Planet Jupiter

First Edition
2023
 PLANETS OF
ORTHODONTICS
Volume 6: Orthodontic Treatment in Growing Patients

Authors

Dr. Mohammed Almuzian

Specialist Orthodontist (UK)
BDS Hons (UoM), MDS Ortho. (Distinction), MSc.HCA (USA), Doctorate Clin.Dent. Ortho. (Glasgow), Cert.SR Health
(Portsmouth), PGCert.Med.Ed (Dundee), MFDRCSIre., MFDSRCSEd., MFDTRCSEd., MOrth.RCSEd., FDSRCSEd.,
MRACDS.Ortho. (Australia)

Dr. Haris Khan

Consultant Orthodontist (Pakistan)
Professor in Orthodontics (CMH Lahore Medical College)
BDS (Pakistan), FCPS Orthodontics (Pakistan), FFDRCS Ortho. (Ire.)

With

Dr. Ali Raza Jaffery

Specialist Orthodontist (Pakistan)
Associate Professor Orthodontics (Akhtar Saeed Medical and Dental College)
BDS (Pakistan), FCPS Orthodontics (Pakistan), MOrth.RCS (Edin.)

Dr. Farooq Ahmed

Consultant Orthodontist (UK)
BDS. Hons. (Manc.), MDPH (Manc.), MSc (Manc.), MFDS (RCS Ed.), PGCAP, MOrth.RCS (Eng.), FDSRCS Ortho.
(Eng.), FHEA
 Acknowledgments

This book is the sum and distillate of work which would not have been possible without the support of our families
and friends. Special thanks to Dr Samer Mheissen and Dr Mark Wertheimer for their valuable time in proofreading this
volume. Additionally, we would like to thank the rest of the contributors to this volume for their time and expertise in
updating individual chapters.
 Contributors
Dr. Samer Mheissen/ Specialist Orthodontist (Syria)
Dr. Mark Wertheimer/ Consultant Orthodontist (South Africa)
Dr. Mushriq Abid/ Specialist Orthodontist and Professor in Orthodontics (Iraq/ UK)
Dr. Emad E Alzoubi/ Specialist Orthodontist and Lecturer of Orthodontics (Malta)
Dr. Loulwa Alnaser/ Specialist Orthodontist (Kuwait/ UK)
Dr Rim Fathalla/ Specialist Orthodontist (Egypt)
Dr Lubna Almuzian/ Specialist Paediatric Dentist (UK)
Dr. Lina Sholi/ Specialist Orthodontist (KSA/ Turkey)
Dr Hisham Abo Alroos/ Specialist Orthodontist (Egypt)
 Copyrights

All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any
means, including photocopying, recording, or other electronic or mechanical methods, without the prior written
permission of Dr Mohammed Almuzian and Dr Haris Khan who have the exclusive copyright, except in the case of
brief quotations embodied in critical reviews and certain other non-commercial uses permitted by copyright law. For
permission requests, contact them at [email protected]
 Preface

Questions expose our uncertainty, and uncertainty has been our motive. The authors and contributors have aggre-
gated this book and the series of books to follow in answer to questions covering the breadth and depths of ortho-
dontics.

This volume describes the most common orthodontic appliances and their applications in orthodontics. The theme
of this chapter is Mercury, as it has been known for a long time because it is visible to the naked eye.

The writing of the book started with the amalgamation of orthodontic notes and the experience of the two main
authors, Dr Mohammed Almuzian and Dr Haris Khan, it organically grew with input from other authors who helped in
proofreading, summarising the key points of each chapter, and implementing the ‘exam night review section. There
have been numerous contributors to this book, we seek to acknowledge them. To give credit where it is due, the role
of the authors and contributors of this volume are listed on the title page of each individual chapter.
Table of Contents
Interceptive orthodontics......................................... 1
Features of developing occlusion..............................................2
Timing of IO................................................................................2
Aims of IO...................................................................................2
Possible problems in the developing dentition.......................2
Lack of space in developing occlusion ...................................3
Management of the lack of space in developing occlusion ...3
Indications of serial extraction..................................................4
Advantages of serial extractions................................................4
Disadvantages of serial extractions...........................................4
Premature loss of primary teeth................................................4
Types of space maintainers........................................................4
Space regaining ...........................................................................5
Balancing and compensatory ..................................................5
Asymmetric dental development..............................................5
Impacted incisors ......................................................................5
Infraoccluded primary teeth.....................................................5
Retained primary teeth..............................................................6
Impacted permanent canines....................................................6
Ectopic eruption of permanent first molar (PFM).................6
The poor prognosis of the permanent first molar..................6
Trauma to the incisors ...............................................................6
Hyperdontia ...............................................................................6
Hypodontia..................................................................................6
Management of anterior crossbites ........................................6
Maxillary midline diastema.......................................................6
Exam night review ....................................................................8

Early treatment of crossbites ................................... 12

Basic terminologies ....................................................................13
Anterior crossbite........................................................................13
Incidence of anterior crossbite..................................................13
Aetiological factors of anterior crossbite.................................13
Problems associated with anterior crossbite ..........................13
Success of treatment of anterior crossbite ...............................13
Treatment modalities of anterior crossbite ............................13
The consequence of posterior crossbite...................................14
Benefits of treating posterior crossbite with displacement ..14
Unilateral posterior crossbite with displacement .................14
Posterior crossbite.......................................................................14
 Prevalence posterior crossbite ..................................................14
Aetiology of posterior crossbite................................................14
Unilateral buccal crossbite with no displacement .................15
Bilateral buccal crossbite ...........................................................15
Posterior mandibular displacement and lingual crossbite....15
EXAM NIGHT REVIEW.........................................................15

Ectopic eruption and impaction of FPM................. 18

Normal eruption process of first permanent molars..............19
Types of ectopic eruption of FPM............................................19
Incidence of ectopic FPM..........................................................19
Aetiology factors of ectopic eruption of FPM.........................19
Complications of ectopic FPM..................................................19
Diagnostic features of ectopic FPM..........................................19
Classification of ectopic FPM ...................................................20
Management of ectopic FPM....................................................20
Methods to regain space following the early loss of PSM .....20
Exam night review......................................................................21

First Permanent Molars with Poor Prognosis......... 24

Incidence of poor prognosis FPMs...........................................25
Advantages of extraction of first permanent molars..............25
Indications for extracting FPMs...............................................25
Options for Timing of Extraction.............................................25
Problems of PFM extraction ....................................................26
Exam night review......................................................................28

Infraocclusion of Primary Teeth ............................. 31

Incidence of IPM.........................................................................32
Clinical presentation of IPM.....................................................32
Aetiology of IPM.........................................................................32
Classification of IPM (Brearley and McKibben, 1973).........32
Clinical presentations of IPM ..................................................32
Treatment options of IPM.........................................................32
Management of IPM...................................................................33
Prognosis of IPM........................................................................34
Consequences of IPM.................................................................34
Exam night review .....................................................................35

Maxillary Midline Diastema.................................... 38

Prevalence of midline diastema................................................39
Causes of midline diastema.......................................................39
Diagnostic feature for a prominent labial frenum .................39
Management of median diastema.............................................39
 Exam night review .....................................................................40

Loss of permanent incisorS...................................... 42

Incidence of traumatic loss........................................................43
Potential problems of missing incisors ...................................43
Rationale for treatment..............................................................43
Multidisciplinary management.................................................43
Factors affecting treatment options..........................................43
Treatment options ......................................................................43
Exam Night Review....................................................................46
Definitive management..............................................................44
Survival rates for each replacement option.............................44
Considerations for opening or closing space of the lost inci-
sors................................................................................................44
Retention......................................................................................45

Mouthguards ........................................................... 48
Prevalence of trauma..................................................................49
Materials used to construct a mouthguard. ...........................49
Types of mouthguard.................................................................49
Exam night review......................................................................50
 1
Interceptive
orthodontics
Written by: Mohammed Almuzian and Haris Khan

In this chapter
1. Timing of Interceptive Orthodontics (IO) 15. Balancing and compensatory extractions of primary
2. Aims of IO dentition

3. Normal features of developing occlusion 16. Asymmetric dental development

4. Routine screening 17. Impacted incisors

5. Possible problems in the developing dentition 18. Infraoccluded primary teeth

6. Lack of space in developing occlusion 19. Retained primary teeth

7. Management of the lack of space in developing occlu- 20. Impacted permanent canines
sion 21. Ectopic eruption of permanent first molar (PFM)
8. Indications of serial extraction 22. The poor prognosis of the permanent first molar
9. Advantages of serial extractions 23. Trauma to the incisors
10. Disadvantages of serial extractions 24. Hypodontia and hyperdontia
11. Premature loss of primary teeth 25. Hypodontia
12. Types of space maintainers 26. Management of anterior crossbites
13. Complications of space maintainers 27. Maxillary midline diastema
14. Space regaining 28. EXAM NIGHT REVIEW

INTERCEPTIVE ORTHODONTICS 1
Interceptive orthodontics (IO) is the timely diagnosis and space is provided by labial positioning of the incisors.
treatment of potential discrepancies in the craniofacial com-
• The utilisation of primate space.
plex. Interceptive treatment aims to reduce or eliminate the
need for future orthodontic treatment. IO is usually carried Leeway space is the term used to describe the difference in
out in the mixed dentition phase but less commonly in the size between primary molars and their permanent successors.
late primary phase. The main advantages of early treatment The successor teeth are generally narrower than the primary
are optimal patient compliance and reduced complexity of teeth. In the lower arch, each quadrant has a Leeway space of
future treatment. Nevertheless, complicated cases may need approximately 2-2.5 mm, while in the upper arch, it is about
future comprehensive treatment during the permanent denti- 1.5mm per quadrant.
tion phase (Chung and Kerr, 1987). In addition to malocclu-
Timing of IO
sions of dental aetiology, skeletal problems can be intercepted
(Sunnak et al., 2015). Timing of IO depends upon the type of malocclusion, pro-
posed interceptive treatment, and dental and skeletal matu-
Appropriate IO may decrease the need for specialist orth-
rity of the patient. For accurate planning, appropriate and ac-
odontic treatment (Kerosuo et al., 2008); it has been reported
curate mixed dentition space analysis should be carried out,
that 15 % of cases developing a malocclusion in the primary
as incorrect calculation of the required space may hinder the
and mixed dentition phase can be corrected entirely, and 49
treatment goals (Galvao et al., 2013, Luu et al., 2011).
% improved by simple IO procedures (Ackerman and Proffit,
1980). Moreover, a previous study reported that one in three Aims of IO
children aged between 9 and 11 would have derived some The aims of IO include:
benefit from IO (Nimri and Richardson, 1997). Interceptive
orthodontics is particularly beneficial in the following condi- • Improved outcomes of the adolescent phase of treat-
tions: ment by minimising the extent of the malocclusion (King et
al., 1990).
• Medically compromised patients
• Removal of primary causative factors of malocclu-
• Physically or mentally handicapped patients, sion (Arvystas, 1998).
• Uncooperative patients. • Elimination of occlusal interferences, such as cross-
Features of developing occlusion bites (Baccetti et al., 1997).
It is essential to understand the normal features of develop- • Correction of skeletal Discrepancy (Tulloch et al.,
ing occlusion during the mixed dentition phase, which starts 1997).
from the age of 5-6 years to the exfoliation of the last primary • Managing arch length discrepancies to avoid or
tooth at about 12 years of age (Fleming et al., 2008). When the minimize future needs for extractions to relieve crowding
first permanent molars erupt, they are usually in a half-unit (Arvystas, 1998).
Class II relationship; these are guided by the distal surfaces of
the primary second molars (flush terminal plane). However, • Interception of developing malocclusion to lessen its
a Class I molar relationship is later achieved via: effects (Petren and Bondemark, 2008).
• Early mesial shift- the mesial movement of molars • Correction of functional interferences (DiBiase,
into the primate space. 2002).
• Late mesial shift- the mesial movement of molars • Preventing or reducing the incidence of trauma, e.g.
into the Leeway space. incisal trauma (Batista et al., 2018).
• Differential mandibular growth. • Prevention of pathology.
The permanent upper incisors are 7.6 mm larger than the pri- • Psychological benefits.
mary incisors, and the lower incisors are 6 mm larger than Possible problems in the developing dentition
their successors. This difference in size is known as incisor
liability, which is ultimately resolved via: General dentists usually screen the developing dentition of
children aged 8-10 to recognise unusual development (Scott
• Jaw/alveolar growth. and Atack, 2015). Radiographs may be required if suspected
• Increase in intercanine width: An extra 2mm space unerupted teeth are developing unusually. The principle of
is provided by increased intercanine width, which is more in A.L.A.R.P (as low as reasonably practicable) should always
the maxillary arch and boys. be considered. Common radiographs are periapical and DPT,
with the later image showing significant findings in 30% of
• Labial eruption of permanent incisors: 1 to 2mm the cases (Neal and Bowden, 1988). The possible problems

2 INTERCEPTIVE ORTHODONTICS
that can be identified in the developing dentition are: • Lower second molar bifurcation is starting to form.
• Lack of space. • The angle between the long axis of crypts of 6 and 7
= 15-30 degrees, and the crypt of lower 7 overlaps the root of
• Premature loss of primary teeth.
lower 6.
• Asymmetric dental development.
Moreover, the elective extraction of the 7s to the relief of pre-
• Retained primary teeth. molar crowding is an another outdated approach in manag-
ing the lack of space in developing occlusion (Richardson
• Infraocclusion of primary teeth.
1992). The requirements for second molar prophylactic ex-
• Impacted incisors. traction (Lehman, 1979) are:
• Impacted permanent canines. • All third molars are present and of normal size and
• Ectopic eruption of the permanent first molar. shape

• Poor prognosis of the permanent first molar. • The third molar of 15 – 30 degrees to the long axis of
the first molar
• Trauma.
• The 3rd molars roots are not developed yet.
• Hypodontia and hyperdontia.
The disadvantages of this approach are:
• Anterior or posterior crossbite.
• Third molars may erupt into an unsatisfactory posi-
• Abnormal habits. tion, which is less common in the maxilla at 3.8%, however, it
Lack of space in developing occlusion is prevalent in the mandible with a risk of 33.8%.

Ideally, spacing should be present in primary dentition; if • Difficult to predict where third molars will erupt un-
the child has crowded primary dentition, it is almost certain satisfactory (Thomas and Sandy, 1995).
that the child would have crowding in permanent dentition. • The second course of treatment to orthodontically
A 3mm spacing in the primary dentition indicates a 50% upright the third molar may be required (Orton and Jones,
chance of crowding in the permanent dentition, while a 6 1987).
mm spacing means that the chances of future crowding are
negligible (Leighton, 1969). Elective extraction of the premolars is another solution to
manage the lack of space in developing occlusion. Early loss
Management of the lack of space in developing occlusion of the first premolars with mesially inclined canines can im-
Extraction of deciduous canines has been suggested to cor- prove certain malocclusions and can reduce time with active
rect mild lower incisor crowding. Houston and Tulley (1989) appliances. Similarly, the extraction of 4s with space mainte-
stated that the extraction of deciduous canines allows some nance can allow impacted 5s to erupt.
correction of the incisor crowding. Stephens (1989) reported Serial extraction is another option. Serial extraction was pop-
that the ideal age group for extraction of deciduous canines is ularised in Europe in the 1930s and was recorded by Kjellgren
9-10 years to allow full development of the intercanine width. (1947). The early philosophy behind serial extractions was to
However, this may result in tipping of the lower incisors lin- align severely crowded teeth without further need for treat-
gually and reducing the arch length. Extraction of upper de- ment. Steps of serial extraction are:
ciduous canines is often suggested to encourage a palatally
placed canine to erupt into a normal position; research has • Relieve crowding in the incisor region by extraction
shown that this is successful in most cases with 69-70% im- of upper and lower Bs and Cs
proving into favourable positions (Ericsson and Kurol, 1988). • Extraction of Ds when half their roots are resorbed.
Elective extraction of the 6s is an outdated approach to man- This encourages the early eruption of 4s before 3s. If extracted
age the lack of space in developing occlusion. Wilkinson’s too early, this may result in delayed eruption and excessive
criteria (1940) for prophylactic management of crowding by space loss.
extracting the 6s are: • Extraction of 4s on eruption to allow alignment of
• Class I incisors. 3s. However, there is no guarantee that the lower premolar
will erupt before the canine so the latter may be impacted.
• All successional teeth and the third molars are pres-
ent.
• Mild anterior segment crowding.
• Moderate posterior crowding.

INTERCEPTIVE ORTHODONTICS 3
However, if this happens, then extraction of the second de- Space maintainers are primarily used in the late mixed denti-
ciduous molars may be an option. tion to prevent posterior teeth’ mesial movement, resulting in
space loss and crowding of permanent teeth but it should be
Nowadays, a modified serial extraction is more common and
carefully monitored at 3-6 months intervals. Space maintain-
it includes applying extraction of the Cs, Ds 4s.
ers are associated with some problems such as pain, caries,
Indications of serial extraction soft tissue overgrowth, fracture of the solder joint, interfer-
ence with the eruption of permanent teeth and exhausting
These include:
(burning) patient compliance. Space maintainers are primar-
• Skeletal Class I. ily indicated in the following circumstances:
• Normal overjet and overbite. • In case of mild crowding where space maintainers
• All permanent teeth are present. can prevent future potential extractions.

• Severe crowding. • In severe crowding where crowding cannot be re-

lieved, even with all first premolar extractions.
• First permanent molars of good prognosis.
• In Class 2 and 3 cases to maintain the position of the
• 4s developmentally ahead of 3s. molars.
Advantages of serial extractions It is worth mentioning that if there is spacing or mild to
These include: moderate crowding demanding a future extraction, no space
maintenance is recommended.
• In theory, no appliance treatment is needed.
Types of space maintainers
• Future appliance therapy may be straightforward
and short in duration (Little 1990), Different types of space maintainers are available such as:

• Good stability due to tooth formation being com- • Band and loop space maintainer: This is a unilateral
pleted in the ideal location for treatment outcomes (Graber, space maintainer used to preserve primary molar space. It is
2011) constructed from 0.9 mm SS wire soldered to the molar band
and adapted to be 1.5 mm above the alveolar ridge.
Disadvantages of serial extractions
• Partial denture space maintainer: This type of space
These include: maintainer is mostly used for bilateral space loss in poste-
• A patient receives multiple extractions (12 teeth). rior teeth. Primary incisors are not crucial for nutrition and
speech development, but partial denture space maintainers
• Extractions of Ds might lead to the impaction of 4s can improve the child’s aesthetics and social wellbeing of the
if the 3s erupt ahead of the 4s. child.
• Difficulty in predicting the amount of incisor crowd- • Distal shoe space maintainer: This appliance pre-
ing. vents mesial movement of the first permanent molar in case
• Space loss through unwanted movement following of premature loss of the second deciduous molar. The distal
extraction of Cs and especially Ds, by a mesial drift of buccal portion of the space maintainer should extend 1 mm below
segments, and lower incisor tip lingually, both reducing the the marginal ridge of the unerupted first permanent molar.
arch length. • Lingual and transpalatal arch: They are bilateral
• Tipping teeth into the extraction site, especially an- space maintainers used in upper and lower arches. According
terior teeth, can cause an increase in overbite (Little 1990). to a systematic review, the lingual arch used on mandibular
molars effectively controls their mesial movement and pre-
• Potential loss of the Leeway space (Chen, 2019). vents distal movement of the incisors (Viglianisi, 2010).
Premature loss of primary teeth • Bonded space maintainers: They are primarily giv-
Extraction of deciduous canines may cause a midline shift. en in the maxillary anterior region. An excellent example of
If pre-existing crowding exists, crowding can localise at the bonded space maintainer for missing permanent incisors is
site of extraction as teeth drift into the site, encouraging sub- a Maryland bridge. In addition to maintaining space, these
sequent teeth to erupt into the site (Borrie and Bearn, 2013). space maintainers provide excellent aesthetics. Unfortunate-
Premature loss of primary teeth may lead to space distribu- ly, these space maintainers have more failure rates than other
tion and arch symmetry issues. Hence, balancing, compen- space maintainers. According to a systematic review, the av-
sating extractions or space maintenance might be indicated erage survival period of bonded space maintainers is 11.2
months (Seehra et al., 2018).

4 INTERCEPTIVE ORTHODONTICS
Space regaining Some patients with asymmetric dental development have
a history of childhood radiation therapy to the head and
It is a procedure that can be employed if space has been lost
neck or traumatic injury. Some of these teeth have severely
due to drifting. Regaining space is limited to 3mm or less
dilacerated roots and will not be candidates for orthodon-
and can be provided using:
tics; this complex situation usually requires early interven-
• Sectional fixed appliance. tion. Surgical and orthodontic treatment for these patients
must be planned and timed carefully; it may require tooth
• Removable appliances such as Schwarz appliances
removal or orthodontic tooth movement.
(McNamara, 2001).
Impacted incisors
• Lip bumper.
Treatment of impacted incisors in patients under nine years
• Headgear.
with incomplete root development of permanent incisors
• Molar distalization techniques. includes:
Balancing and compensatory extractions of primary den- • Remove obstructions such as supernumerary teeth
tition or odontomas (Seehra et al. 2018).
Removal of primary teeth is indicated to reduce/prevent • Create space if required.
a malocclusion of the permanent dentition; however, the
• Maintain the space.
decision to extract primary teeth should be based on tooth
type. Radiographic screening is highly desirable before • Monitor eruption for 18 months – 80% erupt
extracting primary teeth to check for the presence, position spontaneously (Seehra et al. 2018).
and correct formation of the crowns and roots of succes-
• If exposure is required, then expose minimally and
sional teeth.
wait for 6 months. If a tooth is still high, expose and bond
Balancing extractions is the planned extraction of the attachment (such as a gold chain).
same contralateral tooth (same arch on the opposite side)
Treatment of impacted incisors in patients above nine years
to maintain the centreline. While compensation extrac-
with complete or nearly complete root development of
tions are the scheduled extraction of the same tooth in the
permanent incisors includes:
opposing arch (same side of the opposing arch) to prevent
overeruption and posterior occlusal discrepancies. • Remove obstruction.
Early loss of primary incisors has little effect on perma- • Create space if required.
nent dentition, although it can create aesthetic concerns.
• Maintain the space
Hence, it is unnecessary to balance or compensate for the
loss of a primary incisor. At the same time, the early loss of • If permanent incisors are high, then monitor erup-
a unilateral primary canine will likely affect the centreline tion for 12 months.
(in the direction of the lost tooth). The more crowded the • If unerupted at 12 months, expose and bond at-
dentition, the greater the potential effect on the centreline; tachment as required.
therefore, the greater need for balancing. In spaced denti-
tion, the loss of a primary canine is unlikely to affect the Treatment of impacted incisors in patients over 10 years
centreline. includes:
Balancing extractions may be needed in a crowded arch • Remove obstruction.
secondary to premature loss of primary first molars, but • Create space if required.
compensation is not required. However, there is no need to
balance the loss of a primary second molar because their • Maintain the space
loss has no appreciable effect on the centreline. If the pri- • Expose and bond attachment at the first operation.
mary second molar must be extracted, consideration should
be given to fitting a space maintainer to prevent mesial If there is a significant dilaceration of the incisors’ root
migration of the first permanent molar. or ankylosis, incisor removal and replacement might be a
sensible option.
Asymmetric dental development
Infraoccluded primary teeth
Asymmetric eruption (one side ahead of the other by 6
months or more) requires careful monitoring; an absence of Please see the chapter on Infraocclusion of Primary Teeth
outright pathology often requires early treatment, such as for more information.
selective extraction of primary or permanent teeth.

INTERCEPTIVE ORTHODONTICS 5
Retained primary teeth Hyperdontia
A permanent tooth should replace its primary predecessor The interceptive treatment of supernumerary teeth includes:
when approximately three-fourths of the root of the perma-
• Leave and monitor: This is mainly indicated if
nent tooth has formed; however, it is recommended to be
there is no associated pathology, satisfactory eruption of
removed if a primary tooth is retained beyond this point. A
related teeth, or removal would prejudice the vitality of the
retained primary tooth can lead to gingival inflammation
associated teeth.
and hyperplasia, causing pain and deflected path of erup-
tion of the permanent teeth that can result in irregularity, • Extraction followed by orthodontic treatment: This
crowding, and crossbite. is indicated if the supernumerary tooth is causing aesthetic
problems, preventing the eruption of permanent teeth,
Suppose a portion of the permanent tooth crown is visible
causing diastema or displacement, causing pathology or if
and the primary tooth is mobile to the extent that the crown
the active orthodontic alignment of the incisors will result
will move 1 mm in the facial and lingual direction. In that
in close proximity of the incisor roots to the supernumer-
case, it is advisable to encourage the child to “wiggle” the
ary. Extraction of supernumerary teeth is also indicated if its
tooth to achieve exfoliation. If that cannot be accomplished
presence compromises secondary alveolar bone grafting in
over a short period, extraction of the mobile primary tooth
cleft lip and palate patients or if the tooth is present in bone
is indicated. Most over-retained primary maxillary molars
designated for implant placement.
have intact buccal or lingual roots; most over-retained
primary mandibular molars have either the mesial or distal Hypodontia
root still intact, hindering exfoliation.
No treatment for hypodontia in primary dentition is
Once the primary tooth has been removed, moderately indicated. However, removable dentures can be used for
abnormal facial or lingual positioning of the deflected psychological and functional reasons; they require regular
permanent tooth will usually be self-corrected by equilib- adjustments during growth. Though retention and stability
rium forces of the lip, cheeks, and tongue (if the space is may be problematic in those with poorly developed alveolar
adequate). ridges. Hypodontia presented during mixed dentition might
require early primary tooth extraction to allow spontane-
Impacted permanent canines
ous space closure. Some recommend extracting the primary
Table 1 shows several methods for interception. The princi- tooth, allowing permanent teeth to erupt and close space,
ples of interceptive treatment for palatal canines are remove and then reopening space at adulthood by preserving the
any obstruction – this usually means removal of the decidu- bone. Alternatively, composite build-ups to improve the
ous canine, and ensuring adequate space for the eruption aesthetics of microdont permanent teeth or worn deciduous
teeth are indicated. Sometimes, it is better to retain the pri-
Ectopic eruption of permanent first molar (PFM)
mary tooth as long as possible and replace the space with a
Please see the chapter on Ectopic Eruption and Impaction prosthesis after the cession of the growth, as this could help
of First Permanent Molars for more information. preserve alveolar bone. (Bjerklin & Bennett,2000)
The poor prognosis of the permanent first molar Management of anterior crossbites
Please see the chapter on First Permanent Molars with Poor Please see the chapter on Early treatment of crossbites for
Prognosis for more information. more information.
Trauma to the incisors Maxillary midline diastema
The traumatic loss of a maxillary central incisor usually Please see the chapter on Maxillary Midline Diastema for
occurs unilaterally in the mixed dentition and a child with more information.
an increased overjet leading to possible dilacerations and
failure of the eruption (Topouzelis et al., 2010). Short-term
management can be achieved with a simple upper partial
denture. Alternatively, the space can close and reopen in the
permanent dentition before prosthetic replacement. This
allows preservation of alveolar bone but will require fixed
appliance treatment and often space creation in the upper
arch. Long-term management includes space closure and
build-up of lateral incisors or space opening with restor-
ative replacement or autotransplantation of premolar and
subsequent coronal modification.

6 INTERCEPTIVE ORTHODONTICS
Table 1: Interceptive technique for palatally impacted canines

Extraction of the primary canines at the Ericson and Kurol, 1988 78% success rate
age between 10 and 13 years.

Extraction of the primary canines in Power and Short, 1993. In general, 62% showed improvement in eruptive
crowded and uncrowded cases position. In crowded cases the success rate was 14%
as opposed to 86% in un-crowded cases

The extraction of the deciduous canine Olive, 2002 94% success rate
and creation of excess space for the
impacted tooth

Extraction of C + HG. RCT Leonardi et al., 2004 Headgear plus extraction: 80% success rate. Extrac-
tion: 50% success rate. Control 34% success rate.

Extraction of C + HG. RCT Baccetti et al., 2008, Headgear plus extraction: 88% success rate. Extrac-
tion: 65% success rate. Control 36% success rate.

Cochrane review Parkin, 2016 There is currently no evidence to support the extrac-
tion of the deciduous maxillary canine to facilitate
the eruption of the palatally ectopic maxillary per-
manent canine.

Effect of RME and headgear treatment Armi & Baccetti, 2011 RME plus Headgear plus extraction 86% success rate.
on the eruption of palatally displaced Headgear plus extraction: 83% success rate. Control
canines. RCT 36% success rate.

Effects of RME and TPA treatment asso- Bacceti 2011 RME plus Headgear plus extraction 80% success rate
ciated with deciduous canine extraction
Headgear plus extraction: 79%
on the eruption of palatally displaced
canines RCT by EXO 62.5% success rate
Control 28% success rate
A systematic review of the interceptive Kurol 2011 No evidence-based conclusions could be drawn due
treatment of palatally displaced maxil- to the few studies identified, the heterogeneity in
lary canines, , study design, and the unequivocal results

Preventive treatment of ectopically Bonetti 2011, 50% of canines in the TG improved position by one
erupting maxillary permanent canines sector and 13% by two sectors, while on 32% of the
by extraction of C & Ds: RCT canines in CG improved by one sector and none by
two sectors.

INTERCEPTIVE ORTHODONTICS 7
Exam night review • Poor prognosis of the permanent first molar
Interceptive orthodontics is the timely diagnosis and • Trauma
treatment of potential discrepancies in the craniofacial
• Hypodontia and hyperdontia
complex. It is usually carried out in mixed dentition.
• Anterior or posterior crossbite
Aims of IO
• Abnormal habits and local factors
1. Removal of primary causative factors of malocclu-
sion (Arvystas, 1998) Management of the lack of space in developing occlu-
sion
2. Elimination of occlusal interferences such as cross-
bites (Baccetti et al., 1997) • Extraction of deciduous canines
3. Correction of skeletal dysplasia (Tulloch et al., 1997) • Elective extraction of the 6s
4. Managing arch length discrepancies to avoid or • Elective extraction of the 7s to relieve premolar
reduce future needs for extractions to relieve crowding crowding (Richardson 1992).
(Arvystas, 1998)
• Elective extraction of the premolars:
5. Interception of developing malocclusion to lessen
• Serial extraction
its effects (Petren and Bondemark, 2008)
• Utilising Leeway space (Brennan & Gianelly 2000)
6. Correction of functional interferences leading to
ideal occlusion (DiBiase, 2002) Indications of serial extraction
7. Preventing or reducing the incidence of trauma, e.g. • Sever crowding
incisal trauma (Batista et al., 2018). • Skeletal Class I
8. Prevention of pathology • Normal overjet and overbite
9. Psychological benefits • 4s developmentally ahead of 3s
10. Improved outcomes of the adolescent phase of treat- • First permanent molars of good prognosis
ment including (King et al., 1990):
• All permanent teeth present
• Reduced treatment span,
Advantages of serial extractions
• Increased stability,
• In theory, no appliance treatment is needed
• Improved aesthetics,
• Future appliance therapy may be more straightfor-
• Less chances of permanent teeth extraction. ward and shorter (Little 1990),
11. To minimise the extent of malocclusion by: • Better stability due to tooth formation completed in
• Maintaining midline and minimising crowding, the ideal location for treatment outcomes (Graber, 2011)
• Preventing the development of full unit Class 2 mo- Disadvantages of serial extractions
lars. • Exposed patients to multiple extractions (12 teeth),
Possible problems in the developing dentition • No guarantee, extractions of Ds can lead to impac-
• Lack of space tion of 4s if the 3s erupt ahead of the 4s
• Premature loss of primary teeth • Growth prediction problems: Difficult to predict the
amount of incisor crowding
• Asymmetric dental development
• Space loss with extractions of Cs and especially Ds,
• Retained primary teeth
by the mesial drift of buccal segments, lower incisors tip
• Infraocclusion of primary teeth lingually, both of these reduces the arch length
• Impacted permanent incisors • Tipping of teeth into extractions sites, especially an-
terior teeth, causes deep overbite (Little 1990)
• Impacted permanent canines
Types of space maintainers
• Ectopic eruption of the permanent first molar
• Band and loop space maintainer

8 INTERCEPTIVE ORTHODONTICS
 • Partial denture space maintainer: • Satisfactory eruption of related teeth
• Distal shoe space maintainer: • Removal would prejudice the vitality of the associ-
ated teeth.
• Lingual arch.
B. Extract plus orthodontic treatment mainly indicat-
• Bonded space maintainers:
ed if:
Impacted incisors
• Supernumerary teeth caused the aesthetic problem.
1. Children under nine years with incomplete root devel-
• Supernumerary teeth prevent the eruption of per-
opment of permanent incisor:
manent teeth.
• Remove obstruction.
• Supernumerary teeth caused diastema or displace-
• Create space or maintain the space ment.
• Do not uncover bone from unerupted incisors • Supernumerary teeth caused pathology
maintain the integrity of the follicle.
Hypodontia
• Monitor eruption for 18 months – 80% erupt spon-
A. Treatment for hypodontia in primary dentition
taneously
• No treatment is indicated at this stage.
• If exposure is required, expose minimally to elimi-
nate soft tissue obstruction and wait for 6 months. If a B. Removable dentures for psychological and func-
tooth is still high, expose and bond bracket. tional reasons Mixed dentition (involve mainly the inter-
ceptive treatment)
2. Children above nine years with complete or nearly
complete apex: 1. Extract one tooth early to allow space closure.
• Remove obstruction. 2. Composite build-ups
• Create space if required. 3. Removable dentures
• Maintain the space 4. Orthodontic space redistribution
• If the permanent incisor is high, then monitor erup- 5. Retained primary tooth
tion for 12 months.
Management of anterior crossbites include
• If the tooth is still unerupted at 12 months, expose
• Habit cessation
and bond attachment as required.
• Selective grinding
3. Children referred late (over 10 years):
• Extraction of the opposing primary tooth
• Remove obstruction.
• Bodily movement with the use of 2*4 fixed appli-
• Create space if required.
ance
• Maintain the space
• Simple tipping movement with the use of URA
• Expose and bond attachment at the first operation.
• Protraction facemask
Impacted permanent canines
Management of posterior crossbites
The principles of interceptive treatment for palatal ca-
1. Encourage habit to stop
nines are:
2. Removal of premature contacts of the baby teeth
• Remove any obstruction – this usually means re-
moval of the deciduous canine, 3. Posterior onlay
• Ensure adequate space for eruption, 4. Extraction of the severely displaced single tooth.
• Table 1 shows several methods for interception. 5. Expand upper arch with:
Supernumerary teeth • URA with midpalatal screw, success rates are 50%
A. Leave and monitor mainly indicated if: • Coffin spring + posterior capping,
• There is no associated pathology • Quadhelix. (QH and RME success rates is 100%)

INTERCEPTIVE ORTHODONTICS 9
References Petrén S, Bondemark L. Correction of unilateral posterior
AL NIMRI, K. & RICHARDSON, A. 2000. Interceptive crossbite in the mixed dentition: a randomized controlled
orthodontics in the real world of community dentistry. Int J trial. Am J Orthod Dentofacial Orthop. 200 2018. Survival
Paediatr Dent, 10, 99-108. of Bonded Space Maintainers: A Systematic Review. Int J
Clin Pediatr Dent, 11, 440-445.
ARVYSTAS, M. G. 1998. The rationale for early orthodontic
treatment. American Journal of Orthodontics and Dentofa- SCOTT, J. K. & ATACK, N. E. 2015. The developing occlu-
cial Orthopedics, 113, 15-18. sion of children and young people in general practice: when
to watch and when to refer. Br Dent J, 218, 151-6.
BACCETTI, T., FRANCHI, L., MCNAMARA, J. A., JR.
& TOLLARO, I. 1997. Early dentofacial features of Class SUNNAK, R., JOHAL, A. & FLEMING, P. S. 2015. Is ortho-
II malocclusion: a longitudinal study from the deciduous dontics prior to 11 years of age evidence-based? A system-
through the mixed dentition. Am J Orthod Dentofacial atic review and meta-analysis. J Dent, 43, 477-86.
Orthop, 111, 502-9. TOPOUZELIS, N., TSAOUSOGLOU, P., PISOKA, V. &
BATISTA, K. B., THIRUVENKATACHARI, B., HARRI- ZOULOUMIS, L. 2010. Dilaceration of maxillary central
SON, J. E. & O’BRIEN, K. D. 2018. Orthodontic treatment incisor: a literature review. Dent Traumatol, 26, 427-33.
for prominent upper front teeth (Class II malocclusion) in TULLOCH, J. F., PROFFIT, W. R. & PHILLIPS, C. 1997.
children and adolescents. Cochrane Database Syst Rev, 3, Influences on the outcome of early treatment for Class II
Cd003452. malocclusion. Am J Orthod Dentofacial Orthop, 111, 533-
BORRIE, F. & BEARN, D. 2013. Interceptive orthodontics- 42.
-current evidence-based best practice. Dent Update, 40, VIGLIANISI, A. 2010. Effects of lingual arch used as space
442-4, 446-8, 450. maintainer on mandibular arch dimension: a systematic re-
CHUNG, C. K. & KERR, W. J. 1987. Interceptive orthodon- view. Am J Orthod Dentofacial Orthop, 138, 382.e1-382.e4.
tics: application and outcome in a demand population. Br
Dent J, 162, 73-6.
DIBIASE, A. 2002. The timing of orthodontic treatment.
Dent Update, 29, 434-41.
FLEMING, P. S., JOHAL, A. & DIBIASE, A. T. 2008. Manag-
ing malocclusion in the mixed dentition: six keys to success.
Part 1. Dent Update, 35, 607-10, 612-3.
KING, G. J., KEELING, S. D., HOCEVAR, R. A. & WHEEL-
ER, T. T. 1990. The timing of treatment for Class II maloc-
clusions in children: a literature review. Angle Orthod, 60,
87-97.
LEIGHTON, B. C. 1969. The early sighs of malocclusion.
Rep Congr Eur Orthod Soc, 353-68.
NEAL, J. J. & BOWDEN, D. E. 1988. The diagnostic value of
panoramic radiographs in children aged nine to ten years. Br
J Orthod, 15, 193-7.
NIMRI, K. A. & RICHARDSON, A. 1997. Applicability of
interceptive orthodontics in the community. Br J Orthod,
24, 223-8.
PETREN, S. & BONDEMARK, L. 2008. Correction of
unilateral posterior crossbite in the mixed dentition: a ran-
domised controlled trial. Am J Orthod Dentofacial Orthop,
133, 790.e7-13.
SEEHRA, J., YAQOOB, O., PATEL, S. ET AL. National clini-
cal guidelines for the management of unerupted maxillary
incisors in children. Br Dent J 224, 779–785 (2018).

10 INTERCEPTIVE ORTHODONTICS
11
 2
Early treatment of
crossbites
Written by: Mohammed Almuzian, Haris Khan, Loulwa Alnaser

In this Chapter
1. Basic terminologies 16. Posterior mandibular displacement and lingual cross-
2. Anterior crossbite bite

3. Incidence of anterior crossbite 17. EXAM NIGHT REVIEW

4. Aetiological factors of anterior crossbite

5. Problems associated with anterior crossbite
6. Factors affecting the success of treatment of anterior
crossbite
7. Treatment modalities of anterior crossbite
8. Posterior crossbite
9. Prevalence posterior crossbite
10. Aetiology of posterior crossbite
11. Consequence of posterior crossbite
12. Benefits of treating posterior crossbite with displace-
ment
13. Unilateral posterior crossbite with displacement
14. Unilateral buccal crossbite with no mandibular dis-
placement
15. Bilateral buccal crossbite

12 Early treatment of crossbites

2
The British standard glossary of dental terms defines crossbite as a • Supernumerary teeth,
transverse discrepancy in the tooth relationship. A crossbite may be
unilateral, bilateral, localised, or involve segments. • Ectopic eruption,
Early correction of anterior or posterior crossbite is recommended, • Lingual path of eruption,
especially if there is a functional displacement of the mandible;
• Trauma resulting in repositioned or sub-luxated
otherwise, it can perpetuate the mature jaws resulting in skeletal
disharmony (Zegan et al., 2015). An old orthodontic maxim states
tooth,
that “The best time to treat a crossbite is the first time it is seen”. • Arch length discrepancy,
If anterior crossbite is left untreated, it can cause mobility and
fracture of anterior teeth, periodontal breakdown, and temporo- • Developmental anomalies, e.g., cleft lip and palate,
mandibular dysfunction. and
Basic terminologies • Skeletal class III base.
• Buccal crossbite: The buccal cusps of the lower teeth oc- Problems associated with anterior crossbite
clude buccally to the upper teeth; the lower arch is relatively wider
These include:
• Lingual crossbite: The buccal cusp of the lower teeth
occludes lingual to the upper teeth palatal cusp; the lower arch is • Periodontal problems (gingival recession, bone
relatively constricted (Petren and Bondemark, 2008). dehiscence or traumatic bite),
• Anterior crossbite: Used to describe a reverse overjet of • Enamel wear,
one or more incisor teeth. There is an abnormal labiolingual incisal
relationship as one or more upper anterior teeth occlude lingual to • Mandibular displacement,
incisal edges of the lower front teeth (Tsai, 2001). If all present inci- • Tooth displacement out of arch line, and
sors are in an anterior crossbite, the term reverse overjet is used.
• Temporomandibular dysfunction though the evi-
• Centric relation (CR) of the mandible represents the
dence is conflicting on this topic.
position of the condyle in the most anterior and superior position
in the glenoid fossa. Factors affecting the success of treatment of anterior cross-
• Centric occlusion (CO) represents the final position of bite
teeth in occlusion. The success in treating anterior crossbite depends on many
• Displacement can be defined as a discrepancy between factors, including but not limited to:
CR and CO where the mandible encounters a deflecting or uncom-
fortable early contact point and displaces. • Patient’s compliance,

Anterior crossbite • Upper incisors inclination, more favourable for

upright or retroclined incisors,
Anterior crossbite has dental or skeletal aetiologies. In a
dental crossbite, functional displacements of the mandible • The degree of the dental crossbite discrepancy in
are present due to premature contacts of the teeth, leading to the anteroposterior direction,
CO-CR shift. In addition to that, the skeletal bases may be • Presence of available space,
normal. The cause is usually the positioning or axial inclina-
tion of the involved teeth (McEvoy, 1983). Skeletal aetiology • Degree of an overbite more favourable if the over-
is the likely reason if there is an anterior crossbite in centric bite is increased or average,
relation. In crowded cases, upper incisors erupt palatally and Treatment modalities of anterior crossbite
are trapped, resulting in limited lateral excursive movements
Treatment of anterior crossbite includes:
and an anterior crossbite.
• Inclined functional anterior bite plane,
Incidence of anterior crossbite
• Wooden tongue blades,
Anterior crossbite of a dental origin is found in approxi-
mately 4-5% of the population (Hannuksela and Väänänen, • Selective grinding and extraction of the primary
1987, Major and Glover, 1992), while in preadolescent orth- teeth: In the case of premature contacts, the options are
odontic patients, the incidence of anterior crossbite is 26.7% selective grinding of the primary teeth or extracting the op-
(Vithanaarachchi and Nawarathna, 2017). posing primary tooth.
Aetiological factors of anterior crossbite • Upper removable appliance (URA) with Z-spring,
double cantilever spring, sectional screw plate or crossed
These include:
cantilever spring.
• Retained primary teeth (McEvoy, 1983),

Early treatment of crossbites 13

• 2x4 fixed appliance: It is advisable to use a 2x4 fixed Solow and Tallgren had suggested that this effect may be
appliance with a Roth prescription to manage the U1s roots produced due to mouth breathing or airway obstruction
torque. Once an adequate overbite is achieved, there is no (Solow and Tallgren, 1976).
need for retention after correcting an anterior crossbite. To
• Parafunctional habits such as prolonged digit or
avoid potential root contact of the upper laterals and canines
thumb-sucking habits.
during incisors’ labial movement, removal of the primary
canine may be necessary to facilitate the eruption of U3s. In • Other causes include congenital causes: cleft lip and
some situations, it may be necessary to bond U2s after U3s palate, trauma or pathology of the TMJ.
have partially erupted to prevent root resorption.
The consequence of posterior crossbite
• Functional or orthopaedic appliances: In the case of
Displacement associated with posterior crossbite might lead
skeletal aetiology of the crossbite, functional or orthopaedic
to:
appliances can be used. This includes Frankel III appliance,
chin cup, or reverse pull headgear. According to a meta- • Abnormal dental and skeletal growth (McNamara,
analysis, interceptive treatment using reverse pull headgear 2002),
to correct crossbite due to maxillary hypoplasia is more • Temporomandibular joint problems (McNamara
effective in early mixed dentition (Kim et al., 1999). and Turp, 1997, Ninou and Stephens, 1994, O’Byrn et al.,
If the crossbite results from the change in axial inclination 1995). However, the association between posterior crossbite
of the involved teeth, a 2x4 appliance or URA with posterior with displacement and the afterwards development of TMD
capping is recommended. According to a randomised clini- is weak (Mohlin and Thilander, 1984), or
cal trial, early treatment of anterior crossbite can be under- • Tooth grinding (Malandris and Mahoney, 2004).
taken using removable or fixed therapy. Both options have
similar long-term stability (Wiedel and Bondemark, 2015). Benefits of treating posterior crossbite with displacement
Posterior crossbite These include:
In the case of unilateral posterior crossbite, the transverse • Avoid tooth surface loss.
discrepancy is likely to be symmetrical with cusp-to-cusp • Aesthetic benefits by widening the buccal corridor.
contact of the buccal cusps in RCP; however, the mandible
displaces laterally to one side to help achieve more func- • Psychological benefits.
tional and comfortable occlusion. • Creation of space to relieve crowding.
A posterior crossbite in the mixed dentition can be a predic- • Avoid TMD in the susceptible patient (weak evi-
tive factor of skeletal discrepancy in the permanent denti- dence).
tion. Hence, mixed dentition posterior crossbite can persist
into the permanent dentition. • Avoid exacerbation of plaque-related periodontal
damage.
Prevalence posterior crossbite
• Eliminate the undesirable growth modification
Prevalence of posterior crossbite is between 8- 22 % (Kutin effects of the displacement, resulting in true mandibular
and Hawes, 1969, Egermark-Eriksson et al., 1990, Heikin- asymmetry (Pinto et al., 2001). Interceptive correction of
heimo, 1978, Perillo et al., 2009). However, 80% of these posterior crossbite and displacement elimination is advis-
crossbites are associated with mandibular displacement with able to avoid worsening the skeletal discrepancy (Harrison
no difference between gender and race. and Ashby, 2001, Proffit, 2000). Therefore, it is essential to
Aetiology of posterior crossbite prevent the development of posterior crossbite in the perma-
nent dentition, which may reduce the need for fixed appli-
The aetiologies of posterior crossbite include: ances in permanent dentition (Petrén et al., 2003).
• Skeletal factors due to mismatch in the relative Unilateral posterior crossbite with displacement
widths of the arches or true skeletal asymmetry, i.e., hemi-
mandibular elongations In most cases, the crossbite is accompanied by a mandibular
displacement, also termed forced crossbite, which causes a
• Dental factors due to posterior crowding, an im- midline deviation. There is evidence of asymmetric muscu-
proper inclination of the dentition or ectopic teeth. lar activity and altered bite force in children with a posterior
• Soft tissue factors such as adenoid problems and crossbite with displacement. Treatment options of unilateral
mouth breath, thus leading to low tongue position with posterior crossbite with displacement include:
an increased lower facial height and subsequent crossbite
(Linder-Aronson, 1972).

14 Early treatment of crossbites

• Encourage the patient to stop the parafunctional EXAM NIGHT REVIEW
habit,
• Buccal crossbite → The buccal cusps of lowers teeth
• According to systematic reviews, selective grinding occlude buccally to the buccal cusps of the upper teeth
of the primary canine has a success rate of 27-90% (Harrison
• Lingual crossbite → The buccal cusps of the mandib-
and Ashby, 2001, Petrén et al., 2003). However, 16-50 % of
ular teeth occlude lingually to the palatal cusps of the maxil-
untreated patients also show spontaneous correction (Petrén
lary teeth,
et al., 2003),
• Anterior crossbite → A reverse overjet of one or
• Extraction of a single severely displaced primary
more incisor
tooth,
• Reverse overjet→ All incisor is in anterior crossbite
• Posterior onlays,
• Displacement→ Discrepancy between the CR and
• Expansion of the upper arch: According to a
CO
Cochrane review, there is low to moderate-quality evidence
that quad helix appliance can be more effective than remov- Anterior crossbite
able expansion appliance in correcting posterior crossbite in
• Crowdinngually →limited lateral excursive move-
early mixed dentition ( 8-10 years) (Agostino et al., 2014),
ments & development of anterior crossbite.
• A combination of selective grinding and maxillary
• Anterior crossbite → dental/skeletal aetiology.
expansion.
• Dental crossbite, functional displacement of Mn by
Unilateral buccal crossbite with no mandibular displace-
premature contacts→ CO-CR shift.
ment
Incidence of anterior crossbite
It is usually due to underlying skeletal asymmetry, e.g.,
unilateral cleft or unilateral condylar hyperplasia. Treatment • Dental anterior cross bite 4-5% (Hannuksela and
options could be accepting the occlusion or surgical inter- Väänänen, 1987, Major and Glover, 1992),
vention for severe cases. • Preadolescence 26.7% (Vithanaarachchi and
Bilateral buccal crossbite Nawarathna, 2017).
It is usually associated with a skeletal discrepancy in trans- Aetiological factors of anterior crossbite
verse, antero-posterior or both planes. There is no associ- • Retained primary teeth (McEvoy, 1983),
ated displacement nor functional indication for treatment
in cases with a bilateral crossbite. Treatment options for • Supernumerary teeth,
bilateral crossbite are maxillary expansion with either slow • Ectopic eruption,
or rapid expansion protocols. However, care should be taken
to avoid the development of iatrogenic unilateral crossbite • Lingual path of eruption,
with displacement post-expansion. • Trauma resulting in repositioned or sub-luxated
Posterior mandibular displacement and lingual crossbite tooth,

Posterior mandibular displacement is mainly associated • Arch length discrepancy,

with Class II Division 2, and it is better to be treated as soon • Developmental anomalies, e.g., cleft lip and palate,
as possible to avoid TMJ problems. In cases with a lingual
crossbite, the lower buccal cusps occlude lingually to the up- • Skeletal Class III base.
per palatal cusps, also termed scissor bite. Problems of anterior crossbite
Treatment options depend upon which arch has the discrep- • Periodontal problems (gingival recession, bone de-
ancy and the aetiology of the crossbite, whether dental or hiscence or traumatic bite),
skeletal. In children, expansion can be achieved in the af-
fected arch. For upper arch expansion, Quadhelix appliances • Enamel wear,
can be used, while for the lower arch expansion, Bihelix ap- • Mandibular displacement,
pliances or Schwarz expansion appliances can be used with
slow expansion protocols. If the lingual crossbite is due to • Tooth displacement out of arch line,
the posterior position of the mandible, growth modification • Temporomandibular dysfunction though the evi-
to bring the mandible forward is the best option in children. dence is conflicting on this topic.

Early treatment of crossbites

15
Management of anterior crossbite • Maxillary expansion →slow /rapid expansion.
• Inclined functional anterior bite plane/blocks • 8-10Y slow expansion is preferred.
• Wooden tongue blades Management of posterior mandibular displacement
• Selective grinding and extraction of the primary • Common→ Class II div 2, require fixed appliances.
teeth
Benefits of treating posterior crossbite with displacement
• Upper removable appliance (URA) /fixed appliance
• Prevent mandibular asymmetry (Pinto et al., 2001),
(2x4 appliance)
• Avoid tooth surface loss.
• Functional or orthopaedic appliances
• Aesthetic benefits by widening the buccal corridor,
Prevalence posterior crossbite
• Psychological benefits,
• Prevalence of posterior crossbite is between 8 to 22
% (Kutin and Hawes, 1969, Egermark-Eriksson et al., 1990, • Creation of space to relieve crowding,
Heikinheimo, 1978, Perillo et al., 2009).
• Avoid TMD in susceptible patient (weak evidence),
• 80% of posterior crossbites leads to mandibular dis-
• Avoid exacerbation of plaque related periodontal
placement
damage.
Aetiology of posterior crossbite
• Skeletal factors
• Dental factors
• Soft tissue factors
• Local Habits such as a prolonged digit or thumb-
sucking habits
• Congenital causes
Management of unilateral posterior crossbite with displace-
ment
• Stop parafunctional habit.
• Selective grinding of the primary canine has a suc-
cess rate of 27-90%.
• Extraction of the single severely displaced primary
tooth.
• Posterior onlays though some believe that this ap-
proach is ineffective (Petrén,2008)
• Expand upper arch.
• A combination of selective grinding and maxillary
expansion can be done.
Management of unilateral crossbite with no mandibular dis-
placement
• Correction is seldom indicated
• Surgery for severe cases is the only treatment op-
tion.
Management of bilateral crossbite
• Skeletal discrepancy in transverse, antero-posterior
or both planes.

16 Early treatment of crossbites

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dentition and nasopharynx. Trans Eur Orthod Soc, 177-86. primary dentition. ASDC J Dent Child, 68, 27-32, 10.
MAJOR, P. & GLOVER, K. 1992. Treatment of anterior VITHANAARACHCHI, S. N. & NAWARATHNA, L. S.
crossbites in the early mixed dentition. Journal (Canadian 2017. Prevalence of anterior crossbite in preadolescent orth-
Dental Association), 58, 574-5, 578-9. odontic patients attending an orthodontic clinic. Ceylon
Med J, 62, 189-192.
MALANDRIS, M. & MAHONEY, E. K. 2004. Aetiology, di-
agnosis and treatment of posterior crossbites in the primary ZEGAN, G., DASCALU, C. G., MAVRU, R. B. & GOLOV-
dentition. Int J Paediatr Dent, 14, 155-66. CENCU, L. 2015. RISK FACTORS AND PREDICTORS OF
CROSSBITE AT CHILDREN. Rev Med Chir Soc Med Nat
MCEVOY, S. A. 1983. Rapid correction of a simple one-
Iasi, 119, 564-71.
tooth anterior cross bite due to an over-retained primary
incisor: clinical report. Pediatric dentistry, 5, 280-282.
MCNAMARA, J. A. 2002. Early intervention in the trans-
verse dimension: Is it worth the effort? American Journal of
Orthodontics and Dentofacial Orthopedics, 121, 572-574.
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Journal of Orthodontics, 6, 192-204.

Early treatment of crossbites 17

 3
Ectopic eruption and
impaction of first
permanent molars
Written by: Mohammed Almuzian, Haris Khan

In this Chapter
1. Normal eruption process of first permanent mo-
lars (FPM)
2. Types of ectopic eruption of FPM
3. Incidence of ectopic FPM
4. Aetiology factors of ectopic eruption of FPM
5. Complications of ectopic FPM
6. Diagnostic features of ectopic FPM
7. Classification of ectopic FPM
8. Management of ectopic FPM
9. Method for disimpaction of erupted impacted
FPM (McDonald, 2011)
10. Methods to regain space following the early loss
of PSM
11. Case presentation
12. Exam night review

18
Normal eruption process of first permanent molars • Increased mesiodistal width of FPM (Pulver, 1968,
Bjerklin, 1994).
Upper first permanent molars (FPM) tooth germ as-
sumes a downward, backward and outward orientation • Abnormal eruption angle of the FPM (Chapman,
before the eruption. Lower FPM tooth germ assumes an 1923, Pulver, 1968, Chintakanon and Boonpinon,
upwards and forward orientation before the eruption. As 1998).
the eruption continues, upper and lower FPMs adopts a
• Lack of early mesial shift of primary molars (Chap-
more vertical position. The eruption process can be halt-
man, 1923).
ed by various genetic, molecular, cellular, or tissue causes
(Barberia-Leache et al., 2005). • Delayed calcification of FPM (Pulver, 1968).
Types of ectopic eruption of FPM B. Bone and jaw-related factors such as:
The ectopic eruption is defined as either the eruption of • Posteriorly position maxilla in relation to the cra-
a tooth in an abnormal position or the permanent tooth nial base (Pulver, 1968, Canut and Raga, 1983).
following an abnormal path of eruption (Nikiforuk,
• Small dental arches (Chapman, 1923).
1948). While impaction is defined as a tooth that fails to
erupt due to an impeding obstruction, not due to its ab- • Small maxilla base (Canut and Raga, 1983).
normal position (Yaseen et al., 2011). • Decreased intercanine width and decreased antero-
Ectopic eruption of FPM is a condition in which the FPM posterior growth of the jaws (O’Meara, 1962).
is impeded from a complete eruption by the primary • Altered chronology of bone growth at the tuberos-
second molar (PSM); subsequently, the PSM is usually ity area in relation to calcification and eruption of the
resorbed and may exfoliate prematurely. There are two FPM (Barberia-Leache et al., 2005).
types of ectopic eruption of FPM (Young, 1957):
• Decreased regional bone growth and ramus remod-
• Reversible type (jump case): The FPM ectopia re- elling (Nikiforuk, 1948).
solves spontaneously and erupts into a normal position
in 66% of cases. C. Heredity factors such as developmental disorders
(Bjerklin et al., 1992, Mooney et al., 2007). The probabil-
• Irreversible type (hold case): The FPM remains im- ity of siblings having ectopic eruption of FPM is 19.8%,
peded against the PSM until intervention occurs or pre- implicating a genetic factor (Kurol and Bjerklin, 1982a)
mature PSM exfoliation occurs.
D. Epigenetic factors: Evolutionary changes have
Incidence of ectopic FPM resulted in a reduction in the size of the arch to occupy a
FPM and canines are among the most frequently found full number of permanent teeth (Sweet, 1939).
ectopic teeth, followed by lower canines, premolars Complications of ectopic FPM
and upper lateral incisors (Sim, 1973, Wei, 1988). Ecto-
pic eruption of upper FPM shows a prevalence of 4.3% Ectopic FPM is rarely symptomatic but can lead to
(range 2-6%) (Bjerklin, 1994), and males are more affect- pulpitis of the PSM or neuralgic pain in the impaction
ed by ectopic eruption than females (Bjerklin and Kurol, zone. The irreversible type can lead to mesial migration
1981). Ectopic FPM are more frequent in the upper arch of FPM, loss of arch length, increased chances of impac-
when compared to the lower arch (Bjerklin and Kurol, tion of the second premolar and root resorption and
1981, Kennedy, 2008). The frequency of FPM is 4 times premature exfoliation of PSM. There seems to be a weak
higher in patients with cleft lip and palate than in non- correlation between the resorption degree of the PSM
cleft children (Bjerklin et al., 1993; Bjerklin, 1994) with and the millimetres of FPM impaction (Barberia-Leache
no predominance for the left or right side and unilateral et al., 2005).
or bilateral. Most ectopic FPM are reversible (66%), with Diagnostic features of ectopic FPM
the spontaneous eruption occurring at age seven when
the ectopic tooth ‘jumps’ out from the influence of the The clinical presentation of ectopic FPM includes:
PSM. This reversible eruption was more common in fe- • Pain at the region of PSM due to pulpitis in the
males compared to males (Young, 1980). absence of caries (Starkey, 1961).
Aetiology factors of ectopic eruption of FPM • Increased mobility of PSM.
The cause of ectopic eruption of FPM is not well known • Premature exfoliation of PSM.
and considered to be multifactorial, including:
• Unilateral or bilateral delay in the emergence of
A. Tooth-related factors such as: FPM (Heikkinen et al, 2001).

 (FWRSLFHUXSWLRQDQGLPSDFWLRQRIILUVWSHUPDQHQWPRODUV
 • Disturbed eruption path of FPM where the distal eruption.
cusps emerge before mesial cusps (Campbell, 1991).
• If no further root resorption of PSM is noticed
• Eruption of FPM mesial to its normal path. with no change in the vertical position of the FPM, it is
recommended to expose the unerupted FPM followed
• Bulbous PSM and small jaw
by an observational period of three months. If there is
• Radiographic appearance of FPM impaction no improvement after three months, treatment should
against the distobuccal root of a deciduous tooth. be initiated to move the impacted FPM distally.
Hence, sequential radiographic superimposition can
• If further resorption of PSM is noticed, then inter-
also aid diagnosis.
vention should be initiated without delay. The primary
Classification of ectopic FPM molar might be removed, accepting subsequent space
loss.
Ectopic FPM can be classified according to the degree of
root resorption of PSM (Kurol and Bjerklin, 1982b) If the root resorption of upper PSM is greater than
1.5mm, we should consider these options:
• Grade I (Mild): There is limited resorption, affect-
ing the cementum of the PSM or with minimum dentin • The PSM is asymptomatic with less than 1mm of
resorption. mobility, and the FPM is partially erupted, treatment to
move the unerupted tooth distally should be initiated.
• Grade II (Moderate): There is resorption of dentin
of the PSM without pulp exposure. • The PSM is asymptomatic with mobility less than
1mm and FPM is unerupted, the surgical exposure and
• Grade III (Severe): Pulp exposure of the distal root
traction of the molar should be considered to move it
of the PSM.
distally.
• Grade IV (Very severe): Severe resorption of the
• The PSM is symptomatic or its mobility is greater
PSM that affects the mesial root of and potential loss of
than 1mm, it is better to consider extraction of PSM and
PSM (Sweet, 1939).
space management after the eruption of FPM.
Grades I and II spontaneously self-correct without arch
Method for disimpaction of erupted impacted FPM
length loss or further resorption. Treatment interven-
(McDonald, 2011)
tion is required in grade III or more (primarily irrevers-
ible types). A 0.20- or 0.22-mm brass wire can be looped and
tightened around the contact between PSM and FPM,
Management of ectopic FPM
and the wire should be tightened every two weeks. This
Diagnosis is usually incidental through routine ra- technique is effective when a small amount of resorption
diographs (5 -7 years) as pain is rarely reported. Early is present and limited molar movement is required. Steel
diagnosis and intervention benefit from preventing pre- spring clip separators can be also used and activated
mature loss of PSM and the development of a localised on a bi-weekly basis. Elastomeric separators are not
malocclusion (Proffit et al., 2018). The interceptive treat- recommended due to the chance of being dislodged and
ment approach depends on several factors, including submerged in the periodontal region.
(Kennedy and Turley, 1987) (a) the amount of enamel
In cases of severe resorption where the distal movement
ledge (degree of impaction) between FPM and PSM,
of FPM is required, simply fixed appliances can be em-
where mild impaction usually corrects spontaneously
ployed. The options available with fixed appliances are:
(Gleerup et al., 1995), (b) the degree of mobility of PSM,
(c) the presence of pain or infection in the PSM, (d) the • Halterman appliance: It consists of the orthodontic
clinical eruption status of the FPM and (e) the eruptive band on PSM with an attached distal spring to disim-
positional changes of FPM. If the root resorption of pact the FPM (Yuen et al., 1985).
upper PSM is less than 1.5mm, then PSM is kept under
• Humphrey appliance: Its design is close to the Hal-
observation for 3-6 months, as 90% of ectopic FPMs
terman appliance but includes a transpalatal or lingual
self-correct by the age of seven years (Kennedy and Tur-
arch for anchorage support.
ley, 1987). However, only 10% self-correct at age eight
or nine (Bjerklin and Kurol 1981). After six months of • Sectional fixed appliance with the band and looped
observation, one of the following three options needs to spring, two bonded brackets or a looped or open coil
be considered: spring.
• If no further resorption of PSM is noticed and the Methods to regain space following the early loss of PSM
FPM has improved vertically, continue monitoring FPM
Space regaining should be performed as early as pos-

(FWRSLFHUXSWLRQDQGLPSDFWLRQRIILUVWSHUPDQHQWPRODUV 
 sible after the premature loss of the PSM to minimise Exam night review
tipping of the molars, rotation of the FPM into crossbite,
Ectopic eruption is the eruption of a tooth in an abnor-
and impaction of the second premolar. Space regaining
mal position, or where the permanent tooth assumes an
can be achieved using facebow/headgear or remov-
abnormal eruption path (Nikiforuk, 1948). U6s & U3s
able appliances with a spring or expansion screw to
are amongst the most frequently found ectopic teeth, fol-
distalise FPM (Kurol and Bjerklin, 1984). This can be
lowed by L3s, L5s & U2s (Sim, 1973, Wei, 1988)
combined with an anterior bite plate to create posterior
disocclusion, allowing the uprighting of the mesially Ectopic eruption of first permanent molar
tipped FPM. Moreover, a removable appliance and high
There are two types of ectopic eruption of FPM, accord-
pull headgear can be adopted (Nudger appliance). The
ing to Young (Young, 1957):
removable appliance tips the crown of the molar distally,
while the force of the high-pull headgear directed above • Reversible type (jump cases): The FPM spontane-
the centre of rotation of the molar helps in distalizing ously self corrects.
the root. It has been reported that the resorption of • Irreversible type (hold cases): The FPM remains im-
PSM is generally stopped once FPM erupts (Kurol and peded against the PSM.
Bjerklin, 1982a).
Incidence of ectopic FPM
• Ectopic PFM in the upper arch has a prevalence of
4.3% (range 2-6%) (Bjerklin, 1994) and is more common
in the upper than the lower arch (Bjerklin and Kurol,
1981, Kennedy, 2008).
• 4 times the higher frequency in the cleft lip palate
(Bjerklin et al., 1993, Bjerklin, 1994).
• Most ectopic FPM are reversible (66%). Reversible
eruption spontaneously erupts at age 7. The reversible
eruption is found more in females (Young, 1980).

Aetiology of ectopic FPM

• Tooth related factor
• Bone and jaw-related factors.
• Heredity factors
• Epigenetic factors

Complications of ectopic FPM

• Pulpitis of the PSM.
• Neuralgic pain in the zone of impaction.
Irreversible type can lead to:
• Mesial migration of FPM.
• Loss of arch length.
• Impaction of the second premolar.
• Root resorption and premature exfoliation of PSM.
Classification of ectopic eruption of
• Grade I (Mild): Resorption of cementum only, or
mild dentin.

 (FWRSLFHUXSWLRQDQGLPSDFWLRQRIILUVWSHUPDQHQWPRODUV
 • Grade II (Moderate): Resorption of dentin without References:
pulp exposure. BARBERIA-LEACHE, E., SUAREZ-CLÚA, M. C. & SAAVEDRA-
• Grade III (Severe): Pulp exposure of the distal root ONTIVEROS, D. 2005. Ectopic eruption of the maxillary first per-
of PSM. manent molar: characteristics and occurrence in growing children.
The Angle orthodontist, 75, 610-615.
• Grade IV (Very severe): Severe resorption that af-
BJERKLIN, K. 1994. Ectopic eruption of the maxillary first perma-
fects the mesial root of the PSM (Sweet, 1939). nent molar. An epidemiological, familial, aetiological and longitu-
• dinal clinical study. Swed Dent J Suppl, 100, 1-66.

Disimpaction of the impacted FPM BJERKLIN, K. & KUROL, J. 1981. Prevalence of ectopic eruption
of the maxillary first permanent molar. Swed Dent J, 5, 29-34.
BJERKLIN, K., KUROL, J. & PAULIN, G. 1993. Ectopic eruption of
FPM erupts (McDonald, 2011) the maxillary first permanent molars in children with cleft lip and/
or palate. Eur J Orthod, 15, 535-40.
• Brass wire or separators: A 20 or 22 mm brass wire
can be looped and tightened. BJERKLIN, K., KUROL, J. & VALENTIN, J. 1992. Ectopic eruption
of maxillary first permanent molars and association with other
• Fixed appliances: In cases of more severe resorption tooth and developmental disturbances. Eur J Orthod, 14, 369-75.
where the distal movement of FPM is required, fixed ap- CANUT, J. A. & RAGA, C. 1983. Morphological analysis of cases
pliances can be employed. with ectopic eruption of the maxillary first permanent molar. Eur J
FPM is an unerupted (McDonald, 2011) Orthod, 5, 249-53.
CHAPMAN, H. 1923. First upper permanent molars partially
Following surgical exposure to the FPM, the techniques
impacted against second deciduous molars. International Journal
above can be implemented.
of Orthodontia, Oral Surgery and Radiography, 9, 339-345.
Potential side effects CHINTAKANON, K. & BOONPINON, P. 1998. Ectopic eruption
• Tipping of the molars. of the first permanent molars: prevalence and etiologic factors.
Angle Orthod, 68, 153-60.
• Rotation of the FPM into crossbite.
GLEERUP, A., BJERKLIN, K. & KUROL, J. 1995. Discriminant
• Impaction of the second premolar. analysis in treatment evaluation of ectopic eruption of the maxil-
lary first permanent molars. Eur J Orthod, 17, 281-91.
KENNEDY, D. B. 2008. Management of an ectopically erupting
permanent mandibular molar: a case report. Pediatr Dent, 30, 63-5.
KUROL, J. & BJERKLIN, K. 1982a. Ectopic eruption of maxillary
first permanent molars: familial tendencies. ASDC J Dent Child,
49, 35-8.
KUROL, J. & BJERKLIN, K. 1982b. Resorption of maxillary second
primary molars caused by ectopic eruption of the maxillary first
permanent molar: a longitudinal and histological study. ASDC J
Dent Child, 49, 273-9.
KUROL, J. & BJERKLIN, K. 1984. Treatment of children with
ectopic eruption of the maxillary first permanent molar by cervical
traction. Am J Orthod, 86, 483-92.
MCDONALD, R. 2011. McDonald and Avery’s Dentistry for the
Child and Adolescent. St. Louis: Mosby Elsevier.
MOONEY, G., MORGAN, A., RODD, H. & NORTH, S. 2007.
Ectopic eruption of first permanent molars: A preliminary report
of presenting features and associations. European Archives of Pae-
diatric Dentistry, 8, 153-157.
NIKIFORUK, G. 1948. Ectopic Eruption: Discussion and clinical
report. J Ont Dent Assoc, 25, 243-6.
O’MEARA, W. F. 1962. Ectopic eruption pattern in selected perma-
nent teeth. Journal of Dental Research, 41, 607-616.
PROFFIT, W. R., FIELDS, H. W., LARSON, B. & SARVER, D. M.

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2018. Contemporary orthodontics, Elsevier Health Sciences.
PULVER, F. 1968. The etiology and prevalence of ectopic eruption
of the maxillary first permanent molar. ASDC J Dent Child, 35,
138-46.
ROBERTS, M. W. 1986. Treatment of ectopically erupting maxil-
lary permanent first molars with a distal extended stainless steel
crown. ASDC J Dent Child, 53, 430-2.
STARKEY, P. 1961. Infection following ectopic eruption of first
permanent molars: case report. J. Dent. Chil., 28, 327-330.
SWEET, C. A. 1939. Ectopic eruption of permanent teeth. The
Journal of the American Dental Association, 26, 574-579.
YASEEN, S. M., NAIK, S. & ULOOPI, K. 2011. Ectopic eruption-A
review and case report. Contemporary clinical dentistry, 2, 3.
YOUNG, D. 1980. Ectopic eruption of the first permanent molar. J
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Child. 1957;24:153–62

23
Ectopic eruption and impaction of first permanent molars
 4
First Permanent
Molars with Poor
Prognosis
Written by: Mohammed Almuzian, Haris Khan

In this Chapter
1. Incidence of poor prognosis First Permanent Molars
(FPMs)
2. Advantages of extraction of FPMs
3. Indications for extracting FPMs
4. Options for Timing of Extraction
5. Problems of PFM extraction
6. Balancing and compensating extractions
7. Treatment planning for the loss of FPM
8. Exam night review

24 FPM with Poor Prognosis

The poor prognosis of the first permanent molars (FPMs) is a • As part of compensating extractions.
consequence of caries, endodontic complications, or developmental
• Increased angle of the mandible plane with the cranial
anomalies such as hypoplasia (Ong and Bleakley, 2010). The orth-
base.
odontic literature has opined that the extraction of FPMs with poor
prognosis (Gill et al., 2001). FPMs are not the tooth of choice for • Anterior open bite with tooth contacts on first molars
extraction in the context of orthodontic treatment; however, there (Aras, 2002)
are various clinical situations where FPMs extraction enforced ex-
traction is the only choice (Sandler et al., 2000). Most orthodontists Options for Timing of Extraction
try to avoid extraction of FPMs as such cases are more technically 1. Early extraction of the 6s
challenging than conventional premolar extraction or non-ex-
traction cases (Ong and Bleakley, 2010). The ideal timing of FPMs Early 6s extraction is usually performed at the age of 7-8 years. This
extraction can result in the second permanent molars replacing the approach is indicated in patients with pain to reduce the restorative
FPM spontaneously. burden or in uncooperative children. This means that orthodontic
treatment would be delayed until the patient is more cooperative.
Incidence of poor prognosis FPMs However, delaying orthodontic treatment may reduce the FPM
space. So if future crowding/space requirements are substantial, it
FPM is considered the most caries-prone tooth in the permanent
may require complex mechanics depending on the radiographical
dentition (Ong and Bleakley, 2010) as more than 50% of children
evidence of the presence and absence of the third molars. If third
over the age of 11 years have some caries experience in this tooth
molars are absent in the presence of significant space requirements,
(Todd and Dodd, 1985). The most recent survey showed that
distalization will be required. If the space requirements exceed
around half (46%) of 15-year olds and a third (34%) of 12-year-olds
the limits of distalization, then premolar extraction will be carried
children have decay experience in their permanent teeth (Child
out. Another potential problem associated with early extraction is
Dental Health Survey, England, Wales and North Ireland, 2013).
the unerupted second premolar which might tip and drift distally,
12% of referred extraction cases in the UK involve FPMs (Brad- and the lower labial segment might retroclined, hence, increasing
bury, 1985). The poor prognosis of FPM is also the result of hypo- the overbite. Therefore, a minor orthodontic treatment might be
plasia, with approximately 6% of children having hypoplasia in one needed to upright mesially angulated second molars in the absence
or more FPMs (Seow, 1997). Molar–incisor hypomineralisation of anterior crowding (Cobourne et al., 2014).
(MIH) is found in about 15% of Caucasian children, which could
2. Extraction at optimal timing/ interceptive treatment (8-
significantly affect the long-term prognosis of FPM in severe cases
10 years)
(Koch et al., 1987).
Extraction of FPM with poor prognosis should be considered at
Advantages of extraction of first permanent molars
an ideal developmental age to achieve spontaneous space closure if
These include: comprehensive orthodontic treatment is not indicated (Alkhadra,
2017). According to Wu and colleagues, there is a lack of qual-
• Removes tooth with poor prognosis (Williams and ity evidence for an optimal extraction time of FPMs with a poor
Hosila, 1976). prognosis (Wu et al., 2017). According to RCS guidelines, the most
• Removes a potential source of future infection. favourable chronological age range for extraction of FPMs is 8-10
years, ideally after the eruption of lateral incisors but before the
• Accelerates the eruption of the third molar. eruption of the second permanent molar and/or the second premo-
• Helps in the successful eruption of third molars, espe- lar (Thilander and Skagius, 1970).
cially where the arch length is short (Halicioglu et al., 2014, Ay et When the bifurcation of 7s is visible on the radiograph, it is likely
al., 2006). for maximum spontaneous space closure to occur (Sandler et
Indications for extracting FPMs al., 2000). Other criteria which increase spontaneous closure are
mesio-angulation of the 7s, ideally the angle between the long axis
FPM extraction is performed when the tooth has a poor prognosis. of crypts of the 7s and the root of 6s should range from 15˚-30˚
A decision made ideally by the general/paediatric dentist and the with an an overlap of the 7s crypts over the root of the 6s.
orthodontist, though this might not always be possible (Couborne,
2014). Some of the most common reasons to consider FPMs Patel et al. showed that dental age, angulation of 7s, and presence of
extraction are: 8s were predictive factors to spontaneous space closure. However,
the development of the roots of 7s was not a predictive factor for
• Extensive loss of crown structure due to caries or hypo- spontaneous space closure (Patel, 2017)
plasia
Extraction timing is more critical for the lower arch than the
• Poor root canal treatment upper arch because of the distally angulated follicle of the upper
• Periapical pathology second permanent molar, leading to rapid forward migration (Gill
et al., 2001). There is no firm conclusion about the ideal timing of
Extractions of PFM can also be carried out in: extraction of FPM for the maxilla. Extraction at optimal timing is
• Cases with posterior crowding or severe anterior crowd- indicated if:
ing, which cannot be relieved by first premolar extraction • All permanent teeth are present, including third molars.
• Heavily filled first molars and healthy premolars

FPM with Poor Prognosis 25

• Skeletal and dental Class I relationships. Treatment planning for the loss of FPM
• Mild incisor or moderate buccal crowding in the arch The treatment planning depends on the types of malocclusion and
absence of rotations. the amount of crowding:
• Mandibular second molar roots half-formed with evi- 1. Class I malocclusion
dence of calcification in the bifurcation.
In Class I malocclusion with minimal crowding the aim is to ex-
Extraction at optimal timing offers the advantages of spontaneous tract at the optimal time to allow second molars to erupt in a good
space closure by the eruption of second permanent molars and position and spaces to close spontaneously. However, balancing
subsequent completion of the molar dentition by the eruption of extractions are not required in both arches while compensatory
third molars. However, the cons of this approach is that the devel- extraction of lower FPM is not required. On the other hand, com-
opment of the third molar may not be visible on radiographs until pensatory extraction of upper FPM can be undertaken if this tooth
the age of 14 years, and they can be congenitally missing in 25-35% remains unopposed for a long time (Cobourne et al., 2014).
of cases (Peck, 1996)
In Class I malocclusion with moderate buccal segment crowding
3. Delayed extraction the aim is to extract at the optimal time to allow second molars to
erupt in a good position, providing space to relieve crowding. Bal-
In this case, the FPM of poor prognosis is temporarily restored and
ancing extraction of the contralateral FPM, if compromised, would
used as a space maintainer, enabling the extraction to be delayed
be considered in the case of bilateral posterior segment crowd-
until the 7s have fully erupted. The space of the FPM is therefore
ing. Compensating extraction of upper FPM can be carried out to
available to resolve significant space requirements (e.g. crowding,
resolve the crowding of the bicuspids.
overjet). Indications for delayed extraction of FPM include:
In Class I malocclusion with moderate labial segment crowding,
• Cooperative patient
a little spontaneous correction of crowding is expected follow-
• The presence of premolar crowding is possibly due to the ing FPM extraction. To relieve moderate crowding in the labial
early loss of primary teeth; segment, extractions of FPM can be delayed until the eruption of
the 7s; the extraction spaces can then be used to achieve alignment
• Distally tipped the second molar.
with orthodontic treatment (using the 7s as anchorage). Alterna-
• Crowding or increased overjet tively, extractions can be done at the optimal time, and crowding
can be relieved in the permanent dentition with the help of premo-
However, there are some drawbacks associated with delaying the lar extraction if required. Third molars should also be present in
extraction of FPM, including: this case as the first molars have already been extracted.
• The second molars can rotate mesiolingually and tip 2. Class II malocclusion
mesially, resulting in spacing, poor mesial contact with the second
premolar, and occlusal interference (Thilander and Skagius, 1970, In Class II malocclusion with minimal lower arch crowding, FPM
Normando et al., 2010); extraction should be considered optimal to help the successful
eruption of 7s and control the second premolars. If the upper FPM
• The lower second premolars can rotate and tip distally, remain unopposed for a prolonged time, a simple removable appli-
worsening the contact point (Thunold, 1970); ance can be used to prevent over-eruption, a functional appliance
• The lower labial segment can retrocline, resulting in can be used directly to correct the incisor relationship or elective
increased overbite (Thunold, 1970 and Richardson, 1979); extraction of healthy upper FPM can be performed if at risk of
over-erupting, but third molars should be present.
• Necking of the alveolus can make subsequent space
closure difficult. In Class II malocclusion with minimal upper arch crowding, if
FPM requires immediate extraction, treatment can be started to
Problems of PFM extraction correct the incisor relationship with the help of a functional appli-
The potential problems of PFM extraction are presented in table 1. ance or removable appliance and headgear. Fixed appliances can
be used later to detail the occlusion. Extraction of FPM at optimal
Balancing and compensating extractions timing, allowing the 7s to erupt followed by premolar extraction
once the permanent dentition is established. Ideally, the third
Balancing extractions refer to an extraction in the same molar should be present. If the FPM can be restored or tempo-
arch but on the opposite side to maintain midline and molar rised, then extraction can be delayed after the eruption of the 7s.
symmetry. It is rarely required for the extraction of FPM. At The resultant extraction space can be used to correct the incisor
the same time, compensating extraction refers to extraction relationship.
on the same side but in the opposing arch. Generally indi-
In Class II malocclusion with lower arch crowding, if third molars
cated for the upper FPM when the lower FPM is extracted, are present, extractions can be performed at an optimal time and
this avoids over-eruption of the unopposed upper molar allow the eruption of 7s. Premolars can be extracted at a later
(Holm, 1970). However, the risk of over-eruption of upper stage to relieve crowding. Extraction of FPM after the eruption of
FPM seems to be small, although evidence is often based on 7s allows space to relieve crowding. Balancing and compensating
small samples (Jalevik and Moller, 2007, Mejare et al., 2005). extractions are not usually required.

26 FPM with Poor Prognosis

Table 1: Potential problems of PFM extraction
Potential problems Possible solutions

Mandibular arch Power and Short, 1993. • Closing spaces on full-sized archwires (19x25) stain-
less steel;
• Using MBT prescription brackets with -10˚ torque
reduces molar lingual rolling.
• Using light forces in space closure
Closing 8 to 9 mm of space between the • Placing tip back bends in the final rectangular wires;
second premolar and the second molar
• Using dead ligature across the extraction space after
has a tendency for root divergence
closure for a few months to allow gingival fibers to reorganize.
Using Class II elastics results in lingual • Using full-sized archwires;
rolling of lower second molars.
• Adding buccal crown torque to lower molars;
• Running the elastics from the lingual surface of
second molars.
The long span of the archwire leads to • Placing 0.9 mm internal diameter stainless steel tub-
trauma to the soft tissues and deflection ing;
of the wire during mastication.
• Archwires up to but excluding the full-sized arch-
wires should be cinched back.
If the follicle of the lower second premo- • Extraction of lower E should be considered in these
lar is distally tipped, mesialization of the cases.
lower second molar can lead to lower
second premolar impaction.

Due to occlusal surface loss of lower • Intrusion of the upper molar might be needed.
PFM as a result of caries, upper PFM
over erupts. This makes mesialization of
the lower second molar difficult.

Maxillary arch Space closure is rapid due to the distally Anchorage reinforcement with a headgear or Nance appli-
angulated second molar follicle, conical ance, especially in high-angle cases.
roots, which are less suitable for anchor-
age and the tendency to rotate around
their palatal root.

In Class II malocclusion with upper arch crowding, due to .3. Class III malocclusion
the high space requirements in the upper arch, FPM should
A a general rule, in class III cases, extraction of upper mo-
be temporised if possible. Suppose the upper FPM is unop-
lars should be avoided if possible. Suppose extractions are
posed and the third molars are present radiographically. In
needed in the upper arch. In that case, it can be performed
that case, their extraction might be indicated, but the patient
once the anterior crossbite is corrected, and balancing and
should be informed that premolar extractions might be
compensating extractions are not recommended, espe-
indicated in the future.
cially in the lower arch. Even if extraction of FPM has been
In Class II division 2 malocclusion, maintaining the overbite performed at an optimal time in class III cases, a tendency
reduction might be challenging in cases requiring prolonged towards residual spaces has been described as the mandible
space closure after FPM extraction. There is evidence of inci- continues to grow (Teo, 2013).
sor minimal uprighting and deepening the bite with FPM
extractions (Richardson, 1979).

FPM with Poor Prognosis 27

Exam night review • The lower labial segment might be retroclined, in-
creasing the overbite
Aetiology
• In the absence of anterior crowding, minor ortho-
Incidence
dontics might still be needed to upright
• FPM is considered to be the most caries-prone
Extraction at optimal timing/ interceptive treatment (8-
tooth.
10 years)
• 12% of referred extraction cases in the UK involve
Indications
FPMs (Bradbury, 1985).
• Around the right age for the interception
• Approximately 6% of children have hypoplasia in
one or more FPM (Seow, 1997). • All permanent teeth are present, including third
molars, though third molars development may not be
• MIH is found in approximately 15% of Caucasian
visible until 14 years.
• Class I skeletal and dental relationships
Indications
• Mild incisor or moderate buccal crowding in the
arch absence of rotations;
• Extensive loss of crown structure due to caries or • Mandibular second molar roots half formed with
hypoplasia evidence of calcification in the bifurcation.
• Poor root canal treatment Advantages
• Periapical pathology Spontaneous space closure
• Cases with posterior crowding or severe anterior Disadvantages
crowding, which cannot be relieved by first premolar ex-
3rd molars development may not be visible until 14 years
traction
• Heavily filled first molars and healthy premolars
Delayed extraction
• As part of compensating extraction
Indications
• Anterior open bite with tooth contacts on first mo-
lars (Aras, 2002). • Cooperative patient
• Crowding or increased OJ
Extraction timing options (Cobourne et al., 2014) Advantages
Early extraction (7-8 years) Space from the compromised tooth can be used in treat-
ing malocclusion.
Indications
Disadvantages
• Uncooperative child
• 7s rotate mesiolingually and tip mesially, = poor
• Patient in pain
mesial contact = occlusal interference (Thilander and
Advantages Skagius, 1970, Normando et al., 2010)
• Less restorative burden. • Lower 5s rotate and tip distally (Thunold, 1970)
• Orthodontic treatment can be delayed until the pa- • The lower labial segment retrocline = increased
tient is more cooperative overbite (Thunold, 1970 and Richardson, 1979);
Disadvantages • Necking of the alveolus = difficult space closure.
• Remaining crowding is challenging to treat.
• Third molars may not be evident at this age.
• Large space requirements may also require premo-
lar extractions
• 5s drift distally

28 FPM with Poor Prognosis

References RICHARDSON, A. 1979. Spontaneous changes in the inci-
sor relationship following extraction of lower first perma-
Alkhadra T. (2017). A Systematic Review of the Conse-
nent molars. Br J Orthod, 6, 85-90.
quences of Early Extraction of First Permanent First Molar
in Different Mixed Dentition Stages. Journal of Interna- SANDLER, P. J., ATKINSON, R. & MURRAY, A. M. 2000.
tional Society of Preventive & Community Dentistry, 7(5), For four sixes. Am J Orthod Dentofacial Orthop, 117,
223–226. doi:10.4103/jispcd.JISPCD_222_17 418-34.
ARAS, A. 2002. Vertical changes following orthodontic SEOW, W. K. 1997. Clinical diagnosis of enamel defects:
extraction treatment in skeletal open bite subjects. Eur J pitfalls and practical guidelines. Int Dent J, 47, 173-82.
Orthod, 24, 407-16.
THUNOLD, K. 1970. Early loss of the first molars 25 years
AY, S., AGAR, U., BICAKCI, A. A. & KOSGER, H. H. 2006. after. Rep Congr Eur Orthod Soc, 349-65.
Changes in mandibular third molar angle and position after
TODD, J. E. & DODD, T. 1985. Children’s Dental Health
unilateral mandibular first molar extraction. Am J Orthod
in the United Kingdom, 1983: A Survey Carried Out by
Dentofacial Orthop, 129, 36-41.
the Social Survey Division of OPCS, on Behalf of the
BRADBURY, A. J. 1985. A current view on patterns of United Kingdom Health Departments, in Collaboration
extraction therapy in British health service orthodontics. Br with the Dental Schools of the Universities of Birmingham
Dent J, 159, 47-50. and Newcastl, Stationery Office.
COBOURNE, M. T., WILLIAMS, A. & HARRISON, M. WILLIAMS, R. & HOSILA, F. J. 1976. The effect of differ-
2014. National clinical guidelines for the extraction of first ent extraction sites upon incisor retraction. Am J Orthod,
permanent molars in children. Br Dent J, 217, 643-8. 69, 388-410.
Gill, D. S., Lee, R. T., & Tredwin, C. J. (2001). Treatment Teo, T. K. Y., Ashley, P. F., Parekh, S., & Noar, J. (2013). The
planning for the loss of first permanent molars. Dental up- evaluation of spontaneous space closure after the extrac-
date, 28(6), 304-308. tion of first permanent molars. European Archives of
Paediatric Dentistry, 14(4), 207-212.
HALICIOGLU, K., TOPTAS, O., AKKAS, I. & CELIKOGLU,
M. 2014. Permanent first molar extraction in adolescents Wu, M., Chen, L., Bawole, E., Anthonappa, R. P., & King,
and young adults and its effect on the development of third N. M. (2017). Is there sufficient evidence to support an op-
molar. Clin Oral Investig, 18, 1489-94. timum time for the extraction of first permanent molars?.
European Archives of Paediatric Dentistry, 18(3), 155-161.
HOLM, U. 1970. Problems of compensative extraction in
cases with loss of permanent molars. Rep Congr Eur Orthod Thilander, B. I. R. G. I. T., & Skagius, S. T. U. R. E. (1970).
Soc, 409-27. Orthodontic sequelae of extraction of permanent first
molars. A longitudinal study. In Report of the congress.
Koch, G., Hallonsten, A. L., Ludvigsson, N., Hansson, B.
European Orthodontic Society (p. 429).
O., Hoist, A., & Ullbro, C. (1987). Epidemiologic study of
idiopathic enamel hypomineralisation in permanent teeth of
Swedish children. Community dentistry and oral epidemiol-
ogy, 15(5), 279-285.
JALEVIK, B. & MOLLER, M. 2007. Evaluation of spontane-
ous space closure and development of permanent dentition
after extraction of hypomineralized permanent first molars.
Int J Paediatr Dent, 17, 328-35.
MEJARE, I., BERGMAN, E. & GRINDEFJORD, M. 2005.
Hypomineralized molars and incisors of unknown origin:
treatment outcome at age 18 years. Int J Paediatr Dent, 15,
20-8.
Normando, A. D. C., Maia, F. A., da Silva Ursi, W. J., &
Simone, J. L. (2010). Dentoalveolar changes after unilateral
extractions of mandibular first molars and their influence
on third molar development and position. World journal of
orthodontics, 11(1).
ONG, D.-V. & BLEAKLEY, J. 2010. Compromised first

FPM with Poor Prognosis 29

 5
Infraocclusion of
Primary Teeth
Written by: Mohammed Almuzian, Haris Khan

In this Chapter
1. Incidence of IPM
2. Clinical Presentation of IPM
3. Aetiology of IPM
4. Classification of IPM (Brearley and McKibben,
1973)
5. Clinical presentations of IPM
6. Treatment options of IPM
7. Management of IPM in case of absence of the
permanent successor tooth
8. Management of IPM in the presence of the per-
manent successor tooth
9. Prognosis of IPM
10. Consequences of IPM
11. Exam night review

31 Infraocclusion of Primary Teeth

 Infraocclusion of primary teeth (IPM) refers to primary milial pattern of inheritance (Kurol, 1981) and is mainly
molars that remain stationary without no clear obstruc- associated with the agenesis of the permanent successor
tion whilst the neighbouring teeth continue to erupt at (Biederman, 1968).
a normal pace, resulting in the occlusal surfaces of the
• Metabolic disorders such as disturbance of local me-
primary molars being inferior to the occlusal plane of
tabolism (Biederman, 1968). Primary first mandibular
the adjacent teeth. IPM initially erupted in occlusion.
molars have the shortest distal alveolar crest. Therefore,
However, the eruption rate slows down and no longer
there is a strong correlation between the infraocclusion
maintains a pace with neighbouring teeth, resulting in
of primary mandibular molars, tilting of teeth and alveo-
infra-occlusion.
lar crest levels of the ankylosed tooth (Peretz et al., 2013).
Numerous terms have been used to describe this anom- Other potential metabolic disorders include altered tooth
aly, i.e., ankylosis, arrested eruption, submerged, buried, resorption, which is characterised by periods of resorp-
sunken, retained tooth, depression, dis-inclusion, impac- tion and hard tissue regeneration (Kronfeld, 1955).
tion, infra-occlusion, incomplete eruption, intrusion, re-
Classification of IPM (Brearley and McKibben, 1973)
impaction, re-inclusion, secondary retention, shortened
tooth, submerged tooth, and suppressed eruption. These include:
Incidence of IPM • A mild form in which the occlusal surface of the in-
fraoccluded molar lies above the contact area of the ad-
The incidence of IPM varies depending on age; it is 14%
jacent teeth and below the occlusal height by less than 1
in 8-9 years old children, and 2% in adolescents aged 12
mm.
years and older. IPM is more common in females than
males (Kurol and Thilander, 1984). • A moderate form in which the occlusal surface of
affected teeth is approximately at the level of the inter-
There is an increase in prevalence in the lower jaw, with
proximal contact points of the adjacent teeth.
the lower to upper jaw ratio of 10:1 due to the different
curvatures of the arches (Arhakis and Boutiou, 2016, Bie- • A severe form in which the occlusal surface is below
derman, 1956). the interproximal contact points of the adjacent teeth.
Permanent molars may also be seen in infra-occlusion, Clinical presentations of IPM
but primary molars are more commonly affected (Bie-
Clinical signs of infraocclusion include being gingival to
derman, 1956). In the lower arch, the first molars have a
the occlusal table of the adjacent teeth. Another sign of
higher incidence than the second molars (Steigman et al.,
IPM is the presence of ankyloses which can be confirmed
1973, Andlaw, 1977, Peretz et al., 2013).
by:
Clinical presentation of IPM
• A high metallic sound on percussion test (Arhakis
Clinically, the appearance of IPM can vary from mild in- and Boutiou, 2016),
fraocclusion to the complete disappearance of the tooth
• Loss of mobility mainly occurs when more than 10%
within the bone (Kurol, 1981). Tipping of the adjacent
of the root surface is ankylosed (Ne et al., 1999),
teeth and a decrease in the arch length have been report-
ed (Tieu et al., 2013) • Extensive root resorption on an immobile tooth in-
dicates ankylosis (Ekim and Hatibovic-Kofman, 2001).
Aetiology of IPM
• Radiographical findings of IPM include obliteration
There is considerable uncertainty in the aetiology of in-
of the lamina dura; the CBCT method can provide more
fraocclusion. The most probable aetiological factors are
details but has limitations due to voxel size limitations.
(Kurol, 1981):
• Vertical bone defect and absence of a permanent
• Jaw growth disturbance (most probable).
successor are other radiographical features.
• Environmental such as injury to Hertwig’s epithelial
Treatment options of IPM
root sheath due to trauma, infection or excessive masti-
catory pressure (Biederman, 1968). As per some of the Treatment decisions are guided by the assessing param-
old theories, this injury can result in disturbance of the eters such as (Ekim and Hatibovic-Kofman, 2001):
root resorption process and failure in the normal erup- • Presence or absence of a permanent successor,
tive process of the tooth (Dixon, 1963). Moreover, iatro-
genic damage secondary to radiation or chemotherapy • Onset of the problem and time of diagnosis,
and idiopathic reasons (Kurol, 1981) has been reported • Resorption rate,
• Genetic (Via Jr, 1964) usually follows a definite fa-

Infraocclusion of Primary Teeth 32

 • Rate of progression of infraocclusion, infection/inflammation, a coronectomy of the IPMs
could be a sensible option. This approach maintains the
• Risk of adverse effects over time,
alveolar bone’s width and allows it to continue its verti-
• Predictive clinical patterns of infraoccluded prima- cal growth due to the stretching of transeptal fibres from
ry molars. adjacent teeth (Mohadeb et al., 2015).
Early diagnosis of IPM offers more treatment options, 6. Distraction osteogenesis: It is usually prescribed if
such as interceptive treatment. As IPMs are not respon- the successor of the IPM is missing with no further ver-
sive to orthodontic movement, treatment options in- tical growth remaining. Light orthodontic forces can be
clude: applied to level the infraoccluded segment.
1. Watchful waiting for monitoring for six months if Management of IPM in case of absence of the permanent
a permanent successor is present (Kurol and Thilander, successor tooth
1984). Usually, infra-occlusion is temporary, and the re-
These include:
tained primary tooth will eventually be lost as a perma-
nent successor erupts (Howe et al., 2015). Ideally, infra- • Early-onset, early diagnosis, slow root resorption,
occluded teeth should be exfoliated when the permanent slow rate of progression of ankylosis: Occlusal build-ups
successor has two-thirds of its root formed. The patient of the IPM or, if the IPM is exfoliating, encouraging the
should be encouraged to wobble the primary molar near patient to mobilise the tooth by wobbling, followed by
the natural exfoliation age. space management (e.g., orthodontic space closure or
prosthetic replacement).
2. Early extraction: If teeth do not exfoliate at the ideal
time, early conventional extractions can be carried out to • Early-onset, early diagnosis, slow root resorption,
avoid complicated and invasive interventions later. One fast rate of progression of ankylosis: Treatment options
way to avoid surgery is to place coloured elastic separa- include extraction, luxation or temporary built-up of in-
tors/rubber bands around the IPM at the level of CEJ fraoccluded teeth. Space management should follow the
(Walker and King, 2017). Over days, the tooth will sepa- extraction (e.g. orthodontic space closure or prosthetic
rate from its gingival attachment causing minimal dis- replacement).
comfort. This technique can be used on other deciduous
• Early-onset, early diagnosis, fast root resorption: It
teeth. In advanced cases of IPM, access for atraumatic
is recommended to observe and monitor normal exfo-
extraction can be achieved via uprighting the associated
liation followed by space management (e.g., orthodontic
tipped teeth with a removable appliance or segmental
space closure or prosthetic replacement).
fixed appliance. A 2 x 4 appliance can also be used for
this purpose. Space maintenance should be considered to • Early-onset, late diagnosis: If excessive tipping of the
avoid space loss secondary to extraction. In some cases, adjacent teeth is observed, then orthodontic uprighting
permanent premolar teeth may fail to erupt; hence surgi- of the adjacent teeth is followed by a build-up of the oc-
cal exposure and orthodontic traction might be required clusal surface or extraction of the IMP.
once more than two-thirds of the root is formed.
• Late-onset: Occlusal build-up to preserve the tooth
3. Luxation: Atraumatic luxation is a documented until the tooth exfoliates; this should be followed by orth-
method for mobilising an IPM. It involves breaking the odontic space closure or prosthetic replacement.
bony union between the alveolus and the tooth. There-
Management of IPM in the presence of the permanent suc-
fore, IPM may continue eruption and natural exfoliation.
cessor tooth
Factors affecting a luxation decision involve the age of
the patient, degree of infraocclusion, tipping of neigh- These include:
bouring teeth, and the permanent successor’s position • Early-onset, early diagnosis: In mild infraocclusion,
(Jenkins and Nichol, 2008, Parisay et al., 2013). Luxation the IPM tends to exfoliate normally. Therefore, it should
is associated with a risk of causing replacement resorp- be monitored for six months; if infraocclusion progress-
tion (ankyloses) or inflammatory resorption. es, then extraction will be indicated. In moderate and
4. Restoration of the occlusal table (composite onlays): severe infraocclusion, immediate extraction should be
This approach helps prevent the tipping and crowding combined with a space maintainer using a transpalatal or
of the adjacent teeth, retain the IPM, maintain the bone lingual arch.
quantity for future transplantation or implant therapy, • Early-onset, late diagnosis: If tipping is observed,
and prevent food trapping around the IPM. orthodontic uprighting should be done combined with
5. Coronectomy: For severe IPMs in the absence of extraction of the involved teeth, followed by a space
maintainer for future prosthetic replacement.

33 Infraocclusion of Primary TEETH

 • Late-onset, slow/ fast progression of infraocclusion:
Extraction of involved teeth and a space maintainer is
recommended (Biederman, 1962, Ekim and Hatibovic-
Kofman, 2001).
Prognosis of IPM
The following features, either alone or in combination,
will demonstrate a potentially poor prognosis for a pri-
mary molar:
• Caries,
• Root resorption,
• Bone resorption,
• Periapical or inter-radicular pathology,
• Ankylosis,
• Infraocclusion,
• Gingival recession
However, if IPM survives to twenty years of age, contin-
ued long-term function can be expected (Bjerklin and
Bennett, 2000).
Consequences of IPM
These include:
• Delayed exfoliation of IPM.
• Delayed eruption or even impaction of permanent
teeth (Tieu et al., 2013).
• Negative impact on oral hygiene procedures and fu-
ture restorations.
• Ankylosis with the subsequently increased difficulty
of extraction.
• Tipping of the adjacent teeth due to stretching of the
trans-septal fibres.
• Occlusal disturbance due to overeruption of the op-
posing teeth.
• Damage to the adjacent teeth.
• Loss of space.
• Encouraging lateral tongue thrust habits and subse-
quently developing a lateral open bite.

Infraocclusion of Primary Teeth 34

Exam night review •
effect canCoronectomy
be prevented by using a thick archwire for sliding,
or double cable mechanics (Hutchinson, 2011)
IPMs are primary molars that remain stationary in the ab- • Distraction osteogenesis
sence of any obstruction. At the same time, the neighbour- fRow-boat effect: if canines are mesially tipped, regardless
Prognosis of IPM
ing teeth continue to erupt at a normal pace resulting in the of the presence of the space distal to them, full engagement
occlusal surfaces of the primary molars lying inferior to the •of the brackets
Caries,results in a tendency of the incisors teeth to
occlusal plane of the adjacent teeth. procline. This can be prevented by avoiding full arch engage-
• Root resorption,
ment, segemental retaction of the canine, by-passing canine
Incidence
•brackets or
Bone resorption,
by-passing incisors, until enough spaces are pro-
• 14% in children aged 8-9, and 2% of adolescents 12 vided for anterior alignemnt. Rowboat effects are also seen
• Periapical or inter-radicular pathology,
years and older, in engaging distally orientated canines in a continuous wire,
•which results
Ankylosis,
in extrusion and proclination of incisors.
• More common in females than males (Kurol and
Thilander, 1984). • • Infraocclusion,
Gable and are incorporated into the re-
bends: They
• traction loop configuration
Gingival recession to provide a negative
• There is an increased prevalence in the lower jaw
counter-moment (Braun and Garcia, 2002). Ideally
compared to the upper jaw by a ratio of 10:1
placed 40-45°, closer to the posterior teeth each side
to increase
Consequences the arm of the counter- moment (Proffit
of IPM
Aetiology et al., 2006). Bends on the mesial side are called al-
• Delayed
pha bends exfoliation
while theofdistal
IPM.bends are known as beta
• Environmental: • bends
Delayed (Katona et al.,
eruption 2013).impaction of permanent
or even
• Genetic: teeth (Tieu Classification
Geometry et al., 2013).
• Metabolic disorders: •The relationship
Negativeofimpact on oral hygiene
slot angulation of oneprocedures and
bracket slot (A)
future restorations.
to an adjacent bracket slot angulation (B) can be classified
•into six geometries whichthe
Ankylosis with determines the
subsequent end results
increased of the
difficulty
Classification (Brearley and McKibben, 1973) force system:
of extraction.
• Mild: Occlusal surface →above contact area of adja-
•• ClassTipping
I geometry:
of theThe bracket
adjacent slotsdue
teeth areto
parallel but not-
stretching of
cent teeth and below the occlusal height by less than 1 mm. Gin a straight line (A/B=+1).
the trans-septal fibres.
• Moderate: Occlusal surface →at the level of the
•• ClassOcclusal
II geometry: The ration
disturbance between
due to A/B is of
overeruption equal
the to
interproximal contact points of the adjacent teeth. +0.8.
opposing teeth.
• Severe: Occlusal surface is below the interproximal
•• ClassDamage
III geometry: The ration
to the adjacent between A/B is equal to
teeth.
contact points of the adjacent teeth. +0.5.
• Loss of space.
• Class IV geometry: The ration between A/B is equal to
• -0.5.Encouraging lateral tongue thrust habits and subse-
Diagnosis
quently developing a lateral open bite.
• Presence or absence of a permanent successor, • Class IV geometry: The ration between A/B is equal to
-0.75.
• The onset of the problem and time of diagnosis,
• Class V geometry: The ration between A/B is equal to
• Resorption rate, -0.4.
• Rate of progression of infraocclusion, • Class VI geometry: The ration between A/B is equal t
• Risk of adverse effects over time, o -1.

• Predictive clinical patterns of infraoccluded pri- Forces required to move teeth

mary molars. The magnitude of the forces required to move teeth varies
depending on the type of movement and type of teeth.

Treatment options It is generally agreed that:

• Watchful waiting • For bodily movement, 70-120 g of force is required

• Early extraction: • For intrusion, 10-20 g of force is required

• Luxation: • For tipping, 35-60 g of force is required

• Restoration of the occlusal table (composite onlays) • For extrusion, 35-60g of force is required

35 Infraocclusion of PRIMARY TEETH

References TIEU, L. D., WALKER, S. L., MAJOR, M. P. & FLORES-MIR, C.
2013. Management of ankylosed primary molars with premolar
ANDLAW, R. J. 1977. Submerged deciduous molars: a prevalence
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survey in Somerset. J Int Assoc Dent Child, 8, 42-5.
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ARHAKIS, A. & BOUTIOU, E. 2016. Etiology, Diagnosis, Conse-
VIA JR, W. F. 1964. Submerged deciduous molars: familial tenden-
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cies. The Journal of the American Dental Association, 69, 127-129.
Dent J, 10, 714-719.
WALKER, C. G. & KING, R. 2017. Extraction of Gingivally Re-
BIEDERMAN, W. 1956. The incidence and etiology of tooth anky-
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51, 480.
BIEDERMAN, W. 1962. Etiology and treatment of tooth ankylosis.
American Journal of Orthodontics, 48, 670-684.
BIEDERMAN, W. 1968. The problem of the ankylosed tooth. Dent
Clin North Am, 409-24.
BJERKLIN, K. & BENNETT, J. 2000. The long-term survival of
lower second primary molars in subjects with agenesis of the pre-
molars. Eur J Orthod, 22, 245-55.
BREARLEY, L. J. & MCKIBBEN, D. H., JR. 1973. Ankylosis of pri-
mary molar teeth. I. Prevalence and characteristics. ASDC J Dent
Child, 40, 54-63.
DIXON, D. 1963. Observations on submerging deciduous molars.
Dent., 13, 303-316.
EKIM, S. L. & HATIBOVIC-KOFMAN, S. 2001. A treatment
decision-making model for infraoccluded primary molars. Int J
Paediatr Dent, 11, 340-6.
HOWE, B. J., COOPER, M. E., VIEIRA, A. R., WEINBERG, S. M.,
RESICK, J. M., NIDEY, N. L., WEHBY, G. L., MARAZITA, M. L. &
MORENO URIBE, L. M. 2015. Spectrum of Dental Phenotypes in
Nonsyndromic Orofacial Clefting. J Dent Res, 94, 905-12.
JENKINS, F. & NICHOL, R. 2008. Atypical retention of infraoc-
cluded primary molars with permanent successor teeth. European
Archives of Paediatric Dentistry, 9, 51-55.
KRONFELD, R. 1955. Histopathology of the Teeth: And Their Sur-
rounding Structures, Lea & Febiger.
KUROL, J. 1981. Infraocclusion of primary molars: an epidemio-
logic and familial study. Community Dent Oral Epidemiol, 9,
94-102.
KUROL, J. & THILANDER, B. 1984. Infraocclusion of primary
molars and the effect on occlusal development, a longitudinal
study. Eur J Orthod, 6, 277-93.
NE, R. F., WITHERSPOON, D. E. & GUTMANN, J. L. 1999. Tooth
resorption. Quintessence Int, 30, 9-25.
PARISAY, I., KEBRIAEI, F., VARKESH, B., SORURI, M. & GHA-
FOURIFARD, R. 2013. Management of a severely submerged
primary molar: a case report. Case reports in dentistry, 2013.
PERETZ, B., ABSAWI-HURI, M., BERCOVICH, R. & AMIR, E.
2013. Inter-relations between infraocclusion of primary mandibu-
lar molars, tipping of adjacent teeth, and alveolar bone height.
Pediatr Dent, 35, 325-8.
STEIGMAN, S., KOYOUMDJISKY-KAYE, E. & MATRAI, Y. 1973.
Submerged deciduous molars in preschool children: an epidemio-
logic survey. J Dent Res, 52, 322-6.

36 Infraocclusion of PRIMARY TEETH

Infraocclusion of PRIMARY TEETH 37
 6
Maxillary
Midline
Diastema
Written by: Mohammed Almuzian, Haris Khan

In this Chapter
1. Prevalence of midline diastema
2. Causes of midline diastema
3. Diagnostic feature for a prominent labial frenum
4. Management of median diastema
5. Exam night review

38 Maxillary Midline Diastema

Prevalence of midline diastema It depends primarily upon the removal of the underlying
cause. In the deciduous and mixed dentition, no treatment
The prevalence of maxillary median diastema varies ac-
is recommended. In permanent dentition, the options are an
cording to age and racial groups. An epidemiological study
aesthetic build-up of the central incisors or active orthodon-
on children in the UK showed that 46% of the cohort had
tic treatment to close a diastema is usually carried out in the
diastema at age six, 33% at age nine, 18% at age twelve, and
permanent dentition using URA or fixed sectional appliance.
12% at age thirteen (Gardiner, 1967).
Permeant fixed retention is highly recommended after clos-
In adults, the prevalence of median diastema in Caucasians ing the median diastema. There is a high risk of relapse with
is within the range of 1.6-22.3 % (McVay and Latta, 1984; a high incidence in patients with greater than 2mm diastema
Lavelle, 1970; Keene, 1963). There is an ethnic predilec- and those with family tendency (Edwards, 1977).
tion to black people compared to the Caucasian population
An adjunctive procedure like a frenectomy may be needed
(Richardson et al., 1973), with males being more commonly
(Edwards, 1977) though opinions vary on when to do a
affected than females.
frenectomy. A frenectomy before orthodontic treatment
Causes of midline diastema provides better surgical access, and, in theory, the scar tissue
contraction can help approximate the maxillary incisors.
These include:
Commonly, a frenectomy is carried out near or at the end of
1. Physiological causes such as: treatment.
• Normal development in the deciduous dentition.
• Physiological diastema before the eruption of the
permanent canines (Broadbend stage).
• Proclination of upper incisors.
2. Pathological causes such as:
• Congenitally missing teeth.
• Presence of a supernumerary teeth.
• Microdontia (peg-lateral incisors).
• Abnormal frenal attachments (controversial role in
aetiology).
• Abnormal shape or crown-root angulation of the
centrals.
• Abnormal pressure habits (tongue thrust, digit
sucking).
• Pathological migration of the anterior maxilla teeth
(rarely).
• Cyst
3. Trauma leading to tooth loss in the incisor region.
4. Iatrogenic causes include incorrect orthodontic
mechanics and during the active maxillary expansion phase.
Diagnostic feature for a prominent labial frenum
Maxillary median diastema is often seen between the maxil-
lary central incisors on direct visualisation. Blanching in the
region of the frenum could be seen when tension is applied
by lifting the upper lip. A spade-shaped or notched inter-
maxillary segment can be visible on radiographic examina-
tion.
Management of median diastema

Maxillary Midline Diastema 39

Exam night review References
Prevalence of midline diastema: 46% had diastema at age 6, 33% at Edwards JG. (1977) The diastema, the frenum, the frenectomy: a
age 9, 18% at age 12, and 12% at age 13 clinical study. Am J Orthod 71: 489-508.
Causes of midline diastema Gardiner JH. (1967) Midline spaces. Dent Pract Dent Rec 17: 287-
297.
These include:
Keene HJ. (1963) Distribution of diastemas in the dentition of man.
• Physiological causes Am J Phys Anthropol 21: 437-441.
• Pathological causes Lavelle CL. (1970) The distribution of diastemas in different human
• Trauma population samples. Scand J Dent Res 78: 530-534.
• Iatrogenic causes McVay TJ and Latta GH, Jr. (1984) Incidence of the maxillary mid-
line diastema in adults. J Prosthet Dent 52: 809-811.
Richardson ER, Malhotra SK, Henry M, et al. (1973) Biracial study
Diagnostic feature for labial frenum of the maxillary midline diastema. Angle Orthod 43: 438-443.
These include:
• Direct visualisation.
• Blanching on lifting the upper lip.
• A notched intermaxillary segment on the radiograph.
• Diastema with crowding elsewhere.

Management of median diastema

These include:
• Remove the underlying cause.
• Options are an aesthetic build-up of the centrals or active
orthodontic treatment to close a diastema using URA or a fixed
sectional appliance.

40 Maxillary Midline Diastema

41
 7
Loss of
permanent
incisorS
Written by: Mohammed Almuzian, Haris Khan, Lubna Almuzian

In this Chapter
1. Incidence of traumatic loss
2. Potential problems of missing incisors
3. Rationale for treatment
4. Multidisciplinary management
5. Factors affecting treatment options
6. Interceptive treatment
7. Provisional management
8. Definitive management
9. Survival rates for each replacement option
10. Considerations for opening or closing space of the lost
incisors
11. Retention
12. Case presentation
13. Exam night review

42
Trauma is the most common cause for the loss of permanent Factors affecting treatment options
incisors; commonly, the central incisor is lost. Other aetiologies
include caries, endodontic complications, and developmental Patient factors such as:
anomalies such as hypoplasia and clefts. Low levels of calcium or • Compliance & motivation
phosphate can also result in premature loss of permanent incisors
(Gunn, 1969). • Main concern (aesthetics-function)
Incidence of traumatic loss • Medical condition
Epidemiological studies indicate that the annual incidence of • Social status
dental trauma globally is approximately 4.5%. The majority involve
the maxillary central incisors (Lam, 2016). 3% of children with an Dental factors such as:
increased overjet (3-6mm) in the mixed dentition have a severe in- • Oral hygiene & dental health
jury such that it may lead to loss of the upper incisors. The percent-
age of severe injury rises to 10% with a significant overjet ( >6mm) • Degree of crowding/spacing
(Jarvinen, 1978). According to a systematic review, children of
0-6 years with an increased overjet of ≥3mm have odds of 3.37 for • Presenting malocclusion
trauma compared to children with average overjet. Children in Skeletal factors such as:
the mixed dentition (7-11 years) with an overjet of >5mm have an
odds of 2.43 of trauma, and 12-year-old children with an overjet • The skeletal pattern in three planes
>5mm have an odds of 1.81. (Arraj et al., 2019). The chances of an-
terior tooth trauma increase with the overjet and lip incompetency.
• Bone quality
Girls have more chances of traumatic injuries to the anterior teeth • Time elapsed since the loss of the tooth
than boys of the same overjet (Nguyen et al., 1999).
Soft tissue factors such as:
Potential problems of missing incisors
• Lip support
These include:
• Smile line
• Aesthetic concerns.
• Smile aesthetics
• Space loss.
• Tipping and rotation of adjacent teeth. Dental care such as

• Midline shift. • Availability

• Spacing between anterior teeth. • Cost
• Development of class 3 incisor relationship or anterior Treatment options
crossbite,
Summary of the options in (Figure 1)
• Necking of alveolar bone.
Interceptive treatment
Rationale for treatment
Interceptive treatment involves reducing the patient’s risk
These include: of trauma through patient education, mouthguards, and
• Appearance, growth modification. A Cochrane review suggests that there
is low to moderate-quality evidence that early treatment of
• Speech (lisping), prominent upper incisors is more effective in reducing the
• Psychological benefit, and incidence of trauma than providing one course of orthodon-
tic treatment in the adolescent (Batista et al., 2018a)
• Function (incising food).
Provisional management
Multidisciplinary management
An acrylic partial denture or thermoplastic formed pros-
Loss of permanent incisors requires multidisciplinary plan- thesis containing a tooth pontic is recommended as a space
ning; the objective is to plan the aims and objectives before maintainer (Mallard et al., 2016). Space maintainers are
starting treatment. Collaboration is between orthodontics used:
and restorative fields; surgical input may explore all options.
MDT planning aims to enable each speciality to plan their • To improve aesthetics (Crawford et al., 2008),
treatment with an awareness of the others’ plan, establish a • To restore function,
common goal, and provide the maximum information and
efficiency for the patient’s treatment. • To prevent space loss,
• To prevent tipping of teeth,

Loss of Maxillary incisorS 43

• To avoid a potential midline shift. Survival rates for each replacement option
Some suggest allowing spontaneous space closure/loss These include:
initially to persevere alveolar bone height, as short-term
management, followed by later orthodontic space opening • Resin-bonded bridge: According to a systematic
of the lost tooth followed by permanent prosthetic replace- review, the estimated survival rate of cantilever RBBs was
ment, therefore maintaining the alveolar bone (Kokich and 91.4% after 5 years and 82.9% after 10 years. (Thoma et al.,
Crabill, 2006). 2017)

Definitive management • Conventional fixed bridge: According to a system-

atic review, the estimated survival rate of the conventional
These include: fixed bridge was 93.8% after 5 years and 89.2% after 10
1. No active treatment: After giving sufficient infor- years. (Pjetursson et al., 2007)
mation, the patient should freely make their own choice, • Implant: According to a systematic review, im-
especially those who have no concerns regarding appearance plant-supported prosthesis’s estimated survival rate was
or function. Also, this option should be supported when 95.6% after 5 years and 93.1% after 10 years. (Pjetursson et
there are dental or medical health contraindications that al., 2012).
make the potential risk of treatment outweigh the benefit of
the treatment. • Auto-transplantation: According to a systematic
review, the estimated survival rate of auto-transplanted teeth
2. Space closure followed by reshaping the adjacent ranges from 75-91% over 6 years period. (Machado et al.,
teeth aiming to achieve group and therapeutic Class II molar 2016a)
relationship on the affected side.
Considerations for opening or closing space of the lost in-
3. Orthodontic space opening followed by replace- cisors
ment using either:
Patient compliance, arch length discrepancy, buccal segment
• Removable partial denture as an intermediate-term relationship, adjacent tooth colour, tooth form, and gingival
measure (Bowden and Harrison, 1994), margin height are key factors in space opening or closure.
• Fixed conventional dental bridge as an intermedi- Broad general principles are below:
ate or long-term measure (Romero et al., 2018), If the patient has skeletal Class II, space closure is a pre-
• Cantilever resin-bonded bridge as an intermediate ferred option as it will help in reducing the associated over-
or long-term measure, jet. Aesthetic consequences of large spaces should be consid-
ered (Sharma, 2013), even in the case of space closure. This
• Implant-supported crown as a long-term measure can be managed with an acrylic pontic tooth attached to
(Dietschi and Schatz, 1997), or the archwire. In space closure, the size of the pontic can be
• Auto-transplantation. gradually reduced (1mm/month) to accommodate space
closure and maintain a degree of aesthetics. If functional
For the replacement of maxillary lateral incisors, the tooth appliance treatment is planned, space opening is likely the
of choice is the lower first premolar because of its crown and preferred option; the pontic tooth can be incorporated into
root form (Paulsen et al., 2006). However, any single-rooted the functional appliance.
premolar can be used for auto-transplantation.
On the other hand, if the patient presents with a skeletal
Auto-transplantation should be carried out as soon as pos- Class III pattern, space opening is the preferred option as
sible following avulsion of the incisor to preserve alveolar it will help advance the upper incisors and improve the
bone, ideally, when there is 2/3-3/4 root of the tooth to be overjet. However, some case series have shown space closure
transplanted is formed, this will maximise the potential for in all malocclusion types from Class I, II, and III involving
the transplanted tooth to maintain vitality, and root forma- TADs (Amm et al., 2019)
tion is likely to continue at the recipient site (Kvint et al.,
2010). The root development stage is the most important According to a systematic review, orthodontic space closure
factor for the future vitality of the transplanted tooth (An- for a missing maxillary lateral incisor has better periodontal
dreasen et al., 1990). The long-term success for auto-trans- index scores and more favourable aesthetics than the tooth
plantation is promising (79-100%) (Kvint et al., 2010, Tanaka replacement option. However, this evidence included only
et al., 2008) . It has been reported that 4.8% of transplanted case-control studies with a high risk of bias, so it should be
teeth become ankylosed with time, while almost one fifth interpreted carefully (Silveira et al., 2016)
(19%) show root resorption (Machado et al., 2016b).

44
Loss of Maxillary incisorS
Retention
According to a Cochrane database systematic review, there
is no enough high-quality evidence to recommend anyone
approach to retention over another (Littlewood et al.,2016).
As a general rule, when orthodontic space closure is
planned, a fixed retainer is often indicated to prevent the re-
opening of spaces. On the other hand, when space opening
is planned, a vacuum-formed or Hawley retainer with artifi-
cial teeth can be used to avoid gaps in appearance and allow
a period of settling before the definitive restorative work.

Figure 1: Summarising the definitive management options for missing incisors

Loss of Maxillary incisorS 45

Exam Night Review Reference
Traumatic loss AMM, E. W., ANTOSZEWSKA-SMITH, J. & BOLEY, J.
2019. Canine substitution of congenitally missing maxil-
• Dental trauma globally is at about 4.5%.
lary lateral incisors in Class I and Class III malocclusions by
• Overjet larger than 3 mm have twice the risk of using skeletal anchorage. American Journal of Orthodontics
injury to anterior teeth than children with an overjet smaller and Dentofacial Orthopedics, 156, 512-521. e6.
than 3 mm (Nguyen et al., 1999).
ANDREASEN, J. O., PAULSEN, H. U., YU, Z. & BAYER, T.
• Chances of anterior teeth trauma increase with 1990. A long-term study of 370 autotransplanted premolars.
the increase in overjet lip incompetency. Girls have more Part IV. Root development subsequent to transplantation.
chances of anterior teeth trauma than boys in the same over- Eur J Orthod, 12, 38-50.
jet group (Nguyen et al., 1999).
ARRAJ, G. P., ROSSI‐FEDELE, G. & DOĞRAMACI, E. J.
2019. The association of overjet size and traumatic dental
injuries—A systematic review and meta‐analysis. Dental
Potential problems of missing incisors
traumatology, 35, 217-232.
• Aesthetic concerns,
BATISTA, K. B., THIRUVENKATACHARI, B., HARRI-
• Space loss, SON, J. E. & D O’BRIEN, K. 2018a. Orthodontic treatment
• Tipping and rotation of adjacent teeth, for prominent upper front teeth (Class II malocclusion) in
children and adolescents. Cochrane Database of Systematic
• Midline shifting, Reviews.
• Spacing between anterior teeth, and BATISTA, K. B., THIRUVENKATACHARI, B., HARRI-
• Development of Class III incisor relationship or SON, J. E. & O’BRIEN, K. D. 2018b. Orthodontic treatment
anterior crossbite, and for prominent upper front teeth (Class II malocclusion) in
children and adolescents. Cochrane Database Syst Rev, 3,
• Necking of alveolar bone. Cd003452.
BOLTON, W. A. 1958. Disharmony in tooth size and its
Interceptive treatment relation to the analysis and treatment of malocclusion. The
Angle Orthodontist, 28, 113-130.
• Mouthguards
BOWDEN, D. E. & HARRISON, J. E. 1994. Missing anterior
• Growth modification (Thiruvenkatachari et al., teeth: treatment options and their orthodontic implications.
2013, Batista et al., 2018b). Dent Update, 21, 428-34.
Provisional management DIETSCHI, D. & SCHATZ, J. P. 1997. Current restorative
Space maintainer: Acrylic partial denture or thermoplastic modalities for young patients with missing anterior teeth.
formed prosthesis containing a tooth pontic is recommend- Quintessence Int, 28, 231-40.
ed space maintainers (Mallard et al., 2016). Space maintain- JARVINEN, S. 1978. Incisal overjet and traumatic injuries
ers are used: to upper permanent incisors. A retrospective study. Acta
• To improve aesthetics (Crawford et al., 2008), Odontol Scand, 36, 359-62.

• To restore function, KHALAF, K., MISKELLY, J., VOGE, E. & MACFARLANE,

T. V. 2014. Prevalence of hypodontia and associated factors:
• To prevent space loss, a systematic review and meta-analysis. Journal of orthodon-
• To avoid the tipping of teeth, tics, 41, 299-316.
• To prevent a potential midline shift. KOKICH, V. G. & CRABILL, K. E. 2006. Managing the pa-
tient with missing or malformed maxillary central incisors.
Some suggested allowing spontaneous space closure/loss American journal of orthodontics and dentofacial orthope-
Definitive management dics, 129, S55-S63.
• No active treatment LAM, R. 2016. Epidemiology and outcomes of traumatic
dental injuries: a review of the literature. Australian dental
• Space closure
journal, 61, 4-20.
• Orthodontic space opening

46 Loss of Maxillary incisorS

MACHADO, L., DO NASCIMENTO, R., FERREIRA, D., THICKETT, E., TAYLOR, N. G. & HODGE, T. 2007.
MATTOS, C. & VILELLA, O. 2016a. Long-term progno- Choosing a pre-adjusted orthodontic appliance prescription
sis of tooth autotransplantation: a systematic review and for anterior teeth. Journal of orthodontics, 34, 95-100.
meta-analysis. International journal of oral and maxillofacial
THIRUVENKATACHARI, B., HARRISON, J. E.,
surgery, 45, 610-617.
WORTHINGTON, H. V. & O’BRIEN, K. D. 2013. Orth-
MACHADO, L. A., DO NASCIMENTO, R. R., FERREIRA, odontic treatment for prominent upper front teeth (Class
D. M., MATTOS, C. T. & VILELLA, O. V. 2016b. Long-term II malocclusion) in children. Cochrane Database Syst Rev,
prognosis of tooth autotransplantation: a systematic review Cd003452.
and meta-analysis. Int J Oral Maxillofac Surg, 45, 610-7.
THOMA, D. S., SAILER, I., IOANNIDIS, A., ZWAHLEN,
MALLARD, W. A., DEURING, W. N., OWENS, B. M., PHE- M., MAKAROV, N. & PJETURSSON, B. E. 2017. A system-
BUS, J. G. & UMSTED, D. E. 2016. Provisional Replacement atic review of the survival and complication rates of resin‐
of Anterior Teeth: A Review of Clinical Techniques and Case bonded fixed dental prostheses after a mean observation
Report in a Dental School Training Experience. J Tenn Dent period of at least 5 years. Clinical oral implants research, 28,
Assoc, 96, 31-38. 1421-1432.
NGUYEN, Q. V., BEZEMER, P. D., HABETS, L. & PRAHL-
ANDERSEN, B. 1999. A systematic review of the relation-
ship between overjet size and traumatic dental injuries. Eur J
Orthod, 21, 503-15.
PAULSEN, H. U., ANDREASEN, J. O. & SCHWARTZ, O.
2006. Tooth loss treatment in the anterior region: auto-
transplantation of premolars and cryopreservation. World J
Orthod, 7, 27-34.
PJETURSSON, B. E., BRÄGGER, U., LANG, N. P. &
ZWAHLEN, M. 2007. Comparison of survival and com-
plication rates of tooth‐supported fixed dental prostheses
(FDPs) and implant‐supported FDPs and single crowns
(SCs). Clinical oral implants research, 18, 97-113.
PJETURSSON, B. E., THOMA, D., JUNG, R., ZWAHLEN,
M. & ZEMBIC, A. 2012. A systematic review of the survival
and complication rates of implant‐supported fixed dental
prostheses (FDP s) after a mean observation period of at
least 5 years. Clinical oral implants research, 23, 22-38.
ROMERO, M. F., HADDOCK, F. J. & BRACKETT, W. W.
2018. Replacement of a Missing Maxillary Central Incisor
Using a Direct Fiber-Reinforced Fixed Dental Prosthesis: A
Case Report. Oper Dent, 43, E32-e36.
ROSA, M. & ZACHRISSON, B. U. 2001. Integrating esthetic
dentistry and space closure in patients with missing maxil-
lary lateral incisors. Journal of clinical orthodontics, 35,
221-238.
SHARMA, N. S. 2013. Riding pontic: A tool to keep patients
smiling. International journal of clinical pediatric dentistry,
6, 127.
SILVEIRA, G. S., DE ALMEIDA, N. V., PEREIRA, D. M. T.,
MATTOS, C. T. & MUCHA, J. N. 2016. Prosthetic replace-
ment vs space closure for maxillary lateral incisor agenesis:
a systematic review. American Journal of Orthodontics and
Dentofacial Orthopedics, 150, 228-237.

Loss of Maxillary incisorS 47

 8
Mouthguards
Written by: Mohammed Almuzian, Haris Khan

In this Chapter
1. Prevalence of trauma
2. Materials used to construct a mouthguard
3. Types of mouthguard
4. Exam night review

48
 A mouthguard is a resilient device placed inside the but are bulky, uncomfortable and poorly retentive.
mouth, which helps reduce injuries to the teeth and as-
• Maxillary custom-formed mouthguards are fabri-
sociated tissues, specifically during sports activities. A
cated in a dental laboratory, and they are vacuum-formed
mouthguard is essential in preventing sport-related den-
for maxillary dentition with a 3-5mm thick sheet of EVA
tal trauma (Ada Council on Access et al., 2006). A lit-
polymer. Though expensive, these mouthguards are very
erature review concluded that mouthguards are the most
retentive and comfortable.
effective way of preventing dental injuries while playing
contact sports (Newsome et al., 2001). It is recommend- • Bimaxillary custom-formed mouthguards are stock
ed that all orthodontic patients wearing fixed appliances, mouthguards for orthodontic use, which cover both the
who participate in contact sports, should wear a sports upper and lower fixed appliances simultaneously. They
mouthguard to protect against possible dental injury. are made from rubber and can be trimmed to size for
greater comfort.
Prevalence of trauma
• Orthoguards are the most recent addition to the
In children, sports accidents reportedly account for 10-
market. They instantly fit an incorporated channel to
39% of all dental injuries (Newsome et al., 2001). The
accommodate a fixed appliance and any potential tooth
peak of these injuries occurs at the age of 8 to 11 years. In
movements.
most trauma cases, 80% of the maxillary central incisors
are involved (Zerman and Cavalleri, 1993).
Patients with an increased overjet and proclined upper in-
cisors are more prone to trauma (Todd and Dodd, 1985).
Children with increased overjet (larger than 3mm) have
twice the chance of incisor trauma, and boys have more
chance of having incisor trauma than girls (Nguyen et
al., 1999). A systematic review and meta-analysis found
that the threshold for trauma is an overjet of≥3mm and
≥5mm in the primary and early secondary dentition, re-
spectively (Arraj et al., 2019).
A study found that the causes of traumatic dental injuries
of the primary dentition are older children, inadequate
lip coverage and anterior open bite (Corrêa-Faria et al.,
2016).
Materials used to construct a mouthguard.
These include:
• Ethylene-vinyl acetate (EVA)
• Polyvinylchloride (PVC) material (similar to a pres-
sure-formed retainer)
• Rubber base silicon
Types of mouthguard
These include:
• Stock mouthguards are pre-formed mouthguards,
and they are available over the counter in a variety of
sizes. These are made from EVA and are inexpensive but
have poor retention, limited protection and can not be
modified.
• Mouth-formed mouthguards are also known as ‘boil
and bite mouthguards, and they are made from a ther-
moplastic material, which is softened in hot water for 45-
60 seconds and then moulded by the patient onto their
teeth and gingivae. These mouthguards are inexpensive

Mouthguards 49
Exam night review References
• The literature does not provide clear evidence on which ADA COUNCIL ON ACCESS, P., INTERPROFESSIONAL,
type of mouthguard should be recommended for patients with R. & AFFAIRS, A. D. A. C. O. S. 2006. Using mouthguards
fixed orthodontic appliances. to reduce the incidence and severity of sports-related oral
• A survey found that more patients wear mouthguards injuries. Journal of the American Dental Association (1939),
while playing football and basketball; orthodontists tend to rec- 137, 1712-20; quiz 1731.
ommend boil-and-bite mouthguards, while patients prefer stock
mouthguards (Bastian et al., 2020). ARRAJ, G. P., ROSSI-FEDELE, G. & DOGRAMACI, E. J.
2019. The association of overjet size and traumatic dental
• It is suggested that custom-formed laminate mouth- injuries-A systematic review and meta-analysis. Dent Trau-
guards with greater layers and thickness have significantly im-
matol, 35, 217-232.
proved the orofacial protection (Salam and Caldwell, 2008).
• Custom mouthguards are considered by many to be the BASTIAN, N. E., HEATON, L. J., CAPOTE, R. T., WAN, Q.,
most protective option; other mouthguards can be effective if worn RIEDY, C. A. & RAMSAY, D. S. 2020. Mouthguards during
correctly. orthodontic treatment: Perspectives of orthodontists and
a survey of orthodontic patients playing school-sponsored
basketball and football. Am J Orthod Dentofacial Orthop,
157, 516-525.e2.
CORRÊA-FARIA, P., MARTINS, C. C., BÖNECKER, M.,
PAIVA, S. M., RAMOS-JORGE, M. L. & PORDEUS, I. A.
2016. Clinical factors and socio-demographic characteris-
tics associated with dental trauma in children: a systematic
review and meta-analysis. Dent Traumatol, 32, 367-78.
NEWSOME, P. R., TRAN, D. C. & COOKE, M. S. 2001. The
role of the mouthguard in the prevention of sports-related
dental injuries: a review. Int J Paediatr Dent, 11, 396-404.
NGUYEN, Q. V., BEZEMER, P. D., HABETS, L. & PRAHL-
ANDERSEN, B. 1999. A systematic review of the relation-
ship between overjet size and traumatic dental injuries. Eur J
Orthod, 21, 503-15.
SALAM, S. & CALDWELL, S. 2008. Mouthguards and orth-
odontic patients. J Orthod, 35, 270-5.
TODD, J. E. & DODD, T. 1985. Children’s dental health
in the United Kingdom, 1983: a survey carried out by the
Social Survey Division of OPCS, on Behalf of the United
Kingdom Health Departments, in Collaboration with the
Dental Schools of the Universities of Birmingham and New-
castl, Stationery Office.
ZERMAN, N. & CAVALLERI, G. 1993. Traumatic injuries to
permanent incisors. Endod Dent Traumatol, 9, 61-4.

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