BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION

Management of the Developing Dentition and

Occlusion in Pediatric Dentistry
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Management
2021 * of the developing dentition and occlusion in pediatric dentistry.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2021:408-25.

Abstract
This best practice asserts that the management of developing dentition and occlusion is an essential part of comprehensive oral health care
and that early diagnosis and treatment of abnormalities can aid patients in achieving the goal of a stable, functional, and esthetic occlusion.
The document outlines the components of the clinical examination and necessary diagnostic records and emphasizes the importance of the
diagnostic summary for determining treatment priorities and timing. Considerations for management according to each stage of dentition
(primary, mixed, adolescent, adult) are presented along with treatment objectives and recommendations for relevant dental concerns,
including oral habits, congenitally-missing or supernumerary teeth, ectopic eruption, and ankylosis or primary failure of eruption. Lastly,
the document provides discussion of arch length discrepancy, space maintenance, space regaining, crossbites, and Class II and Class III
malocclusions. Providers may use this document as a resource for gathering crucial diagnostic information and making informed decisions
regarding the timing, sequence, and appropriateness of interventions.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and recommendations regarding management of developing dentition and occlusion.

KEYWORDS: MALOCCLUSION, SPACE MAINTENANCE, CROSSBITE, ANKYLOSIS, TOOTH ERUPTION, ORAL HABITS, SUPERNUMERARY TEETH

Purpose length discrepancy; fields: all; limits: within the last 10 years,
The American Academy of Pediatric Dentistry (AAPD) humans, English, and birth through age 18. Papers for review
recognizes the importance of managing the developing denti- were chosen from these searches and from references within
tion and occlusion and its effect on the well-being of infants, selected articles. When data did not appear sufficient or were
children, and adolescents. Management includes the recog- inconclusive, recommendations were based upon expert and/
nition, diagnosis, and appropriate treatment of dentofacial or consensus opinion by experienced researchers and clinicians.
abnormalities. These recommendations are intended to set
forth objectives for management of the developing dentition Background
and occlusion in pediatric dentistry. Guidance of eruption and development of the primary, mixed,
and permanent dentitions is an integral component of com-
Methods prehensive oral health care for all pediatric dental patients.
Recommendations on management of the developing dentition Such guidance should contribute to the development of a
and occlusion were developed by the Developing Dentition permanent dentition that is in a stable, functional, and esthe-
Subcommittee of the Clinical Affairs Committee and adopted tically acceptable occlusion and normal subsequent dentofacial
in 1990.1 This document by the Council of Clinical Affairs is development. Early diagnosis and successful treatment of
a limited modification of the previous revision, last revised in developing malocclusions can have both short-term and long-
2019.2 This revision is based upon a new PubMed /MEDLINE
search using the terms: tooth ankylosis, Class II malocclusion,
® term benefits while achieving the goals of occlusal harmony
and function and dentofacial esthetics.3-5 Dentists have the
Class III malocclusion, interceptive orthodontic treatment, responsibility to recognize, diagnose, and manage or refer
evidence-based, dental crowding, ectopic eruption, dental im- abnormalities in the developing dentition as dictated by the
paction, obstructive sleep apnea syndrome (OSAS), occlusal
development, craniofacial development, craniofacial growth,
airway, facial growth, oligodontia, oral habits, occlusal wear
ABBREVIATIONS
and dental erosion, anterior crossbite, posterior crossbite, space AAPD: American Academy Pediatric Dentistry. AP: Anteroposterior.
maintenance, third molar development, and tooth size/arch CBCT: Cone-beam computed tomography. EE: Ectopic eruption.
OSAS: Obstructive sleep apnea syndrome. PFE: Primary failure of
eruption. TMD: Temporomandibular joint dysfunction.
* The 2021 revision was limited to the section on ankylosis.

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complexity of the problem and the individual clinician’s Diagnostic records may include:
training, knowledge, and experience.6 1. Extraoral and intraoral photographs to:
Many factors can affect the management of the developing a. supplement clinical findings with oriented facial
dental arches and minimize the overall success of any treatment. and intraoral photographs; and
The variables associated with the treatment of the developing b. establish a database for documenting facial
dentition that will affect the degree to which treatment is changes during treatment.
successful include, but are not limited to: 2. Diagnostic dental casts to:
1. chronological/mental/emotional age of the patient a. assess the occlusal relationship;
and the patient’s ability to understand and cooperate b. determine arch length requirements for intraarch
in the treatment. tooth size relationships;
2. intensity, frequency, and duration of an oral habit. c. determine arch length requirements for interarch
3. parental support for the treatment. tooth size relationships; and
4. compliance with clinician’s instructions. d. determine location and extent of arch asymmetry.
5. craniofacial configuration. 3. Intraoral and panoramic radiographs to:
6. craniofacial growth. a. establish dental age;
7. concomitant systemic disease or condition. b. assess eruption problems;
8. accuracy of diagnosis. c. estimate the size and presence of unerupted teeth;
9. appropriateness of treatment. and
10. timing of treatment. d. identify dental anomalies/pathology.
A thorough clinical examination, appropriate pretreatment 4. Lateral and AP cephalograms to:
records, differential diagnosis, sequential treatment plan, a. produce a comprehensive cephalometric analysis
and progress records are necessary to manage any condition of the relative dental and skeletal components in
affecting the developing dentition. the AP, vertical, and transverse dimensions;
Clinical examination should include: b. establish a baseline growth record for longitudinal
1. Facial analysis to: assessment of growth and displacement of the
a. identify adverse transverse growth patterns includ- jaws; and
ing asymmetries (maxillary and mandibular); c. determine dental maturity relative to skeletal
b. identify adverse vertical growth patterns; maturity and chronological age.
c. identify adverse sagittal (anteroposterior [AP]) 5. Other diagnostic views (e.g., magnetic resonance
growth patterns and dental AP occlusal dishar- imaging, cone-beam computed tomographic images
monies; and [CBCT]) for hard and soft tissue imaging as
d. assess esthetics and identify orthopedic and ortho- indicated by history and clinical examination.
dontic interventions that may improve esthetics
and resultant self-image and emotional A differential diagnosis and diagnostic summary are
development. completed to:
2. Intraoral examination to: 1. establish the relative contributions of the soft tissue
a. assess overall oral health status; and and dental and skeletal structures to the patient’s
b. determine the functional status of the patient’s malocclusion.
occlusion. 2. prioritize problems in terms of relative severity.
3. Functional analysis to: 3. detect favorable and unfavorable interactions that may
a. determine functional factors associated with the result from treatment options for each problem area.
malocclusion; 4. establish short-term and long-term objectives.
b. detect deleterious habits; and 5. summarize the prognosis of treatment for achieving
c. detect temporomandibular joint dysfunction stability, function, and esthetics.
(TMD), which may require additional diagnostic A sequential treatment plan will:
procedures. 1. establish timing priorities for each phase of therapy.
2. establish proper sequence of treatments to achieve
Diagnostic records may be needed to assist in the evaluation short-term and long-term objectives.
of the patient’s condition and for documentation purposes. 3. assess treatment progress and update the biomechan-
Prudent judgment is exercised to decide the appropriate ical protocol accordingly on a regular basis.
records required for diagnosis of the clinical condition.7
Diagnostic orthodontic evaluations fall into three major
categories: (1) health of the teeth and oral structures, (2)
alignment and occlusal relationships of the teeth, and (3)
facial and jaw proportions.7

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Stages of development of occlusion c. presence of habits along with their dental and
General considerations and principles of management: The skeletal sequelae;
stages of occlusal development include: d. openbite; and
1. Primary dentition: Beginning in infancy with the e. airway problems.
eruption of the first tooth, usually about six months Radiographs are taken with appropriate clinical
of age, and complete from approximately three to indicators or based upon risk assessment/history.
six years of age when all primary teeth are erupted. 2. Early mixed dentition stage: The objectives of evalu-
2. Mixed dentition: From approximately age six to 13, ation continue as noted for the primary dentition
primary and permanent teeth are present in the stage. Palpation for unerupted teeth should be part
mouth. This stage can be divided further into early of every examination. Panoramic, occlusal, and peria-
mixed and late mixed dentition. pical radiographs, as indicated at the time of eruption
3. Adolescent dentition: All succedaneous teeth have of the lower incisors and first permanent molars,
erupted, second permanent molars may be erupted provide diagnostic information concerning:
or erupting, and third molars have not erupted. a. unerupted teeth;
4. Adult dentition: All permanent teeth are present.7,8 b. missing, supernumerary, fused, and geminated teeth;
c. tooth size and shape (e.g., peg or small lateral
Historically, orthodontic treatment was provided mainly for incisors);
adolescents. Interest continues to be expressed in the concept d. positions (e.g., ectopic first permanent molars);
of interceptive (early) treatment as well as in adult treatment. e. developing skeletal discrepancies; and
Treatment and timing options for the growing patient have f. periodontal health.
increased and continue to be evaluated by the research com- Space analysis can be used to evaluate arch length at
munity.9,10 Many clinicians seek to modify skeletal, muscular, the time of incisor eruption.
and dentoalveolar abnormalities before the eruption of the 3. Late mixed dentition stage: The objectives of the
full permanent dentition. evaluations remain consistent with the prior stages,
A thorough knowledge of craniofacial growth and develop- with an emphasis on evaluation for ectopic tooth
ment of the dentition, as well as orthodontic treatment, must positions, especially canines, premolars, and second
be used in diagnosing and reviewing possible interceptive permanent molars.
treatment options before recommendations are made to 4. Adolescent dentition stage: If not instituted earlier,
parents. Treatment is beneficial for many children but may not orthodontic diagnosis and treatment should be
be indicated for every patient with a developing malocclusion. planned for Class I crowded, Class II, and Class III
malocclusions as well as posterior and anterior
Treatment considerations: The developing dentition should crossbites. Third molars should be monitored as to
be monitored throughout eruption. This monitoring at regular position and space, and parents should be informed
clinical examinations should include, but not be limited to, of the dentist’s observations.
diagnosis of missing, supernumerary, developmentally de- 5. Early adult dentition stage: Third molars should be
fective, and fused or geminated teeth; ectopic eruption; space evaluated. If orthodontic diagnosis has not been
and tooth loss secondary to caries; and periodontal and pulpal accomplished, recommendations should be made as
health of the teeth. necessary.
Radiographic examination, when necessary11 and feasible,
should accompany clinical examination. Diagnosis of anomalies Treatment objectives: At each stage, the objectives of
of primary or permanent tooth development and eruption intervention/treatment include managing adverse growth,
should be made to inform the patient’s parent and to plan correcting dental and skeletal disharmonies, improving esthe-
and recommend appropriate intervention. This evaluation is tics of the smile and the accompanying positive effects on
ongoing throughout the developing dentition, at all stages.7,8 self-image, and improving the occlusion.
1. Primary dentition stage: Anomalies of primary teeth 1. Primary dentition stage: Habits and crossbites should
and eruption may not be evident/diagnosable prior be diagnosed and, if predicted not likely to be self-
to eruption, due to the child’s not presenting for correcting, they should be addressed as early as feasible
dental examination or to a radiographic examination to facilitate normal occlusal relationships. Parents
not being possible in a child due to age or behavior. should be informed about findings of adverse
Evaluation, however, should be accomplished when growth and developing malocclusions. Interventions/
feasible. The objectives of evaluation include identi- treatment can be recommended if diagnosis can be
fication of: made, treatment is appropriate and possible, and
a. all anomalies of tooth number and size (as parents are supportive and desire to have treatment
previously noted); done.
b. anterior and posterior crossbites;

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2. Early mixed dentition stage: Treatment consideration anticipatory guidance to help their children stop sucking habits
should address: by age 36 months or younger.12,15,16
a. habits; Bruxism, defined as the habitual nonfunctional and force-
b. arch length shortage; ful contact between occlusal surfaces, can occur while awake
c. intervention for crowded incisors; or asleep. The etiology is multifactorial and has been reported
d. intervention for ectopic teeth; to include central factors (e.g., emotional stress,20 parasomnias,21
e. holding of leeway space; traumatic brain injury,22 neurologic disabilities23) and mor-
f. crossbites; phologic factors (e.g., malocclusion24, muscle recruitment25).
g. openbite; The occlusal wear that may result from bruxism is important
h. surgical needs; and to differentiate from other forms of occlusal loss of enamel
i. adverse skeletal growth. (e.g., erosion caused by diet or gastroesophageal reflux).26
Intervention for ectopic teeth may include extrac- Reported complications of bruxism include dental attrition,
tions of primary teeth and space maintenance/ headaches, TMD, and soreness of the masticatory muscles.20
regaining to aid erupting teeth and reduce the risk Evidence indicates that juvenile bruxism is self-limiting and
of need for permanent tooth extraction or surgical does not persist in adults.27 The spectrum of bruxism man-
bracket placement for orthodontic traction. Treat- agement ranges from patient/parent education, occlusal splints,
ment should take advantage of the child’s growth and psychological techniques to medications.21,22,28,29
and should be aimed at prevention of adverse dental Tongue thrusting, an abnormal tongue position and
relationships and skeletal growth. deviation from the normal swallowing pattern, may be asso-
3. Late mixed dentition stage: Intervention for treat- ciated with anterior open bite, abnormal speech, and anterior
ment of skeletal disharmonies and crowding may be protrusion of the maxillary incisors.30 There is no evidence
instituted at this stage. that intermittent short-duration pressures, created when
4. Adolescent dentition stage: In full permanent denti- the tongue and lips contact the teeth during swallowing or
tion, orthodontic diagnosis and treatment can provide chewing, have significant impact on tooth position.15,30 If the
the most functional, stable, and esthetic occlusion. resting tongue posture is forward of the normal position,
5. Early adult dentition stage: Third molar position or incisor displacement is likely, but if resting tongue posture is
space can be evaluated and, if indicated, the tooth/ normal, a tongue thrust swallow has no clinical significance.15
teeth removed. Full orthodontic treatment should be Self-injurious or self-mutilating behavior (i.e., repetitive
recommended if needed. acts that result in physical injury to the individual) is ex-
tremely rare in the normal child. Such behavior, however, is
Recommendations a chronic condition more frequently seen in special needs
Oral habits populations, having been associated with developmental delay
General considerations and principles of management: or disabilities, psychiatric disorders, traumatic brain injuries,
The habits of nonnutritive sucking, bruxing, tongue thrust and some syndromes.31,32 The spectrum of treatment options
swallow and abnormal tongue position, self-injurious/ for developmentally disabled individuals includes pharmaco-
self-mutilating behavior, and OSAS are discussed in these logic management, behavior modification, and physical
recommendations. restraint.33 Dental treatment modalities include, among others,
Oral habits may apply negative forces to the teeth and lip-bumper and occlusal bite appliances, protective padding,
dentoalveolar structures. The relationship between oral habits and extractions. Some habits, such as lip-licking and lip-
and unfavorable dental and facial development is associational pulling, are relatively benign in relation to an effect on the
rather than cause and effect.12,13 Habits of sufficient frequency, dentition. Severe lip- and tongue-biting habits may be
duration, and intensity may be associated with dentoalveolar associated with profound neurodisability due to severe brain
or skeletal deformations such as increased overjet, reduced damage.33 Management options include monitoring the lesion,
overbite, openbite, posterior crossbite, or increased facial odontoplasty, providing a bite-opening appliance, or extracting
height. The duration of force is more important than its the teeth.33
magnitude14; the resting pressure from the lips, cheeks, and Research on the relationship between malocclusion and
tongue has the greatest impact on tooth position as these mouth breathing suggests that impaired nasal respiration
forces are maintained most of the time.15,16 may contribute to the development of increased facial height,
Nonnutritive sucking behaviors are considered normal in anterior open bite, increased overjet, and narrow palate, but it
infants and young children. Long-term nonnutritive sucking is not the sole or even the major cause of these conditions.34
habits (e.g., pacifier use, thumb/finger sucking) have been OSAS may be associated with narrow maxilla, crossbite,
associated with anterior open bite and posterior crossbite.12,15-19 low tongue position, vertical growth, increased overjet, and
Some evidence indicates that changes resulting from sucking openbite. 35-37 History associated with OSAS may include
habits persist past the cessation of the habit; therefore, it has snoring, observed apnea, restless sleep, daytime neurobehavioral
been suggested that early dental visits provide parents with abnormalities or sleepiness, and bedwetting. Physical findings

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may include growth abnormalities, signs of nasal obstruction, orthodontically versus opening the space orthodontically and
adenoidal facies, and enlarged tonsils.34,38,39 placing a prosthesis or implant depends on many factors. For
The identification of an abnormal habit and the assessment maxillary laterals, the dentist may move the maxillary canine
of its potential immediate and long-term effects on the cra- mesially and use the canine as a lateral incisor or create space
niofacial complex and dentition should be made as early as for a future lateral prosthesis or implant.13,46
possible. The dentist should evaluate habit frequency, duration, Factors that influence the decision are: (1) patient age; (2)
and intensity in all patients with habits. Intervention to canine size and shape; (3) canine position; (4) child’s occlu-
terminate the habit should be initiated if indicated, and sion and amount of crowding; (5) bite depth; (6) profile;
parents should be provided with information regarding con- (7) smile line; and (8) quality and quantity of bone in the
sequences of a habit as well as tools to help in elimination of edentulous area.46,47 Early extraction of the primary canine and/
the habit.12,13 or lateral may be needed.46 Opening space for a prosthesis or
implant requires less tooth movement, but the space needs to
Treatment considerations: Management of an oral habit is be maintained with an interim prosthesis, especially if an
indicated whenever the habit is associated with unfavorable implant is planned. 43,46 Moving the canine into the lateral
dentofacial development or adverse effects on child health or position produces little facial change, but the resultant tooth
when there is a reasonable indication that the oral habit will size discrepancy often does not allow a canine guided occlu-
result in unfavorable sequelae in the developing permanent sion.45,46 Patients generally prefer space closure over implants.47
dentition. Any treatment must be appropriate for the child’s For a congenitally missing premolar, the primary molar
development, comprehension, and ability to cooperate. Habit may either be maintained or extracted with placement of a
treatment modalities include patient/parent counseling, be- prosthesis, autotransplantation, or orthodontic space closure.48-54
havior modification techniques, myofunctional therapy, Maintaining the primary second molar may cause occlusal
appliance therapy (extraoral and intraoral), or referral to problems due to its larger mesiodistal diameter, compared
other providers including, but not limited to, orthodontists, to the second premolar.46 Reducing the width of the second
psychologists, myofunctional therapists, or otolaryngologists. primary molar is a consideration, but root resorption and
The child’s desire to stop the habit is beneficial for managing subsequent exfoliation may occur.13,46 In crowded arches or
oral habits.13 with multiple missing premolars, extraction of the primary
molar(s) can be considered, especially in mild Class III
Treatment objectives: Treatment is directed toward decreasing cases. 13,46,50 For a single missing premolar, if maintaining
or eliminating the habit and minimizing potential deleterious the primary molar is not possible, placement of a prosthesis,
effects on the dentofacial complex. autotransplantation, or implant should be considered.13,47,50
Preserving the primary tooth may be indicated in certain
Disturbances in number cases. However, maintaining a submerged/ankylosed tooth
Congenitally missing teeth may increase the likelihood of an alveolar defect which can
General considerations and principles of management: Hypo- compromise later implant success. 50,51 Consideration for
dontia, the congenital absence of one or more permanent extraction and space maintenance may be indicated.50,51 Con-
teeth, has a prevalence of 3.5 to 6.5 percent.40 Excluding third sultation with an orthodontist and/or prosthodontist may be
molars, the most frequently missing permanent tooth is the considered.
mandibular second premolar followed by the maxillary lateral
incisor.40 In the primary dentition, hypodontia occurs less fre- Treatment objectives: Treatment is directed toward an esthe-
quently (0.1 to 0.9 percent prevalence) and almost always tically pleasing occlusion that functions well for the patient.
affects the maxillary incisors and first primary molars.41 The
chance of familial occurrence of one or two congenitally missing Supernumerary teeth (primary, permanent, and mesiodens)
teeth is to be differentiated from missing lateral incisors in General considerations and principles of management: Super-
cleft lip/palate42 and multiple missing teeth (six or more) due numerary teeth, or hyperdontia, can occur in the primary or
to ectodermal dysplasia or other syndromes43 as the treatment permanent dentition but are five times more common in the
usually differs. A congenitally missing tooth should be sus- permanent.44 Prevalence is reported in the primary dentition
pected in patients with cleft lip/palate, certain syndromes, and from 0.3-0.8 percent and the mixed dentition from 0.52 to
a familial pattern of missing teeth. In addition, patients with two percent.52-55 Between 80 and 90 percent of all super-
asymmetric eruption sequence, over-retained primary teeth, or numeraries occur in the maxilla, with half in the anterior
ankylosis of a primary mandibular second molar may have a area and almost all in the palatal position.52 A supernumerary
congenitally missing tooth.42,44,45 primary tooth is followed by a supernumerary permanent
tooth in one-third of the cases.56 Supernumerary teeth are
Treatment considerations: With congenitally missing perma- classified according to their form and location.52,57
nent maxillary incisor(s) or mandibular second premolar(s),
the decision to extract the primary tooth and close the space

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During the early mixed dentition, 79 to 91 percent of molar’s crown.61,62 EE can be suspected if asymmetric eruption
anterior permanent supernumerary teeth are unerupted.45,53 is observed or if the mesial marginal ridge is noted to be
While more erupt with age, only 25 percent of all mesiodens under the distal prominence of the second primary molar.61,62
(a permanent supernumerary incisor located at the midline) EE of permanent molars can be diagnosed from bitewing
erupt spontaneously.52 Mesiodens can prevent or cause ectopic or panoramic radiographs in the early mixed dentition.61,62
eruption of a central incisor. Less frequently, a mesiodens can This condition occurs in up to three percent of the popula-
cause dilaceration or resorption of the permanent incisor’s tion.61 EE of first permanent molars has been associated with
root. Dentigerous cyst formation involving the mesiodens, in transverse and sagittal crowding and is more common in the
addition to eruption into the nasal cavity, has been reported.52 maxillary arch and in children with cleft lip and palate. 62-64
If there is an asymmetric eruption pattern of the maxillary EE of second permanent molars occurs infrequently.65 EE of
incisors, delayed eruption, an overretained primary incisor, or permanent molars is classified into two types. There are those
ectopic eruption of an incisor, a supernumerary tooth can be that self-correct and others that remain impacted. Previous
suspected.41,42,53 Panoramic, occlusal, and periapical radiographs data suggested that 66 percent of EE permanent molars
all can reveal a supernumerary tooth. To determine the super- self-correct by age seven;45,62 however, a recent cohort study
numerary tooth’s position, either a cone beam radiograph or demonstrated that 71 percent self-correct by age nine.66 In
two periapical or occlusal films reviewed by the parallax rule some cases, definitive treatment is indicated to manage and/
is recommended.52,54 or avoid early loss of the primary second molar and space
loss. 61,62 Increased magnitude of impaction, increased
Treatment considerations: Management and treatment of resorption of the primary tooth, and bilateral occurrence were
hyperdontia differs if the tooth is primary or permanent. Pri- positively associated with irreversible ectopic eruption and
mary supernumerary teeth normally are accommodated into may indicate the need for early intervention.66
the arch and usually erupt and exfoliate without complications.56 The maxillary canine appears in an impacted position in
Surgical extraction of unerupted anterior supernumerary teeth 1.5–2 percent of the population.67 Maxillary canine impaction
during the primary dentition can displace or damage the per- should be suspected when the canine bulge is not palpable,
manent incisor.52 Removal of an erupted mesiodens or other asymmetric canine eruption is evident, or peg shaped lateral
permanent supernumerary incisor results in eruption of the incisors are present.67-71 Panoramic radiographs may demon-
permanent adjacent normal incisor in 75 percent of the cases.52 strate that the canine has an abnormal inclination and/or over-
Extraction of an unerupted supernumerary during the early laps the lateral incisor root. Additional potential radiographic
mixed dentition (i.e., at age six to seven years when the signs of maxillary canine impaction include enlarged follicular
permanent crown has formed completely and the root length sac, lack of root resorption of primary canines, and presence
is less than the crown height) allows for a normal eruptive of premolar impaction.69,70,72
force and eruption of the adjacent normal permanent in- Maxillary incisors can erupt ectopically or be impacted from
cisor.52-54,58 Later removal of the mesiodens reduces the likeli- supernumerary teeth in up to two percent of the population.57
hood that the adjacent normal permanent incisor will erupt Incisors also can have altered eruption due to pulp necrosis
on its own, especially if the apex is completed.52 Inverted conical (following trauma or caries) or pulpal treatment of the primary
supernumerary teeth can be harder to remove if removal is incisor. 73 EE of permanent incisors can be suspected after
delayed, as they can migrate deeper into the jaw.53 After trauma to primary incisors, with pulpally-treated primary
removal of the supernumerary tooth, clinical and radiographic incisors, with asymmetric eruption, or if a supernumerary
follow-up is indicated in six months to determine if the incisor is diagnosed.67,71
normal incisor is rupting. If there is no eruption after six to
12 months and sufficient space exists, surgical exposure and Treatment considerations: Treatment for ectopic molars
orthodontic extrusion may be needed.52,59,60 depends on how severe the impaction appears clinically and
radiographically. For mildly impacted first permanent molars,
Treatment objectives: Removal of supernumerary teeth should where little of the tooth is impacted under the primary second
facilitate eruption of permanent teeth and encourage normal molar, elastic or metal orthodontic separators can be placed
alignment. In cases where normal alignment or spontaneous to wedge the permanent first molar distally.61 For more severe
eruption does not occur, further orthodontic treatment is impactions, distal tipping of the permanent molar is re-
indicated. quired.61 Tipping action can be accomplished with brass
wires, removable appliances using springs, fixed appliances
Localized disturbances in eruption such as sectional wires with open coil springs,74 sling shot-type
Ectopic eruption appliances,75 or a Halterman appliance.76
General considerations and principles of management: Early diagnosis and treatment of impacted maxillary canines
Ectopic eruption (EE) of permanent first molars occurs due to can lessen the severity of the impaction and may stimulate
the molar’s abnormal mesioangular eruption path, resulting in eruption of the canine. Extraction of the primary canine is
an impaction at the distal prominence of the primary second indicated when the canine bulge cannot be palpated in the

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alveolar process and there is radiographic overlapping of the tissue.90,91 Ankylosis can occur rapidly or gradually, in some
canine with the formed root of the lateral during the mixed cases as long as five years post trauma. It also may be transient
dentition.67,77,78 The use of rapid maxillary expansion alone79,80 if only a small bony bridge forms then is resorbed with sub-
or with cervical pull headgear81 in the early mixed dentition sequent osteoclastic activity.92,93
has been shown to increase the potential for eruption of Ankylosis can be verified by clinical and radiographic
palatally-displaced maxillary canines. When the impacted ca- means. Submergence of the tooth, or infraocclusion, is the
nine is diagnosed at a later age (11 to 16 years), if the canine primary recognizable sign, but the diagnosis also can be made
is not horizontal, extraction of the primary canine lessens the through percussion and palpation.94 Lack of physiologic mo-
severity of the permanent canine impaction and 75 percent bility and the presence of a dull tone (in comparison to adjacent
will erupt. 82 Extraction of the first primary molar also has teeth) upon percussion with a metal instrument such as a
been reported to allow eruption of first premolars and to assist dental mirror handle are indicative of ankylosis. Intraoral
in the eruption of the canines.83 This need can be determined radiographic examination, while limited in its two-dimensional
from a panoramic radiograph,84,85 although CBCT will provide view, may show the loss of the periodontal ligament, external
greater localization of the impacted canine.86 Bonded ortho- resorption, and alveolar replacement.89
dontic treatment normally is required to create space or
align the canine. Long-term periodontal health of impacted Treatment considerations: Management of an ankylosed
canines after orthodontic treatment is similar to nonimpacted primary molar with a successor consists of maintaining it until
canines, and there is insufficient data to conclude the best an interference with eruption or tipping/drifting of adjacent
type of surgical technique.87,88 teeth occurs. If associated problems occur, the practitioner
Treatment of ectopically erupting incisors depends on the should extract the ankylosed primary molar and place a
etiology. Extraction of necrotic or over-retained pulpally- lingual arch or other fixed appliance if needed. Management
treated primary incisors is indicated in the early mixed of ankylosed primary molars without successors should take
dentition.73 Removal of supernumerary incisors in the early into consideration the patient’s age, specific tooth condition,
mixed dentition will lessen ectopic eruption of an adjacent comprehensive orthodontic treatment plan including future
permanent incisor. 52 After incisor eruption, orthodontic prosthodontic considerations, and parental preferences. If
treatment involving removable or banded therapy may be severe infraocclusion is anticipated, ankylosed primary molars
needed. without a permanent successor should either undergo extrac-
tion before a large vertical occlusal discrepancy develops or
Treatment objectives: Management of ectopically erupting decoronation to maintain alveolar width and prevent further
molars, canines, and incisors should result in improved loss of vertical height.95,96 Decoronation is the removal of the
eruptive positioning of the tooth. In cases where normal clinical crown and root structure below the soft tissue level
alignment does not occur, subsequent comprehensive ortho- and necessitates removal of the remaining vital pulp tissue. It
dontic treatment may be necessary to achieve appropriate reduces the chance of ridge resorption and the need for bone
arch form and intercuspation. grafting95-97 following a surgical extraction. Decoronation helps
preserve bone until an implant can be placed.98 Extraction of
Ankylosis ankylosed primary molars without a succedaneous tooth can
General considerations and principles of management: assist in resolving crowded arches in complex orthodontic
Ankylosis is a condition in which the cementum of a tooth’s cases.96,99 Consultation with other dental specialists (e.g.,
root fuses directly to the surrounding bone.89 The periodontal orthodontists, prosthodontists) may assist clinicians in their
ligament is replaced with osseous tissue, rendering the tooth treatment decision making.
immobile to eruptive change.89 An ankylosed tooth stays at Surgical luxation of ankylosed permanent teeth with forced
the same vertical level, yet in a growing child appears to orthodontic eruption has been described as an alternative to
submerge as the other teeth continue to erupt. Ankylosis can premature extraction.100 Management of ankylosed permanent
occur in the primary and permanent dentitions, with the most anterior teeth can include build-up of minor infraocclusion,
common incidence involving primary molars. The incidence intentional repositioning (surgical or orthodontic) with splint-
is reported to be between seven and 14 percent in the primary ing, autotransplantation, decoronation91,101,102 or extraction
dentition.90 In the permanent dentition, ankylosis occurs with prosthetic rehabilitation. In permanent incisor decoro-
most frequently following luxation injuries.91 nation, the tooth undergoes endodontic treatment and then
Ankylosis is common in anterior teeth following trauma removal of the clinical crown and the cervical portion of the
(e.g., avulsion) or injury to periodontal ligament cells and is root to a level two millimeters below marginal bone height,
the process of pathological fusion of the external root surface followed by reflecting, repositioning, and suturing a muco-
of the tooth to the surrounding alveolar bone.92 The degree periosteal flap over the root.103 Additional research on man-
of replacement resorption and infraocclusion contribute to agement of ankylosed permanent anterior teeth is needed.92
the severity of ankylosis. Over time, normal bony activity
may result in the replacement of root structure with osseous

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 BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION

Treatment objectives: Treatment of ankylosis should result in occlusion.115 Early extraction of first molars allowing the
the continuing normal development of the permanent denti- second molars to drift forward has also been suggested.109
tion. In the case of replacement resorption of a permanent
tooth, appropriate prosthetic replacement should be planned. Treatment objectives: Since best available evidence does not
support early orthodontic intervention, treatment objectives
Primary failure of eruption of PFE should involve reassurance and education about the
General considerations and principles of management: Primary eruption disorder and preparation for future prosthetic rehabil-
failure of eruption (PFE) is an eruption disorder characterized itation.109 In some cases, early extraction can improve normal
by partial or complete non-eruption of permanent teeth in the development of the alveolus and permanent dentition.109
absence of any mechanical obstruction or syndrome.104 Failure Objectives include space and intra-arch maintenance in
in eruptive mechanisms prevent permanent successors from preparation for future implants, prosthetic rehabilitation, or
following the eruption path after the exfoliation of deciduous corticotomy-assisted tooth movement.109
teeth.105 Posterior teeth are most commonly affected and one
or all four quadrants may be involved.106 Although typically Tooth size/arch length discrepancy and crowding
associated with permanent teeth, examples in the primary General considerations and principles of management:
dentition have been noted.107 Two main phenotypes of PFE Arch length discrepancies include inadequate arch length and
have been identified: (1) All teeth distal to the most mesial crowding of the dental arches, excess arch length and spacing,
non-erupted tooth are affected, or (2) unerupted teeth do not and tooth size discrepancy, often referred to as a Bolton dis-
follow the pattern that all teeth distal to the most mesial in- crepancy.121 These arch length discrepancies may be found in
volved tooth are also affected.108 Hallmark features of PFE conjunction with complicating and other etiological factors
include posterior open bite in the presence of normal vertical including missing teeth, supernumerary teeth, and fused or
growth, infra-occlusion of affected teeth, and the inability to geminated teeth. Inadequate arch length with resulting incisor
move affected teeth orthodontically.109 crowding is a common occurrence with various negative
The reported incidence of PFE is between 0.01 and 0.06 sequelae and is particularly common in the early mixed denti-
percent;110,111 however, some data suggests PFE may be mis- tion.120-125 Studies of arch length in today’s children compared
diagnosed as infra-occlusion or ankylosis.112,113 PFE differs from to their parents and grandparents of 50 years ago indicate less
ankylosis in that eruption fails to occur due to an imbalance arch length, more frequent incisor crowding, and stable tooth
in resorptive and appositional factors related to tooth erup- sizes.126-128 This implies that the problem of incisor crowding
tion.114,115 Teeth with PFE are not initially ankylosed but may and ultimate arch length discrepancies may be increasing in
become ankylosed when orthodontic forces are applied.116 A numbers of patients and in amount of arch length shortage.127-129
systematic review demonstrated 85 percent of patients with Arch length and especially crowding must be considered in
PFE have another family member with the condition.116 PFE the context of the esthetic, dental, skeletal, and soft tissue
has variable expression and has been associated with mutations relationships. Mandibular incisors have a high relapse rate in
in the autosomal dominant parathyroid hormone receptor rotations and crowding.122,123 Growth of the aging skeleton
(PTH1R) gene.116-119 A sample of blood or saliva deoxyribo- causes further crowding and incisor rotations.130 Functional
nucleic acid (DNA) can be used to test for mutations in contacts are diminished where rotations of incisors, canines,
PTH1R.119,120 and premolars exist.131 Occlusal harmony and temporoman-
dibular joint health are impacted negatively by less functional
Treatment considerations: Diagnosis of PFE should be based contacts.131
on a combination of clinical, radiographic, and genetic infor- Initial assessment may be done in early mixed dentition,
mation.115,116 A positive family history also supports a diagnosis when mandibular incisors begin to erupt.122 Evaluation of avail-
of PFE.108 Other than a few anecdotal reports, PFE is strongly able space and consideration of making space for permanent
associated with the failure of orthodontically assisted eruption incisors to erupt may be done initially utilizing appropriate
or tooth movement.108,109 To that point, early orthodontic inter- radiographs to ascertain the presence of permanent successors.
vention of the affected teeth should be avoided.109,114,115,120 To Comprehensive diagnostic analysis is suggested, with evaluation
date there are no established mechanotherapeutic methods of of maxillary and mandibular skeletal relationships, direction
modifying dentoalveolar growth for these patients.109,114,115,120 and pattern of growth, facial profile, facial width, muscle
Space maintenance, up-righting adjacent teeth that have tipped balance, and dental and occlusal findings including tooth
into the sites, prevention of supra-eruption in opposing arch, positions, arch length analysis, and leeway space.
or modification of lateral tongue thrust habits may be addi- Derotation of teeth just after emergence in the mouth implies
tional considerations.109,120 Once growth is complete, multidis- correction before the transseptal fiber arrangement has been
ciplinary treatment options such as single tooth or segmental established.122,131 It has been shown that the transseptal fibers
osteotomies with immediate traction, or selective extractions do not develop until the cementoenamel junction of erupting
followed by implants can be considered to create a functioning teeth pass the bony border of the alveolar process.131 Therefore,
long-term stability of aligned incisors may be increased.132

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BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION

Treatment considerations: Treatment considerations may available for the succeeding permanent tooth, but there is a
include, but are not limited to: lack of consensus or evidence regarding the effectiveness of
1. gaining space for permanent incisors to erupt and space maintainers in preventing or reducing the severity of
become straight naturally through primary canine malocclusion.136
extraction and space/arch length maintenance with
holding arches. Extraction of primary or permanent Treatment considerations: It is prudent to consider space
teeth with the aim of alleviating crowding should maintenance when primary teeth are lost prematurely. Factors
not be undertaken without a comprehensive space to consider include: (1) specific tooth lost; (2) time elapsed since
analysis and a short- and long-term orthodontic tooth loss; (3) occlusion and space assessment; (4) dental age;
treatment plan. (5) presence and root development of permanent successor;
2. orthodontic alignment of permanent teeth as soon (6) amount of alveolar bone covering permanent successor;
as erupted and feasible, expansion and correction of (7) patient’s health history and medical status; (8) patient’s
arch length as early as feasible. cooperative ability; (9) active oral habits; and (10) oral
3. utilizing holding arches in the mixed dentition until hygiene.13,136,137
all permanent premolars and canines have erupted. The literature pertaining to the use of space maintainers
4. maintaining patient’s original arch form.131 specific to the loss of a particular primary tooth type include
5. interproximal stripping of the enamel of mandibular expert opinion, case reports, and details of appliance design.13,
primary canines to allow alignment of crowded lower 138,139
Space maintainers can be designed as fixed unilateral
permanent lateral incisors.133 (band and loop, crown and loop, distal shoe), fixed bilateral
(lower lingual holding arch, Nance appliance, transpalatal arch),
Additional treatment modalities may include, but are not or removable (partial dentures, Hawley type appliance).157
limited to: (1) interproximal reduction; (2) restorative bond- Variations of these appliances have been described. Unilateral
ing; (3) veneers; (4) crowns; (5) implants; and (6) orthognathic space maintainer kits as well as direct bonded techniques
surgery. eliminate laboratory involvement and allow for single visit
delivery; however, the literature describes mixed results on the
Treatment objectives: Well-timed intervention can: longevity of these options compared to success rates of custom
1. prevent crowded incisors. appliances.158-161
2. increase long-term stability of incisor positions. The placement and retention of space maintaining appli-
3. decrease ectopic eruption and impaction of perma- ances requires ongoing compliant patient behavior. Follow-up
nent canines. of patients with space maintainers is necessary to assess inte-
4. reduce orthodontic treatment time and sequelae. grity of cement and to evaluate and clean the abutment
5. improve gingival health and overall dental teeth.141 The appliance should function until the succedaneous
health.122,134,135 teeth have erupted into the arch. However, adjustment or new
appliances may be necessary with continued development and
Space maintenance changes in the dentition.
General considerations and principles of management: The
premature loss of primary teeth due to caries, infection, trauma, Treatment objectives: The goal of space maintenance is to
ectopic eruption, or crowding deviates from the normal exfolia- prevent loss of arch length, width, and perimeter by main-
tion pattern and may lead to loss of arch length. Arch length taining the relative position of the existing dentition.13,138
deficiency can produce or increase the severity of malocclusions The AAPD recognizes the need for controlled randomized
with crowding, rotations, ectopic eruption, crossbite, excessive clinical trials to determine efficacy of space maintainers as
overjet, excessive overbite, and unfavorable molar relation- well as analysis of costs and side effects of treatment.
ships.136 Whenever possible, restoration of carious primary
teeth should be attempted to avoid malocclusions that could Space regaining
result from their extraction.137 The use of space maintainers to General considerations and principles of management: Some
reduce the prevalence and severity of malocclusion following of the more common causes of space loss within an arch are
premature loss of primary teeth should be considered.13,138,139 (1) primary teeth with interproximal caries; (2) ectopically
Adverse effects associated with space maintainers include: erupting teeth; (3) alteration in the sequence of eruption; (4)
(1) dislodged, broken, and lost appliances; (2) plaque accumu- ankylosis of a primary molar; (5) dental impaction; (6) trans-
lation; (3) increase in microorganisms and increase in perio- position of teeth; (7) loss of primary molars without proper
dontal index scores; (4) caries; (5) damage or interference with space management; (8) congenitally missing teeth; (9) abnor-
successor eruption; (6) undesirable tooth movement; (7) mal resorption of primary molar roots; (10) premature and
inhibition of alveolar growth; (8) soft tissue impingement; and delayed eruption of permanent teeth; and (11) abnormal
(9) pain.136,140-146 Premature loss of a primary tooth, especially dental morphology.13,136,139,162,163 Therefore, loss of space in the
in crowded dentitions, has the potential to cause loss of space dental arch that interferes with the desired eruption of the
permanent teeth may require evaluation.

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 BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION

The degree to which space is affected varies according to Such growth aberrations can be due to inherited growth
the arch, site in the arch, and time elapsed since tooth loss.164 patterns, trauma, or functional disturbances that alter normal
The quantity and incidence of space loss are dependent upon growth.167-169
which adjacent teeth are present in the dental arch and their
status.13,136 The amount of crowding or spacing in the dental Treatment considerations: Crossbites should be considered
arch will determine the consequence of space loss.163 in the context of the patient’s total treatment needs. Anterior
crossbite correction can: (1) reduce dental attrition; (2) improve
Treatment considerations: Space can be maintained or regained dental esthetics; (3) redirect skeletal growth; (4) improve the
with removable or fixed appliances.136,138 Some examples of tooth-to-alveolus relationship; (5) increase arch perimeter, (6)
fixed space regaining appliances are active holding arches, pen- help avoid periodontal damage, and (7) prevent the potential
dulum appliances, Halterman-type appliances, and Jones jig. for TMD.168,170 If enough space is available, a simple anterior
Examples of removable space regaining appliances are Hawley crossbite can be aligned as soon as the condition is noted.
appliance with springs, lip bumper, and headgear.138 If space Treatment options include acrylic incline planes, acrylic re-
regaining is planned, a comprehensive analysis should be tainers with lingual springs, or fixed appliances with springs.
completed prior to any treatment decisions. Some factors If space is needed, an expansion appliance also is an option.166
that should be considered in the analysis include: dentofacial Posterior crossbite correction can accomplish the same objec-
development, age at time of tooth loss, tooth that has been tives and can improve the eruptive position of the succedaneous
lost, space available, and space needed.136,138 teeth. Early correction of posterior crossbites with a mandibular
functional shift has been shown to improve functional condi-
Treatment objectives: The goal of space regaining intervention tions significantly and largely eliminate morphological and
is the recovery of lost arch width and perimeter and/or im- positional asymmetries of the mandible.30,171,172 Contemporary
proved eruptive position of succedaneous teeth. Space regained evidence indicates a need for long-term studies to assess the
should be maintained until adjacent permanent teeth have possibility for spontaneous crossbite correction, as current
erupted completely and/or until a subsequent comprehensive proof is conflicting.173 Functional shifts should be eliminated
orthodontic treatment plan is initiated. as soon as possible with early correction169 to avoid TMD
and/or asymmetric growth.167,173 Treatment can be completed
Crossbites (dental, functional, and skeletal) with:
General considerations and principles of management: Cross- 1. equilibration.
bites are defined as any abnormal buccal-lingual relation 2. appliance therapy (fixed or removable).
between opposing incisors, molars, or premolars in centric 3. extractions.
relation.165-167 If the mid lines undergo a compensatory or 4. a combination of these treatment modalities to
habitual shift when the teeth occlude in crossbite, this is correct the alveolar constriction.173
termed a functional shift.163 A crossbite can be of dental or
skeletal origin or a combination of both.163 Skeletal expansion with fixed or removable palatal expand-
A simple anterior crossbite is of dental origin if the molar ers can be utilized until mid line suture fusion occurs.163,165
occlusion is Class I and the malocclusion is the result of an Treatment decisions depend on the:
abnormal axial inclination of maxillary and/or mandibular 1. amount and type of movement (tipping versus bodily
anterior teeth. This condition should be differentiated from a movement, rotation, or dental versus orthopedic
Class III skeletal malocclusion where the crossbite is the result movement);
of the basal bone position.165 Posterior crossbites may be the 2. space available;
result of bilateral or unilateral lingual position of the maxillary 3. AP, transverse, and vertical skeletal relationships;
teeth relative to the mandibular posterior teeth due to tipping 4. growth status; and
or alveolar discrepancy, or a combination. Most often, uni- 5. patients cooperation.
lateral posterior crossbites are the manifestation of a bilateral
crossbite with a functional mandibular shift.167 Dental Patients with crossbites and concomitant Class III skeletal
crossbites may be the result of tipping or rotation of a tooth patterns and/or skeletal asymmetry should receive compre-
or teeth. In this case, the condition is localized and does not hensive treatment as covered in the Class III malocclusion
involve the basal bone. In contrast, skeletal crossbites section.
involve disharmony of the craniofacial skeleton.167,168
Aberrations in bony growth may give rise to crossbites in two Treatment objectives: Treatment of a crossbite should result
ways: in improved intramaxillary alignment and an acceptable
1. adverse transverse growth of the maxilla and interarch occlusion and function.171
mandible.
2. disharmonious or adverse growth in the sagittal (AP)
length of the maxilla and mandible.166,169

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BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION

Class II malocclusion (malposition of the teeth in the arches), skeletal factors

General considerations and principles of management: Class (asymmetry, mandibular prognathism, and/or maxillary
II malocclusion (distocclusion) may be unilateral or bilateral retrognathism), anterior functional shift of the mandible, or a
and involves a distal relationship of the mandible to the combination of these factors.194
maxilla or the mandibular teeth to maxillary teeth. This rela- The etiology of Class III malocclusions can be hereditary,
tionship may result from dental (malposition of the teeth in environmental, or both. Hereditary factors can include clefts
the arches), skeletal (mandibular retrusion and/or maxillary of the alveolus and palate as well as other craniofacial ano-
protrusion), or a combination of dental and skeletal factors.6 malies that are part of a genetic syndrome.195,196 Some environ-
Results of randomized clinical trials indicate that Class II mental factors are trauma, oral/digital habits, caries, and early
malocclusion can be corrected effectively with either a single childhood OSAS.197
or two-phase regimen.174-177 Growth-modifying effects in some
studies did not show an influence on the Class II skeletal Treatment considerations: Treatment of Class III malocclu-
pattern,177-179 while other studies dispute these findings.180,181 sions is indicated to provide psychosocial benefits for the
There is substantial variation in treatment response to growth child patient by reducing or eliminating facial disfigurement
modification treatments (headgear or functional appliance) and to reduce the severity of malocclusion by promoting
and no reliable predictors for favorable growth response have compensating growth.198 Interceptive Class III treatment has
been found.168,174 Some reports state interceptive treatment been proposed for years and has been advocated as a necessary
does not reduce the need for either premolar extractions or tool in contemporary orthodontics, with initiation in the
orthognathic surgery,176,177 while others disagree with these primary-early mixed dentition recommended.199-208 Factors to
findings.182 Two-phase treatment results in significantly longer consider when planning orthodontic intervention for Class
treatment time169,176,183 although the time spent in full bonded III malocclusion are: (1) facial growth pattern; (2) amount of
appliance therapy in the permanent dentition can be signifi- AP discrepancy; (3) patient age; (4) projected patient compli-
cantly less.184 ance; and (5) space analysis.
Clinicians may decide to provide interceptive treatment
based on other factors.176,180 Evidence suggests that, for some Treatment objectives: Interceptive Class III treatment may
children, interceptive Class II treatment may improve self- provide a more favorable environment for growth and may
esteem and decreases negative social experiences, although the improve occlusion, function, and esthetics.109 Although inter-
improvement may not be different longterm.180,185 Early Class ceptive treatment can minimize the malocclusion and poten-
II correction may improve facial convexity and/or reduce tially eliminate future orthognathic surgery, this is not always
incidence of maxillary anterior tooth trauma.186,191 An overjet possible. Typically, Class III patients tend to grow longer and
in excess of three millimeters is associated with an increased more unpredictably and, therefore, surgery combined with
risk of incisor injury, with large overjets (greater than eight orthodontics may be the best alternative to achieve a satisfac-
millimeters) resulting in trauma in more than 40 percent of tory result for some patients, especially if they exhibit facial
children.192,193 characteristics as follows: mandible forward to cranial base,
increase mandibular length, short ramal length, or obtuse
Treatment considerations: Factors to consider when planning gonial angle.59,210-212
orthodontic intervention for Class II malocclusion are: (1) Treatment of a Class III malocclusion can be achieved
facial growth pattern; (2) amount of AP discrepancy; (3) patient using several modalities including protraction therapy with or
age; (4) projected patient compliance; (5) space analysis; (6) without rapid palatal expansion, functional appliances, inter-
anchorage requirements; and (7) patient and parent desires. maxillary elastics with modified miniplates, or chin cup
Treatment modalities include: (1) extraoral appliances head- therapy.199-202,210,213-218 These interventions in a growing patient
gear; (2) functional appliances; (3) fixed appliances; (4) tooth should result in improved overbite, overjet, and intercuspa-
extraction and interarch elastics; and (5) orthodontics with tion of posterior teeth and an esthetic appearance and profile
orthognathic surgery.163 compatible with the patient’s skeletal morphology.

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