Orthodontics

Padhraig S Fleming

Ama Johal and Andrew T DiBiase

Managing Malocclusion in the

Mixed Dentition: Six Keys to
Success Part 1
Abstract: Indications of developing malocclusion are often present in the mixed dentition. With judicious supervision and timely
intervention their effects can be minimized. The general dental practitioner is ideally placed to recognize, manage and correct many such
incipient problems. This first of two papers considers three keys to success involving, normal dental development, deviations from normal
eruption patterns, crossbite correction and habit cessation.
Clinical Relevance: The appropriate management of developing malocclusion may simplify later orthodontic management or indeed
make such intervention unnecessary.
Dent Update 2008; 35: 607-613

Orthodontic treatment is not without the United Kingdom.4 With regular recall intervention to address excessive overjets
biological risk and entails significant time strategies the general dental practitioner is has proven no more effective and less
and financial commitments for patients perfectly placed to identify and occasionally efficient than postponing treatment until
and providers.1 Interceptive orthodontics correct developing occlusal problems in the adolescence.5 The primary indication for
constitutes any measure performed mixed dentition. early intervention in such cases remains
to correct a developing malocclusion It is important to note, however, psychosocial problems and teasing.6
or simplify later orthodontic care.2 It that most definitive orthodontic treatment Likewise, significant arch expansion to
has been suggested that developing is commenced in the late mixed dentition alleviate crowding in the mixed dentition
problems in the mixed dentition could be or early permanent dentition. Earlier has proven unstable.7 Consequently, it is
fully corrected with simple interceptive
treatment in 15% and improved in 49% of
cases.3 As such, routine implementation
of simple interceptive measures would Typical Eruption Range (Years) Maxillary Mandibular
be very welcome, particularly as demand Date (Years)
for treatment outstrips our ability to
provide timely treatment in many parts of
6 67 First molar
6 67 First molar
6 67 Central incisor
Padhraig S Fleming, MOrth RCS
7 78 Central incisor
BDentSc(Hons), MSc, MFDS RCS, MFD RCS,
Senior Registrar in Orthodontics, Royal 7 78 Lateral incisor
London Dental Institute, Ama Johal, 8 89 Lateral incisor
BDS(Hons), MSc, PhD, FDS RCS, MOrth, 10 910 Canine
FDS(Orth) RCS, Senior Lecturer/Consultant
10 1012 First premolar First premolar
Orthodontist, Royal London Dental
Institute, Andrew T DiBiase, BDS (Hons), 11 1012 Second premolar Second premolar
MSc, MOrth, FDS(Orth) RCS, Consultant 11 1112 Canine
Orthodontist, Maxillofacial Unit, Kent and
Table 1. Timing of eruption (after Savara and Steen18).
Canterbury Hospital, Canterbury, UK.
November 2008 DentalUpdate 607

pg607-613 Managing malocclusion 1.indd 1 5/11/08 14:28:29

 Orthodontics
a b
Figure 1. (a, b) Early mesial shift in an open
primary dentition.
a b
Figure 2. (a, b) Late mesial shift in a closed primary dentition.
felt that interception in the mixed dentition
should be confined to situations where
minimal intervention can be of the greatest
proven benefit.
This two-part paper will discuss
Figure 3. Gingival recession related to an anterior normal occlusal development and provide
crossbite with mandibular displacement. guidance on appropriate measures to
address specific occlusal problems likely
to present in the mixed dentition stage of
dental development.
Normal occlusal development
in the mixed dentition
In order to recognize occlusal
anomalies, an appreciation of normal
occlusal development in the mixed
dentition is necessary. The mixed dentition
phase spans the period from eruption of
the first permanent tooth at 56 years
Figure 4. Design of typical upper removable to exfoliation of the last primary tooth at
appliance to address anterior crossbite. Retentive 1213 years, with a variation of up to 18
components: Adams cribs 6/, /6; ball-ended clasps months being considered normal. Common
DE/, /DE; active component: Z-spring; other eruption sequences and timing are given in
feature: posterior capping. Table 1.
608 DentalUpdate
pg607-613 Managing malocclusion 1.indd 2
Typically, first permanent molars
erupt into a half unit two molar relationship
being guided by the flush terminal plane
between the second primary molars seen in
76% of individuals in the primary dentition.8
A Class I molar relationship may develop
naturally by early or late mechanisms
(Figures 1 and 2). Early establishment of
a Class I molar relationship arises due to
mesial migration of the mandibular first
molar in the open mixed dentition to close
the primate spacing present distal to the
lower primary canines. The later mechanism
occurs in an unspaced dentition following
loss of the second primary molars as the
permanent dentition becomes established.
This facilitates greater mesial migration of
the lower first molar as there is a greater
discrepancy between the mesio-distal
widths of the lower deciduous molars and
the succeeding premolars than is the case
in the upper.2
The eruption of the permanent
incisors is normally accompanied by a
transient anterior open bite prior to their
complete eruption. Crowding of the incisors
is typically seen as the combined widths of
the permanent incisors is 7 mm and 5 mm
greater than their primary predecessors
in the maxillary and mandibular arches,
respectively.9 Resolution of this crowding
can occur naturally, during development,
through a variety of mechanisms, including
an increase in inter-canine dimension,
increased arch length due to proclination
of the permanent incisors, and closure of
primate spacing.
Transient lateral fanning of
permanent maxillary incisor teeth, known
as the ugly duckling or Broadbent stage,
occurs prior to eruption of maxillary lateral
incisors and canine teeth. An accompanying
maxillary midline diastema prior to eruption
of the maxillary canines is also regarded
as physiological. Intervention to address
this spacing prior to eruption of maxillary
canines is therefore unjustified.10
Eruption of the canines and
premolars usually occurs between 9 and
13 years of age. Where significant crowding
is present, the available space is used
on a first come, first served basis with
resultant impaction of the canines and
second premolars being common.2 Primary
crowding may cause displacement or buccal
impaction of maxillary canines in particular.
Secondary crowding typically arises in
November 2008
3/11/08 10:51:13

Figure 5. Anterior crossbite with both maxillary
central incisors in crossbite.
the maxillary and mandibular second
premolar region as a result of the early
loss of their predecessors and subsequent
mesial migration and rotation of the first
permanent molar.
Key 1: Correct crossbites with
associated displacement early
Anterior crossbites are a
common finding in the mixed dentition
with maxillary lateral or central incisors
in lingual occlusion.11 Indications for
correction include: aesthetics, with anterior
crossbites giving rise to the development
of a Class III profile; occlusal trauma,
significant incisal wear can occur; and
periodontal damage with loss of clinical
attachment in the lower incisor region as
a result of continued forward mandibular
displacement (Figure 3). A weak association
has also been shown between posterior
crossbites with displacement and
temporomandibular joint dysfunction.12 It
has also been suggested that subjects with
untreated displacements may posture to
avoid the displacement.13 This deliberate
movement later becomes habitual with
asymmetric muscular activity.
Correction of anterior crossbite
may be achieved with fixed14 or removable
appliances. The simplest method involves
provision of an upper removable appliance,
with posterior capping to disengage the
occlusion and T- or Z-springs made from
0.5 mm stainless steel to procline the
involved maxillary incisor (Figure 4).
A simple fixed appliance system
(two-by-four appliance) can be used with
less dependence on patient compliance,
allowing more controlled tooth movement,
and may be more appropriate if more than
one incisor is in crossbite (Figures 57).
November 2008
pg607-613 Managing malocclusion 1.indd 3
Orthodontics
Figure 6. Fixed two-by-four appliance to address
the anterior crossbite and detail the incisor Figure 7. Treated result with adequate overbite
position. for stability.
Irrespective of the mechanics used, the
stability of the result depends on achieving
a positive overbite of one-third to one-half
of the corresponding lower incisor.
Anterior crossbites with two or
more teeth in crossbite, or the presence
of reverse overjet in the absence of a
functional displacement, may signify a
problem of skeletal origin. Such instances
require specialist referral to assess the
nature and magnitude of the skeletal Figure 8. Design of simple upper removable
discrepancy. Growth modification with appliance to address posterior crossbite. Retentive
functional appliances or maxillary components: Adams cribs 6/, /6; ball-ended clasps
protraction devices may be attempted DE/, /DE; active component : midline expansion
to address the antero-posterior skeletal screw; other feature: posterior capping.
discrepancy where a significant skeletal
component to the malocclusion exists.
Early referral is desirable in such cases
as maxillary protraction, using face-
mask therapy, is thought to be most
successful when performed in the early
mixed dentition.15 Patients treated in this
way in the late mixed dentition may still
benefit from the treatment, but to a lesser
extent. Early treatment produces more
favourable post-pubertal modifications in
both maxillary and mandibular structures,
Figure 9. Eruption of maxillary lateral incisor prior
whereas late treatment may only redirect
to the central incisor.
mandibular growth, with greater degrees of
dental change being observed.15
Posterior crossbites in the mixed
dentition may be corrected to prevent disengage the occlusion (Figure 8). The
them from becoming established in the elimination of a contributory digit-sucking
permanent dentition.16 This treatment may habit is essential to achieve stable posterior
be performed using a variety of mechanics, crossbite correction (See Key 3).17
from grinding of premature occlusal
contacts to active appliance therapy with
fixed or removable appliances. The simplest Key 2: Monitor eruption
method to address a posterior crossbite patterns and timing
involves an upper removable appliance, Variation in the pattern and
with a midline screw permitting transverse timing of eruption is seen as the norm. A
expansion of up to 1 mm per week and longitudinal study in America noted that
the inclusion of a posterior bite plane to the most common eruption sequence
DentalUpdate 609
3/11/08 10:52:03
 Orthodontics
Figure 10. A lateral cephalogram showing the central incisor to be present but severely dilacerated.
Figure 11. Panoral radiograph showing mesially-impacted maxillary first molars.
occurred in only 13% of those examined,
with earlier and more variable eruption
seen in girls.18 Nevertheless, gross changes
in the sequence of eruption, delayed
eruption of 2 years, or more and asymmetric
eruption of teeth may warrant further
investigation.
Teeth most commonly
associated with abnormal eruption include
maxillary canines (Key 5), central incisors
and first molars.
610 DentalUpdate
pg607-613 Managing malocclusion 1.indd 4
The absence of a maxillary
central incisor from the mouth while its
antimere is erupted 6 months or more
(Figures 9, 10), or the eruption of maxillary
lateral incisors prior to central incisors,
warrants further investigation.19 The most
common cause of impeded eruption
of a maxillary incisor is a barrel-shaped,
tuberculate supernumerary tooth, which
typically develops palatal to the developing
incisor, preventing its eruption.20 Prompt
referral may allow early removal of the
supernumerary tooth, facilitating natural
eruption of the impacted incisor in up to
90% of cases, provided adequate space is
available in the arch.21,22 Where referral is
delayed, root formation of the impacted
incisor may be advanced, reducing the
potential for natural eruption making
mechanical orthodontic traction necessary.
Mesial impaction of the
maxillary first molar into the second
primary molar occurs in 26% of children
and may be linked to crowding or Class III
malocclusion (Figure 11).23 Spontaneous
correction may occur, although this rarely
happens after 8 years of age. Mild cases may
be managed initially with brass separating
wires or orthodontic elastomeric separators
to disimpact the tooth. Deleterious
sequelae of an unrecognized problem may
include caries, pain, pulpitis, and abscess
formation, as well as premature loss of
the second primary molar, with resultant
space loss leading to potential impaction
of the second premolar. This can produce
a localized malocclusion necessitating
orthodontic correction and space creation
involving extraction of permanent teeth or
extra-oral traction.
Impaction or ectopic eruption
of mandibular second premolars is
almost invariably related to early loss of
its predecessor, loss of the leeway space
and crowding. Rarely, ectopic eruption of
second premolars may follow infraocclusion
of second primary molars; however, the
premolar typically erupts within six months
of the expected timeframe.24 Consequently,
where the permanent successor is present,
extraction of second primary molars is not
usually indicated.
Key 3: Dissuade aberrant habits
Signs of digit-sucking are
common in the mixed dentition, being
seen in 12% of 9-year-olds and 2% of
12-year-olds.25 Effects of digit-sucking
are related to frequency, intensity and
duration of the habit.26 Persistent digit-
sucking for 6 hours daily is associated with
significant malocclusion. The association
between non-nutritive sucking habits and
malocclusion is undisputed, with 61% of
10-year-olds with a persistent habit having
co-existing malocclusion, while only 31%
of those without such a habit are similarly
November 2008
3/11/08 10:55:51
 Orthodontics
Figure 12. Anterior open bite related to digit-
sucking.
affected.27 Specific effects are mediated by
the position of the digit and tongue. The
tongue occupies a lower position away
from the palatal vault, causing transverse
constriction of the maxilla. Associated
abnormalities may include:28
Increased maxillary and relative
prognathism;
Increased maxillary length;
Proclination of maxillary incisors;
Retroclination of mandibular incisors;
Increased overjet;
Reduced overbite;
Unilateral posterior crossbite.
Conservative methods of habit
dissuasion are a simple yet vital strategy,
which should be attempted before
resorting to orthodontic appliances. There
is no consensus as to which method is
more effective, but non-physical methods
should be attempted first, with patient
and parent education a key to success.29
Non-invasive methods include positive
reinforcement by reward, habit reversal
where the child is taught to carry out an
alternative activity when the urge to suck
arises, and reframing. Reframing turns
habit into duty by suggesting that all the
other fingers are being neglected and all
fingers must be sucked for an equal length
of time.29 Other possibilities include the
use of plasters, gloves or bitter-flavoured
agents applied to the digit to make the
habit less satisfying. These non- invasive
techniques should be attempted for 36
months.
Where the habit persists, simple
fixed orthodontic appliances including
palatal arches with one of a variety of
projections including inverted goalposts,
beads or cribs may be used for 6 to 12
months to excellent effect.30 The use of
removable orthodontic appliances may
612 DentalUpdate
pg607-613 Managing malocclusion 1.indd 6
Figure 13. Resolution of malocclusion following
habit cessation and placement of a dissuader
appliance.
also be effective in these cases; however,
they are heavily influenced by compliance31
(Figures 1214).
Conclusions
The general dental practitioner
is ideally positioned to monitor dental
development. This paper highlights three
key areas, which should be considered
during occlusal management in the mixed
dentition and offers guidance on simple
measures to address these problems or
to prevent a significant malocclusion
developing in the permanent dentition.
References
1. Ellis PE, Benson PE. Potential hazards
of orthodontic treatment what your
patient should know. Dent Update 2002;
29: 492496.
2. Richarson A. Interceptive Orthodontics
4th edn. London: BDJ Books, 1999.
3. Ackerman JL, Proffit WR. Preventive
and interceptive orthodontics: a strong
theory proves weak in practice. Angle
Orthod 1980; 50: 7587.
4. Chestnutt IG, Burden DJ, Steele DJ et al.
The orthodontic condition of children
in the United Kingdom, 2003. Br Dent J
2006; 200: 609612.
5. Proffit WR. The timing of early
treatment: an overview. Am J Orthod
Dentofacial Orthop 2006; 129: S47S49.
6. OBrien K, Wright J, Conboy F et al.
Effectiveness of early orthodontic
treatment with the Twin-block
appliance: a multicenter, randomized,
controlled trial. Part 2: Psychosocial
effects. Am J Orthod Dentofacial Orthop
2003; 124: 488494.
Figure 14. Design of upper removable dissuader.
Retentive components: Adams cribs 6/, /6; ball-
ended clasps DE/, /DE; other feature: inverted
goalpost, grill or spur.
7. Little RM, Riedel RA, Stein A. Mandibular
arch length increase during the mixed
dentition: postretention evaluation
of stability and relapse. Am J Orthod
Dentofacial Orthop 1990; 97: 393404.
8. Friel S. The development of ideal
occlusion of the gum pads and teeth.
Am J Orthod 1954; 40: 196227.
9. Moorees CF, Chadma JM. Available
space for the incisors during dental
development: a growth study based on
physiological age. Angle Orthod 1965;
35: 1222.
10. Popovich F, Thompson GW. Maxillary
diastema: indications for treatment. Am
J Orthod 1979; 75: 399404.
11. McIntyre GT. Treatment planning in
Class III malocclusion. Dent Update
2004; 31: 1320.
12. Egermark-Eriksson I, Carlsson GE,
Magusson T, Thilander B. A longitudinal
study on malocclusion in relation
to signs and symptoms of cranio-
mandibular disorders in children and
adolescents. Eur J Orthod 1990; 12:
399407.
13. Mohlin B, Thilander B. The importance
of the relationship between
malocclusion and mandibular
dysfunction and some clinical
applications in adults. Eur J Orthod
1984; 6: 192204.
14. Skeggs RM, Sandler PJ. Rapid correction
of anterior crossbite using a fixed
appliance: a case report. Dent Update
2002; 29: 299302.
15. Franchi L, Baccetti T, McNamara JA.
November 2008
3/11/08 10:56:42

Postpubertal assessment of treatment
timing for maxillary expansion and
protraction therapy followed by fixed
appliances. Am J Orthod Dentofacial
Orthop 2004; 126: 555568.
16. Thilander B, Wahlund S, Lennartsson
B. The effect of early interceptive
treatment in children with posterior
cross-bite. Eur J Orthod 1984; 6: 2534.
17. Harrison JE, Ashby D. Orthodontic
treatment for posterior crossbites.
Cochrane Database Syst Rev 2001; (1):
CD000979.
18. Savara BS, Steen JC. Timing and
sequence of eruption of permanent
teeth in a longitudinal sample of
children from Oregon. J Am Dent Assoc
1978; 97: 209214.
19. Faculty of Dental Surgery, Clinical
Guidelines. Management of Unerupted
Maxillary Incisors. National Clinical
Guidelines, 1997.
20. Foster TD, Taylor GS. Characteristics
of supernumerary teeth in the upper
CochraneSynopses
FULL-MOUTH DISINFECTION FOR
THE TREATMENT OF ADULT CHRONIC
PERIODONTITIS
Eberhard J, Jepsen S, Jerve-Storm P-M,
Needleman I, Worthington HV. Cochrane
Database of Systematic Reviews 2008, Issue
1. Art. No.: CD004622. DOI: 10.1002/14651858.
CD004622.pub2.
Therapy of chronic periodontitis is based
on the mechanical removal of subgingival
bacteria from infected root surfaces in
order to arrest and control the loss of tooth
supporting bone and tissues. Non-surgical
periodontal therapy can be carried out either
quadrantwise in discrete sessions over a
period of several weeks, or within 24 hours
in one or two sessions termed full-mouth
scaling. The latter can be supplemented with
the extended use of an antiseptic agent in
the context of full-mouth disinfection. The
rationale for full-mouth approaches is to
eliminate or reduce pathogenic bacteria from
oral habitats that may lead to re-infection of
already treated sites. The results of this review
have shown that the treatment effects of
full-mouth scaling or full-mouth disinfection
compared to conventional scaling and root
planing are modest and the implications for
periodontal care are not profound. In practice
the decision to select one approach to non-
November 2008
pg607-613 Managing malocclusion 1.indd 7
central incisor region. Dent Pract Dent
Rec 1969; 20: 812.
21. DiBiase DD. Midline supernumeraries
and eruption of the maxillary central
incisor. Dent Pract Dent Rec 1969; 20:
3540.
22. Leyland L, Batra P, Wong F, Llewelyn
R. A retrospective evaluation of the
eruption of impacted permanent
incisors after extraction of
supernumerary teeth. J Clin Pediatr
Dent 2006; 30: 225231.
23. Kurol J, Bjerklin K. Ectopic eruption
of maxillary first permanent molars:
a review. ASDC J Dent Child 1986; 53:
209214.
24. Kurol J, Koch G. The effect of extraction
of infraoccluded deciduous molars: a
longitudinal study. Am J Orthod 1985;
87: 4655.
25. Brenchley ML. Is digit sucking of
significance? Br Dent J 1991; 171:
357362.
26. Larsson E. The effect of finger sucking
surgical periodontal therapy over another
needs to include patient preferences and
convenience of the treatment schedule.
OCCLUSAL INTERVENTIONS FOR
PERIODONTITIS IN ADULTS
Weston P, Yaziz YA, Moles DR, Needleman I.
Cochrane Database of Systematic Reviews
2008, Issue 3. Art. No.: CD004968. DOI:
10.1002/14651858.CD004968.pub2.
Occlusal overload occurs when excessive
force damages the supporting structure
of a tooth. Approximately 15% of the
worlds adult population have advanced
gum disease which causes the supporting
structure of teeth to be compromised. When
occlusal overload occurs at a tooth with
advanced gum disease there is uncertainty
about whether this is detrimental to
achieving gum health. Interventions to
reduce the effect of occlusal overload
on periodontally compromised teeth are
sometimes used. The evidence to support
the effectiveness of these interventions is
limited. This systematic review looked at
the evidence for occlusal interventions in
patients with periodontitis and found one
randomised controlled trial that met the
inclusion criteria. The results of this one trial
were inconclusive. The main conclusion
Orthodontics
on the occlusion: a review. Eur J Orthod
1987; 9: 279282.
27. Popovich F. The prevalence of digit
sucking habits and its relationship
to oral malformations. Applied
Therapeutics 1966; 8: 689691.
28. Moore MB, McDonald JP. A
cephalometric evaluation of patients
presenting with a digit sucking habit.
Br J Orthod 1997; 24: 1723.
29. Levine RS. Briefing paper: oral aspects
of dummy and digit sucking. Br Dent J
1999; 186: 108.
30. Cozza P, Franchi L, Baccetti T,
McNamara JA. Treatment effects of
a modified quad-helix in patients
with dentoskeletal open bites. Am J
Orthod Dentofacial Orthop 2006; 129:
734739.
31. Littlewood SJ, Tait AG, Mandall NA,
Lewis DH. The role of removable
appliances in contemporary
orthodontics. Br Dent J 2001; 191:
304310.
from this systematic review is there is no
evidence for or against the use of occlusal
interventions in clinical practice. There is a
clear need for adequately powered bias-
protected randomised controlled trials to
answer this research question.
INTERVENTIONS FOR REPLACING
MISSING TEETH: ANTIBIOTICS AT DENTAL
IMPLANT PLACEMENT TO PREVENT
COMPLICATIONS
Esposito M, Grusovin MG, Talati M,
Coulthard P, Oliver R, Worthington HV.
Cochrane Database of Systematic Reviews
2008, Issue 3. Art. No.: CD004152. DOI:
10.1002/14651858.CD004152.pub2.
Missing teeth can sometimes be replaced
with dental implants to which a crown,
bridge or denture can be attached. Bacteria
introduced during placement of implants
can lead to infection and sometimes
implant failure. It appears that the oral
administration of 2 grams of amoxicillin 1
hour before placement of dental implants
is effective in reducing implant failures.
More specifically, giving antibiotics to 25
patients will avoid one patient experiencing
early implant losses. It is still unclear
whether postoperative antibiotics are of any
additional benefits.
DentalUpdate 613
3/11/08 10:56:56