding is a resulting average lower incisor crowding of 1.5 mm, with a SD of 1 mm. Thus, lower crowding in the range of 14 mm should be expected in the majority of mixed dentition children at 89 years of age. Figure 2. Lower arch length decreases signicantly on exfoliation of the lower second primary molar as the permanent rst molars shifts forward toward the available E-space. The decrease of 23 mm in each lower quadrant translates to an arch perimeter decrease of 46 mm during this late mesial shift transition period. Space supervision and guidance of eruption 19 of eruption techniques offers potential oppor- tunities for the clinician to signicantly improve tooth sizearch size adjustments for the relief of typical levels of dental arch crowding that present in the mixed dentition age child. Given this potential, diagnostic procedures to evaluate the overall space should be instituted to determine treatment alternatives whenever lower incisor alignment is disrupted by a lack of lower anterior space. Perhaps the most widely accepted diagnostic procedure used to evaluate available space is the use of a mixed dentition space analysis. While numerous mixed dentition ana- lyses have been reported in the literature, studies by Luu et al. 44 and Irwin et al. 45 would suggest that little clinically signicant differences exist between the different methods. If a selected space analysis indicates the overall arch peri- meter could accommodate or be within 23 mm of relieving the presented incisor crowding, the clinician should consider several options to faci- litate dentition adjustments through a sequenced and staged guidance of eruption plan with the timely use of available posterior leeway space. Stage 1Eruption guidance in the mandibular incisor segment (69 years of age) Disking of primary canines The rst option considered when lower incisor crowding is in the range of 24 mm is disking of the primary canines to reduce their mesiodistal diameter in providing additional space to improve the position of the adjacent permanent incisors. The technique of reducing the width of primary canines to provide space for incisor alignment was likely rst introduced in 1851 by Linderer 46 and re-introduced by Hotz 3 in the 1960s. Other clinicians have subsequently presented the concepts of disking both mesial and distal surfaces of the primary canines to enhance the space dimensions for lower incisor alignment. 4751 The disking procedures work best when the malpositioned permanent incisors are displaced lingual to the anterior arch form (Fig. 4). The disking of the mesiolingual corner of the primary canines provides a sluiceway for the lingually positioned incisors to slide forward under the muscular pressure of the tongue. Bilateral disking of the mesiolingual aspect of the primary canines readily provides space of 1 mm and up to 2 mm per side for incisor unraveling (24 mm overall). With proper slicing of the mesiolingual corner of the primary canine at the gingival contact area with the lateral incisor, there is the potential for no measurable encro- achment on the overall leeway space in the quadrant. Labial movement of the lingual dis- placed incisors may actually increase the midline arch length and overall arch circumference as the arch form is rounded out in a forward direction by the action of the tongue. 51 While some clinicians disk the distal surfaces of the primary canines as well as mesial surfaces Figure 3. An increase in lower arch perimeter during the 2-year incisor eruption period (Incage 68 years) is related to increase in intercanine width associated with incisor transition and counter-balanced arch length adjustments. A stable period of arch dimensions follows during the mid-mixed dentition (811 years) until a dramatic decrease in arch length of 23 mm per side is associated with turnover of the buccal dentition, specically second primary molar exfoliation. The resultant decrease in arch perimeter associated with the late mesial shift period (LMS1112 years of age) is on the order of 45 mm. Bell and Sonis 20 to allow more displacement of the intercanine distance, this tends to result in encroachment on the leeway space as a long-term consideration. In the case of labial malpositioned incisors, while disking may provide additional room for incisor alignment, the lips are a more signicant factor in the balance between muscular forces such that the result is a lingual attening of the anterior segment rather than improved incisor position- ing and an associated decrease in overall arch space. In addition to lingual displacement of the incisors and crowding in the range of 24 mm as indicators for a favorable disking outcome, the general guidelines and recommended proce- dures for successful disking of primary canines are as follows: 1. Local anesthesia (block, inltration, or topical anesthetic compound) may be required as the canine must be sliced subgingivally to com- pletely free the contact area. Disking just the crown is not adequate as the contact area is subgingival. Placement of a wedge is some- times necessary to protect the lateral incisor and access the contact area. Thirdly, dentin exposure is usually necessary to reduce the primary canine width adequatelyanother indicator for local anesthesia or nitrous oxide support. Coordinating with restorative work requiring anesthesia in the area may be benecial in treatment planning. 2. A tapered ssured bur (#699 or #169) to allow effective tooth reduction and access without injury to adjacent permanent teeth is recommended. Re-approximating diamond disks or strips at this stage of development is not recommended due to risk of soft tissue injury. Emphasis on the mesiolingual corner of the primary canine rather than the straight mesial surface is facilitated with tapered ssure burs. 3. Timing is critical to allow ease of access and optimal tooth positioning response. Given the normative intercanine width increases during lateral incisor eruption, disking should be delayed until wedging effects of erupting incisors and arch width increases are realized. Disking is best around 7 to 8 years of age in proximity to the completion of lateral incisor eruption. The primary canine roots should be relatively intact without ectopic resorption changes from the erupting lateral Figure 4. Disking the mesiolingual angle of lower primary canines provides additional space for an improved alignment of the permanent incisors without overly encroaching on leeway space. Two examples of primary canine mesiolingual disking and the favorable response in terms of incisor alignment are shown. Top images shows one- time disking using #169 tapered ssure bur and response at 1-year follow-up. Bottom images represents two sequential disking proceduresrst at initial presentation and second at the child 0 s 6-month recall visit. Space supervision and guidance of eruption 21 incisors or due to the eruption timing of the lower permanent canines. Extraction/ectopic loss of primary canines Most often manifest in a signicant tooth size arch size discrepancy of 4 mm or more in the incisor segment, early ectopic loss of a single lower primary canine or even bilateral canine loss through displaced eruption of permanent lateral incisors is a signicant indicator for a thorough orthodontic evaluation (Fig. 5). The ectopic loss of a lower primary canine unilaterally is frequently followed by lingual and distal movement of the incisor segment with shifting of the dental midline toward the side of the pre- mature primary canine tooth loss. The disruption in arch integrity further compounds normal space use for eruption of the permanent cani- nes and premolars in subsequent development. The early bilateral loss of both lower primary canines may allow maintenance of midline and arch symmetry, but ultimately results in signicant lingual retroclination of permanent incisors, deepening of overbite, increased overjet, and bilateral loss of arch length over time. 5254 If one primary canine is lost ectopically during incisor eruption, it is usually desirable to extract the contralateral primary canine to maintain arch symmetry. 5256 While extraction of the contralateral primary canine may improve inci- sor alignment and midline integrity otherwise distorted by the asymmetric anterior space, the early loss of both primary canines will mimic the response seen when bilateral primary canines are ectopically lost. The result will be lingual retro- clination of the permanent incisors, deepening of the overbite, increased overjet, and bilateral loss of arch length. In either scenario of unilat- eral or bilateral loss, alignment problems pro- ducing ectopic loss of primary canines are strong indicators of a signicant incisor liability and arch length deciency that will likely become grossly evident upon permanent canine and premolar eruption. Much more frequent than ectopic loss of lower primary canines, the canines most often remain in the mixed dentition arrangement with the permanent incisors erupted with a crowded malposition. While Figure 5. Unilateral ectopic loss of a lower primary canine typically results in an asymmetric space loss as the incisors shift toward the side of loss and move lingually (A and B). Bilateral ectopic loss of lower primary canines (C and D) allows maintenance of arch symmetry, but results in signicant lingual retroclination and supraeruption of the lower incisors, increased overjet, deepened overbite, and reduction in overall lower arch dimensions. Bell and Sonis 22 disking of the primary canines as described is the procedure of rst choice, elective extraction of the primary canines in an attempt to maintain arch symmetry, coincident midlines, and incisor positional integrity can be considered under cer- tain circumstances. Such intervention becomes more viable when the incisor crowding and lia- bility is greater than 4 mm or when the eruptive alignment and dental midline is signicantly skewed toward one side with a totally blocked incisor from the arch form (Fig. 6). The objective of lower primary canine extraction is to provide space in the arch for an improved incisor align- ment and to maintain midline symmetry with the thought that negative effects on the occlusion (i.e., lingual inclination of incisors, deepened overbite, increased overjet, and additional space loss) can be overcome through later orthodontic tooth movement. 50,54,56,57 This same concept is followed if a primary canine is lost unilaterally during incisor eruption and the contralateral primary canine is removed in an effort to main- tain midline symmetry. 53,54 The clinician must remember that early extraction of lower primary canines will mimic what happens with bilateral ectopic loss and will likely result in notable lower anterior arch collapse. 5557 Therefore, the extraction of primary canines should not be undertaken without parental understanding of the consequences and ideally, orthodontic con- sideration of the long-term implications to the occlusion. Some clinicians recommend the use of a lingual holding arch to control the incisor positioning and prevent encroachment on per- manent canine positions when lower primary canines are lost prematurely (Fig. 7). However, the displacement of the incisors attendant with ectopic loss or early extraction of lower primary canines typically contradicts the passive place- ment of a lingual holding arch at this stage without rst aligning the incisors with active appliance therapy. Early selective extraction of Figure 6. Extraction of lower primary canines. (A) Lingually positioned lateral incisors, dental shift to right, retained left primary lateral. Decision made to extract the primary canines. (B) A year latersymmetry of incisor alignment achieved at expense of arch length and perimeter through lingual and distal movement of the incisors. Figure 7. Loss of primary canineswhat about a lingual holding arch? Usually not that simple as incisors tend to align along LHA wire shaped to the most lingual position, i.e., loss of arch length as incisors drift distal and lingual along lingual wire into the canine space. Space supervision and guidance of eruption 23 primary canines goes beyond a simple rst step in guidance of eruption and actually represents the start of either a phased early treatment proto- col with arch expansion or a serial extraction program. In the context of a non-extraction treatment plan as part of rst-phase arch devel- opment, a 2 4 Edgewise setup to decompensate displacements and position the lower incisors forward into the proper arch form may be indi- cated. The goal of such 2 4 treatment in Phase 1 is to establish coincident midlines, normative overjet and overbite with the maxillary incisors, and increase arch dimensions for eruption of the buccal segment dentition to optimize the poten- tial for a long-term non-extraction treatment plan. After the incisor alignment has achieved the proper anterior positioning with the rst- phase mechanics, a lingual holding arch can be placed as a retainer for the achieved incisor antero-posterior (A-P) positioning (Fig. 8). Stage 2Guidance in mandibular canine/ rst premolar segment (age 1011 years) In patients aged 1011 years, panoramic evalu- ation of the exfoliation and eruption patterns of the posterior segment provides a particular site of assessment for timely mandibular guidance of eruption procedures. The clinician should take note of resorption patterns in the premolar area as well as desired molar adjustments and leeway space usage needed to achieve optimal align- ment while maintaining stable occlusal rela- tionships. In the usual eruption sequencing, the lower canine and rst premolar frequently erupt at approximately the same time frame of 1011 years of age. Since most of the leeway space is located in the size difference between the second primary molar and second premolar area, the canine and rst premolar are forced toward a mesial eruption path. 10,41 The resultant align- ment nds the permanent lower canines posi- tioned labial to the contact area of the lateral incisors with exacerbation of any anterior mala- lignment. To allow distal placement and to minimize malpositioning of the canine labial to the lateral incisor, extraction of the primary rst molar (and primary canine if exfoliating impro- perly) is considered around this time. Disking of the mesial surface of the second primary molar may provide additional space for distal position- ing of the erupting canine and rst premolar. One can utilize up to 23 mm of E-space with coordinated disking of the primary canines, selective extraction of primary canines and rst primary molars, and disking of the mesial surface of the second primary molars (Fig. 9). This second stage of intervention continues the guidance concept of unraveling lower anterior crowding toward the available posterior E-space. As long as the second primary molars are maintained in position as abutments against the fully erupted rst permanent molars during lower canine and rst premolar eruption, no measurable arch length changes should occur through mesial movement of the rst permanent molars. 33,34 As discussed, the major decrease in lower arch length occurs concurrent with exfo- liation of the second primary molar as the rst molar shifts forward (i.e., late mesial shift) into the available E-space. This forward shift of the molars upon loss of the second primary molars typically results in a decrease in lower arch length of 23 mm per mandibular quadrant. Particularly under the impact of erupting second permanent molars, the arch length decrease occurs rapidly from back to front before more anterior teeth can distalize into the available leeway space. Stage 3Guidance in mandibular second premolar/molar segment (age 1112 years) Hopefully, the eruption sequence has followed a normal canine-rst premolar-second premolar pattern so the clinician has had the opportunity to perform the suggested Stage 1 and Stage 2 guidance procedures with guided canine and rst premolar distal positioning along with relief of incisor malpositioning. The next critical tim- ing sequence in a staged guidance program occurs around 1112 years of age in association with the projected exfoliation of the second primary molars. The second premolars fre- quently take a path of eruption along the distal root of the second primary molar and eruption transition problems may occur. Occasionally, extraction of the second primary molar is indi- cated to allow normal eruption of the second premolar if such atypical patterns are noted. In addition to assessing the transitional patterns of the second premolars, consideration should be given to the placement of a lingual holding arch or a lip bumper concurrent with removal of the second primary molars (Fig. 10). If the available Bell and Sonis 24 Figure 8. Phase 1 2 4 arch developmentpre-treatment (upper left): arch changes associated with bilateral ectopic loss of lower primary canines and narrowed maxillary arch form. Upper 2 4 arch development supported by E-spyder expander to emphasize fan-like anterior expansion of maxillary arch (upper right). Tieback of NiTi archwires restrained upper incisors and resulted in some retraction. Lower 2 4 arch development using AW lock stopped sequential archwires (0.016 NiTi, 0.020 NiTi, and 0.020 SS) to advance lower incisors, correct midline discrepancy, and increase arch perimeter to accommodate leeway space adjustments (at 4 months). Active appliances removed at 7-month treatment time (lower left). Retention with upper transpalatal bar and lower lingual holding arch at 18 months post-treatment maintained achieved arch width and arch length changes. Note facial prole changes inuenced by correcting initial excessive overjet and lip interpositioning. Space supervision and guidance of eruption 25 Figure 9. Removal of primary rst molars concurrent with disking the mesial surfaces of second primary molars enhances distal eruptive positioning of the permanent canine and rst premolar as illustrated above on upper left. The case on the lower right had primary canines disked at 8 years and 4 months of age. After exfoliation of primary canines and rst primary molars, lower second primary molars were disked at 10 years and 8 months as the canines and rst premolars erupted. This continued the guidance concept of unraveling anterior crowding toward available leeway/E-space. B e l l a n d S o n i s 2 6 Figure 10. Control of late lower arch length decrease using lingual holding arches and selected extraction of second primary molars allows alignment of crowded lower incisors on the order of 34 mm as the buccal dentition (canines and premolars) erupt more distally into the leeway space maintained by the LHA. S p a c e s u p e r v i s i o n a n d g u i d a n c e o f e r u p t i o n 2 7 buccal segment space is tight, if the optimal use of leeway/E-space for crowding is desirable, and/ or if the second permanent molars are erupting before the second premolars, a lingual arch or lip bumper may be a critical element in controlling lower arch dimensions at this point. In the Gianelly article 9 on the value of leeway space as to treatment timing, lower crowding with an average discrepancy of 4.4 mm could be theoretically accommodated in 72% of the cases that presented with incisor crowding when the leeway space was calculated into a space analysis. Subsequent to that article, treatment-based articles have documented dra- matic and positive alignment effects in the timely use of passive lingual holding arches (LHA) for control of lower leeway space in the late-mixed dentition. 10,11,1416 These LHA studies, individ- ually reviewed and presented chronologically, consistently show that a passive lingual holding arch placed in conjunction with selected removal of second primary molars will stabilize perma- nent rst molars from forward mesial drift, minimize lingual movement of lower incisors, and allow canines and premolars to erupt distally as much as 12 mm into the held leeway space. Such leeway space control has been shown to result in reductions of up to 24 mm in lower incisor irregularity as a consistent nding. DeBaets and Chiarini 10 reported on arch changes in 39 mixed dentition cases with lower anterior crowding treated with passive lingual arch therapy and selected removal of primary molars. Changes over a 4-year period were compared to a matched group of 60 untreated children with similar crowding who received no space supervision. In untreated subjects, lower canine and premolar mesial displacement occurred upon eruption with resulting overlap of the already crowded lower incisors that worsened the anterior displacement. In lingual arch sub- jects, lower anterior crowding decreased an average of 34 mm through the period of second permanent molar eruption. Lower arch length decreased less than 1 mm in children with lingual arches while permanent canines and premolars erupted an average of 1.5 mm (up to 3.5 mm) more distally per side than controls. In sum, the control of molar shifting and sustained arch length using lingual arches allowed spontaneous alignment of crowded lower incisors as the den- tition distalized into the maintained leeway space. Dugoni et al. 11 published similar ndings from 25 mixed dentition patients with reductions in lower incisor crowding greater than 3 mm demonstrated after placement of passive lingual arches and selected primary molar extractions. After an average long-term post- retention period of 10 years, 19 of the 25 patients continued to show clinically satisfactory lower anterior alignment. Compared to 10-year follow- up of orthodontically aligned patients, these results show reductions in lower incisor crowding and long-term stability of the alignment with lingual arch therapy that was greater than or at least equal in effectiveness to active orthodontic treatments. Rebellato et al., 14 assessing cephalograms, study models, and tomograms of the mandi- bular body, reported on arch dimensional chan- ges in 30 mixed dentition patients presenting with incisor crowding of 3 mm or more. In 14 patients treated with passive lingual arches, the arch length did not measurably change over the course of the eruption of the succedaneous teeth while an average arch length decrease of 2.5 mm per side was demonstrated in 16 untreated children used as controls. The arch length changes were related to rst molars moving forward 1.7 mm in the control group compared to only 0.3 mm in the lingual arch group. Concurrently, incisors tipped forward slightly in the lingual arch group (0.4 mm), while lingual uprighting of incisors in the con- trols reduced arch length by 0.65 mm. In sum, the action of the lingual arch was to reduce mesial molar migration and incisor lingual move- ment in controlling the quadrant arch length of 2.49 mm per side compared to non-LHA con- trols. The additional bilaterally sustained arch length resulted in concurrent relief of 34 mm of lower incisor crowding in treatment subjects. Brennan and Gianelly 15 quantied the arch dimensional changes in 107 consecutive mixed dentition patients treated with passive lingual arches through eruption of all succedaneous teeth. Occasional extraction of second primary molars to facilitate eruption of premolars and canines was the only other intervention. Arch length decreased an average of 0.4 mm in the lingual arch patients while arch width increased slightly. The patients presented an average 4.4 mm of total available lower leeway space, which resulted in an average decrease in lower Bell and Sonis 28 incisor crowding from a pre-treatment level of 4.8 mm to 0.2 mm of space post-treatment. The space adjustments were enough to resolve incisor crowding completely in 65 of the lower crowding subjects (roughly 60%). An additional 16 subjects (one in six) had a nal discrepancy of less than 1.0 mm and 13 subjects (one in 10) had a nal discrepancy of less than 2 mm. Only 14 patients (13%) had crowding greater than 2 mm after the full buccal segment eruption was complete. Of note, the majority of patients with higher levels of post-treatment crowding pre- sented with initial ectopic loss of the lower pri- mary canines. In sum, a passive lingual arch with selected removal of primary teeth provided adequate space and eruption guidance to relieve signicant lower incisor crowding in 105 of the 107 subjects. Villalobos et al. 16 reported on 23 patients treated with lingual arches between 10 and 12 years of age compared to 24 matched untreated subjects. Molar and incisor movements were restricted to about a one-half millimeter arch length decrease for the 18 months of lingual arch wear while untreated subjects had a decrease of 2 mm in arch length. The lingual arch also limited rst molar extrusion by about 2 mm compared to non-LHA patients. The study con- cluded that the lingual arch was effective for preservation of arch length and control of ver- tical eruptive movements of banded molars. The cited consecutive and chronologic LHA studies consistently conrm that arch length remains relatively constant or decreases minimally in patients treated with a passive lingual arch in the late transitional mixed dentition period. Forward movement of the lower rst molars and lower incisor lingual movement is reduced notably in accounting for the relative stability of arch length which in turn contributed to approximately 4 5 mm greater arch perimeter than would have been available after normative arch dimensional adjustments in the late transitional dentition. The additional buccal segment space allowed distal eruptive positioning of the lower canines and premolars with a positive inuence on relief of incisor crowding in the range of 34 mm. Thus, the timely use of lingual holding arches and selected extraction of primary molars in the manner described utilizes the leeway space for the relief of typical lower crowding amounts that present in the mixed dentition for about two- thirds to three-fourths of patients. These num- bers are in line with the percentages predicted by Gianelly in his original work 35 and are conrmed in the clinical studies reviewed. 1016 Similar to lingual holding arches for the pres- ervation of lower leeway/E-space, Woods 58 reported on the treatment of 182 late-mixed dentition patients using segmented 2 4 appli- ances to manage leeway space supervision. All 182 patients were started in treatment while second primary molars remained and possessed potential available E-space for relief of crowding. In all cases, upper and lower 2 4 appliances using segmental tip-back archwires were applied to control molar adjustments and incisor alignment. Buccal segments were bracketed and aligned to include second molars upon eruption with an average total treatment time of 28 months. The actual bilateral E-space measured directly from models represented a mean of 4.2 mm, with a range of 1.6 mm. The actual mandibular space requirements averaged 2.6 3.0 mm. About two- thirds of patients had 4 mm or less of crowding, another 25% had 48 mm of crowding, and for about 10%, the crowding was greater than 8 mm. The 2 4 setup followed by sequential full appliances controlled arch dimensions such that the mean change in arch depth was 1.4 mm after treatment was completed. Molars were held back and the lower incisors tipped forward less than 1 mm on average. Canine arch width increased a mean of 0.9 mm. The greater the initial crowding was, the greater the dimensional changes. In most patients with approximately 4 6 mm of crowding, the control of E-space and the anterior Edgewise changes accommodated den- titional alignment. Thus, starting treatment in the late-mixed dentition using a sequenced 2 4 setup allowed the use of E-space and minimal anterior expansion needs to provide about 4 6 mm of space for aligning the mandibular den- tition. Weinberg and Sadowsky 59 reported that similar amounts of arch dimensional changes were found in 30 Class I comprehensive orthodontic patients started in the mixed dentition for the resolution of mandibular arch crowding. The phased Edgewise treatment results represent similar dimensional values as reported with the use of lower lingual holding arches for molar and incisor control. An alternative to lingual holding arches for E-space preservation is the use of a lip bumper or Space supervision and guidance of eruption 29 lip shield in the late transitional dentition to enhance the forward positioning of the incisors, hold the rst molar positioning, and allow some arch development as the buccal segments tran- sition into the adolescent dentition (Figs. 11 and 12). 6070 Primarily acting through incisor pro- clination (about 2 mm on average) as a result of altered muscle equilibrium between the lip and tongue, the lip bumper approach also pro- vides distalization or holding forces against the banded molars to hold leeway space. The molar effects are primarily a result of distal crown tip- ping and not through a true molar bodily dis- talization. Approximately 1 year of lower lip bumper wear appears to be necessary to gain 2 3 mm of arch length beyond the available leeway space. Additionally, evaluation of lip bumper wear over the transition time of canine and premolar eruption indicates that transverse arch width increases of about 13 mm at the canines Figure 11. Case exampleRemovable lip bumper. Lip bumper placed as lower second primary molars exfoliated at age 11 years and 6 months. Bumper placement low in vestibule provided holding force on molars while allowing lip to contour over the bumper to lessen incisor labial movement. After 8 months of bumper wear (age 12 years and 2 months), a signicant relief of anterior crowding resulted. Edgewise appliances aligned the dentition into the established arch form. Bell and Sonis 30 and 45 mm at the molars are possible. Such increases in arch dimension along with mod- ications in muscle function are in turn asso- ciated with improved anterior alignment and more laterally developed arches during the active phase of lip bumper treatment. The application of lip bumpers in the late-mixed dentition offers an arch development technique when forward movement of the incisors can be tolerated, when distal uprighting and/or anchorage stabilization of the molars would enhance overall arch length, and when an increase in arch circumference might be signicant in relieving moderately crowded incisor levels that are beyond simple leeway space preservation with lingual holding arches. Given the reported record of mandibular expansion approaches with an almost inherent tendency to return toward pre-treatment levels, Figure 12. Case exampleSoldered lip bumper placed before second primary molars exfoliated. Bumper positioned at cervical margins provided holding force on molars, reduced lip contact on incisors to enhance labial movement. At 6 months (12 years and 5 months), lower crowding reduced through distal movement of canines and premolars toward E-space, with some arch expansion. Edgewise appliances aligned dentition with retraction of buccal segments and establishment of a broader arch form. Space supervision and guidance of eruption 31 the realization of long-term stability without a structured retention program seems ques- tionable, though the altered functional envi- ronment does offer some advantages over more direct mechanical lower expansion approaches (e.g., Schwarz plates). 70 The complications of conventional xed appliance therapy rarely manifest themselves in the limited appliance approaches of mixed denti- tion guidance of eruption treatment mechanics. However, preservation of the E-space is not a totally benign intervention. By preventing the late mesial shift of the lower rst permanent molars, less posterior arch length is available for the erupting mandibular second permanent molar with a resulting increase in second molar eruption problems. A study by Sonis and Ackerman, 71 in examining 200 patients having undergone E-space preservation with a passive lingual arch for second molar eruption prob- lems, reported that 29 patients had at least one impacted second molara four- to ve-fold increase over normative population reports of impacted lower second molars. A signicant relationship was found between the mandibular rst permanent molar and permanent second molar angulation patterns and likelihood of impaction. An intermolar angulation created by the long axis of the rst and second molar of 241 or greater resulted in a positive predictive value of 1, indicating a high risk of impaction. A similar study by Rubin et al. 72 found that those patients treated with a xed lingual arch for E-space preservation had a 4.7% impaction rate of sec- ond molars, which was associated with an increased intermolar angulation and reduced space distal to the rst molar. Consequently, the prudent clinician observing this relationship will inform the patient of a likely increased length of treatment. Summary of age-appropriate and staged guidance of eruption concepts The control of leeway/E-space adjustments in terms of inuencing arch dimensional changes through various space supervision, and guidance of eruption techniques offers opportunities to signicantly improve lower tooth sizearch size discrepancies in the mixed dentition. The relief of typical levels of lower arch mixed dentition crowd- ing (i.e., less than 34 mm in the mandibular arch) involves a timely, age-appropriate, sequen- ced, and staged protocol involving the following: (1) Preservation of inherent arch dimensions through a comprehensive preventive, restor- ative, and space maintenance oversight pro- gram to optimize the integrity of the primary and the mixed dentitions throughout the transitional periods. (2) After incisor eruption is complete, the aver- age lower alignment shows crowding of 1.5 1.0 mm. No subsequent growth changes will increase lower anterior canine-to-canine arch dimensions. The preferred approach during active incisor transition is to allow any wedging effect of eruption to inuence arch dimensions. After lateral incisor erup- tion is complete at 8 years of age, what you see is what you get! NOW is the time for Stage 1 decision as to no intervention necessary, accept as is, disking of the primary canines, extraction of primary canines, or Phase 1 arch development. (3) Selected disking of primary canines to enhance incisor positions when crowding is in the range of 24 mm and the lower incisors are lingually malpositioned to the arch form is the rst choice of intervention, especially in deepbite/brachyfacial occlusion patterns. If intercanine space can be ne- tuned with disking, tongue pressures will tend to position the lingually displaced incisors forward into an enhanced arch form alignment. Intercanine space of 12 mm per side for incisor alignment can be achieved by disking the mesiolingual corner of the primary canines to provide sluiceway for incisor alignment once the lateral incisors are erupted (usually around 7 to 8 years of age). (4) Decompensation of severe lower incisor malpositioning, midline asymmetry associ- ated with ectopic eruption patterns, and lower incisor crowding at a level where removal of lower primary canines is required to allow proper incisor alignment integrity (greater than 34 mm of liability). Clinicians must understand and relate to the parent that the necessity of early primary canine extraction indicates a signicant tooth size arch size problems. It is frequently step one of a serial extraction program, particularly in Bell and Sonis 32 vertically sensitive dolichofacial patterns. The negative effects with lingual collapse of incisors, arch length loss, deepening of bite, and increased overjet all are signicant detriments in brachyfacial cases. Such levels of tooth sizearch size discrep- ancy may indicate the need for an early Phase 1 intervention using Edgewise 2 4 mechanics to position incisors and molars toward favorable Class I relationships, with incisor integrity, midline coincidence, and normal overbite and overjet. Crowding and incisor positioning discrepancies requiring canine extraction or extensive arch expan- sion to relieve incisor crowding and offset negative effects of space loss are candidates for early 2 4 intervention, and it generally implies a long-range non-extraction protocol as compared to a situation where the extraction of the primary canines is the rst step in a serial extraction plan. The amount of crowding discrepancy and facial type are critical factors in the decision-making proc- ess as to long-term extraction vs. non-extrac- tion plan. Brachyfacial deepbite patients lead to a prioritized arch development with arch expansion to enhance facial balance. Doli- chofacial openbite patients tend to be directed toward a serial extraction protocol that is much more likely to offset vertical facial imbalance. (5) Consideration of selective disking of the mesial surface of the second primary molars to enhance more distal eruptive position- ing of the permanent canines and rst premolars. (6) Timely use of passive lingual holding arches, lip bumpers, and/or late-staged Edgewise setups along with selected extraction of second primary molars to provide space for relief of typical lower crowding amounts (2 4 mm). The space control allows canines and premolars to erupt in more distal positions than under normal transitional patterns. This driftodontics of the buccal segments will in turn result in more intercanine distance for relief of incisor malpositioning in about two-thirds to three-fourths of patients. In keeping with the idea of super- vising space changes in the late transitional dentition, patients should be evaluated before the transition of the buccal teeth in each arch. A good clinical guide for timing is upon the clinical emergence of the lower canines and rst premolars around 1011 years of age. These teeth erupt about 1 year ahead of the nal buccal segment transition, leaving adequate time to assess dimensional needs and plan treatment interventions for the relief of crowding. The dimensional parameters presented through optimal use of available leeway space in the transitional dentition provide the devel- opmental potential for a non-extraction protocol as an achievable priority in the majority of chil- dren. 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