Crowding and space management in the mixed dentition Space management can minimize the development of crowding in the

permanent dentition. It essentially involves: Space maintenance following the premature loss of primary molars. Utilization of the leeway space by placement of holding arches. Space maintenance The best space maintenance treatment is the preservation of the primary molars until natural exfoliation. Although dental health education and improved caries prevention have lowered the number of children who develop malocclusion because of premature loss of primary teeth, it is still one of the most common controllable causes of malocclusion. When a primary second molar is lost prematurely due to caries or to the ectopic eruption of the first permanent molar, the first permanent molar will drift mesially. This is most pronounced in the maxilla with a more rapid shift of the molar and causing a Class II malocclusion. The earlier the loss of the second primary molar and the less the root development of the permanent molar, the greater will be the amount of bodily mesial shift of the permanent molar. Factors to consider for placement of space maintainers Placement of a space maintainer requires care of the appliance and oral hygiene maintenance. A child with poor oral hygiene and high caries risk is not the ideal case for such therapy. Before a decision is made to provide a space maintainer it is often essential to critically evaluate its merits, the need, and the benefit it would provide to the development of normal occlusion. Anterior teeth Loss of one or more primary incisors results in negligible space loss if canines and molars are present. If the eruption of a permanent incisor is delayed, space loss may occur because of migration of adjacent teeth. Posterior teeth Whenever a primary second molar is lost prematurely, whether before or after the eruption of the first permanent molar, there will be some loss of arch length caused by the mesial drift of the permanent molar. Space maintenance is critical in children who have a normal arch length and loose a primary molar. Any loss of space in these children will result in crowding of the permanent teeth. Where space has already been lost it is necessary to regain space and then fit a space maintainer. Types of space maintainer Removable

 They may be worn at the whim of the patient. May be broken. Easily lost when removed by the patient. Removable space maintainers have the shortcomings of all removable appliances. A removable space maintainer that is only worn at night is often sufficient to hold space and prevent the mesial drift of permanent molars. Nightonly wearing of the appliance also reduces the risk of loss or breakage by the patient. The appliance should be washed and inserted immediately before going to bed, then removed, washed and placed in a safe place when not worn. Hawleys appliance is a typical example. Fixed space maintainers Fixed appliances have the advantage that they are worn continuously and do not require patient cooperation in wearing them. It should be noted that the placement of a fixed appliance in a child at high risk of caries may compromise those teeth which are banded or even adjacent teeth. Band and loop appliance is typically used in cases of unilateral loss. Nance appliance or lingual arch can be used if the loss is bilateral. Distal shoe appliances can be used if the first permanent molar is not yet erupted, but are not widely used because of risks of infection. Utilization of the leeway space The combined mesiodistal width of the deciduous molars is greater than that of the premolars. This residual space can be used to relieve mild crowding (12 mm) elsewhere in the arch. A transpalatal arch is used in the maxilla. A lingual arch is used in the mandible. Regaining space Within an arch, space may need to be regained when migration of permanent teeth has already occurred following the loss of adjacent deciduous teeth. Furthermore, space maintenance would then be needed until the permanent successor erupted. Radiographs and study models are essential aids in assessing space needs. It is important to note whether teeth have moved bodily or have tipped into the space. Tipping can be easier to resolve than bodily tooth movement. Radiographic examination should also locate the permanent second molars and establish space available for distalization of the first permanent molars. Appliances used to regain space

Uprighting mechanics: Sectional fixed appliance. Removable appliances ACCO appliance. Full arch fixed appliances.

Distalizing appliances: Distalizing springs or screws. Open coil springs. K loop.

Extra-oral headgear.

Lip bumpers to upright and distalize lower molars.

Permanent molars can be uprighted to regain space for the eruption of premolars by using removable appliances. These are most successful where there is a dental and skeletal Class I pattern with normal vertical proportions. Timed extraction of teeth to resolve intra-arch crowding The total amount of arch length deficiency is the key to planning of timed extractions. For this to be beneficial a cephalometric analysis should show the child to be growing within a normal pattern and that all the permanent teeth are present radiographically and in the normal order of eruption. Extraction of deciduous canines Premature loss of a primary canine as the permanent lateral incisor erupts will result in a midline shift to the same side. Extraction of the contralateral deciduous canine will help prevent a shift occurring. In cases with crowding, the loss of primary canines should be managed by placem ent of a fixed lingual arch to support the incisors and prevent lingual tipping as the midlines correct themselves. As the permanent canines erupt it may be necessary to reduce the mesial of the primary first molars and then, as the first premolars erupt, reduce the mesial of the second primary molar. Serial extraction Where there is an arch deficiency of >4 mm, serial extraction may be considered. The purpose of this treatment is to encourage the early eruption of the first premolars ahead of the permanent canines. The premolars are then removed, allowing room for the canines to erupt spontaneously. Serial extraction is usually limited to the upper arch. Serial extractions in the lower arch usually result in lingual collapse of the lower anterior segment.

Contraindications Serial extraction should not be performed in the following circumstances: Class I malocclusions where the lack of space is slight and the teeth show only mild crowding. Where there is a skeletal discrepancy in the dental arches. When there is a deep overbite or an open bite, these should be treated before undertaking serial extraction. When there are permanent teeth congenitally absent from the dental arch. Treatment stages in serial extraction First, the primary canines are removed to allow spontaneous alignment of the permanent incisors. The primary first molars are removed to allow the eruption of the first premola rs. Once the first premolars are erupted, they are removed and a space maintainer is issued to allow the permanent canines to erupt. Further orthodontic treatment is usually required to align teeth achieve correct root angulation and incisor torque. Thus serial extraction is a planned procedure which demands a minimum of 5 years supervision by the dentist of the developing occlusion. Without such a commitment, the objectives will not be fully achieved and at times the child may well be left with a more severe malocclusion. Spacing Spaces in the deciduous dentition are normal and there is an increased chance of good alignment in the permanent dentition. During the early mixed dentition stage, physio logical spacing is common in the anterior region with the incisors appearing splayed. As the permanent canines erupt this will resolve spontaneously and early treatment should not be contemplated. Dentoalveolar disproportion and tooth size discrepancies can also lead to spacing. Definitive treatment is carried out in the permanent dentition when space closure or tooth build-ups should be considered. Management of missing teeth Spaces in the deciduous dentition are normal and there is an increased chance of good alignment in the permanent dentition. During the early mixed dentition stage, physio logical spacing is common in the anterior region with the incisors appearing splayed. As the permanent canines erupt this will resolve spontaneously and early treatment should not be contemplated. Dentoalveolar disproportion and tooth size discrepancies can also lead to spacing. Definitive treatment is carried out in the permanent dentition when space closure or tooth build-ups should be considered.

Hypodontia is the term used to describe the congenital absence of one or more teeth. These teeth have not developed from the initiation stage of tooth development (see Chapter 9). Diagnosis An understanding of the normal sequence and average age of eruption of permanent teeth will alert the practitioner to the possibility of congenital absence. Any delay in the normal eruption time of permanent teeth or exfoliation of primary teeth should be investigated radiographically. The orthopantomogram (OPG) film will provide the best view for investigation of premolars and molars but is often unclear in the incisor region because of the narrow focal trough. It may be necessary to supplement this with either periapical films or, in the maxilla, an anterior occlusal film. For most children a radiographic survey at age 7 years will demonstrate the prese nce or absence of all permanent teeth except for third molars. It should be noted, however, that there is a large variation especially in the second premolar region. Third molars are generally not radiographically visible before the age of 9 years. A radiograph will show the tooth follicle before calcification begins, and there is a range in developm ent time between the presentation of the follicle and calcification commencing, especially for second premolars. Management Where a permanent tooth is diagnosed as congenitally absent, there are two choices in management: Retain the space after loss of the primary tooth and insert a prosthetic replacement. Orthodontics to close the space. The preferred treatment choice will depend on the severity of the condition (number of absent teeth), location of the missing teeth and the underlying skeletal pattern. Class I patterns The jaw relationship is normal. If the missing tooth is located in the posterior segments, space closure is often the treatment of choice. Occlusal relationships, however, will dictate the decision. On the other hand if one or more incisors are missing it is more appropriate to consider space opening and prosthetic replacement. Class II patterns This malocclusion is characterized by a smaller mandible with an increased overjet. The preferred option for missing teeth in the maxilla, is to close space and reduce the overjet at the same time. The permanent canines can replace lateral incisors, but size, shape and colour must be considered. Restorative techniques using resin veneers and acid-etch can be used to reshape the canines as lateral incisors, restoring the anatomy of the substituted teeth and providing a balanced smile.

Class Ill patterns The maxilla is proportionally smaller than the mandible and there can be a dental crossbite either anteriorly or posteriorly. If teeth are missing in the lower arch, and the skeletal problem can be camouflaged with orthodontics only, it may be advantageous to close space. Conversely if teeth are missing in the maxilla, space opening and tooth replacement is the preferred option to avoid further constriction of the arch. Tooth loss due to trauma Traumatic loss of a maxillary incisor can be treated orthodontically within the same guidelines as those for congenital absence of teeth.