BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION

Management of the Developing Dentition and

Occlusion in Pediatric Dentistry
Latest Revision
2019

Purpose complexity of the problem and the individual clinician’s

The American Academy of Pediatric Dentistry (AAPD) training, knowledge, and experience.6
recognizes the importance of managing the developing denti- Many factors can affect the management of the developing
tion and occlusion and its effect on the well-being of infants, dental arches and minimize the overall success of any treat-
children, and adolescents. Management includes the recog- ment. The variables associated with the treatment of the
nition, diagnosis, and appropriate treatment of dentofacial developing dentition that will affect the degree to which
abnormalities. These recommendations are intended to set treatment is successful include, but are not limited to:
forth objectives for management of the developing dentition 1. chronological/mental/emotional age of the patient
and occlusion in pediatric dentistry. and the patient’s ability to understand and cooperate
in the treatment.
Methods 2. intensity, frequency, and duration of an oral habit.
Recommendations on management of the developing dentition 3. parental support for the treatment.
and occlusion were developed by the Developing Dentition 4. compliance with clinician’s instructions.
Subcommittee of the Clinical Affairs Committee and adopted 5. craniofacial configuration.
in 1990.1 This document by the Council of Clinical Affairs 6. craniofacial growth.
is a revision of the previous version, last revised in 2014.2 7. concomitant systemic disease or condition.
This revision is based upon a new PubMed /MEDLINE ®
search using the terms: tooth ankylosis, Class II malocclusion,
8. accuracy of diagnosis.
9. appropriateness of treatment.
Class III malocclusion, interceptive orthodontic treatment, 10. timing of treatment.
evidence-based, dental crowding, ectopic eruption, dental im- A thorough clinical examination, appropriate pretreatment
paction, obstructive sleep apnea syndrome (OSAS), occlusal records, differential diagnosis, sequential treatment plan, and
development, craniofacial development, craniofacial growth, progress records are necessary to manage any condition affect-
airway, facial growth, oligodontia, oral habits, occlusal wear ing the developing dentition.
and dental erosion, anterior crossbite, posterior crossbite, space Clinical examination should include:
maintenance, third molar development, and tooth size/arch 1. Facial analysis to:
length discrepancy; fields: all; limits: within the last 10 years, a. identify adverse transverse growth patterns includ-
humans, English, and birth through age 18. Papers for review ing asymmetries (maxillary and mandibular);
were chosen from these searches and from references within b. identify adverse vertical growth patterns;
selected articles. When data did not appear sufficient or were c. identify adverse sagittal (anteroposterior[AP])
inconclusive, recommendations were based upon expert and/ growth patterns and dental AP occlusal dishar-
or consensus opinion by experienced researchers and clinicians. monies; and
d. assess esthetics and identify orthopedic and ortho-
Background dontic interventions that may improve esthetics and
Guidance of eruption and development of the primary, mixed, resultant self-image and emotional development.
and permanent dentitions is an integral component of com- 2. Intraoral examination to:
prehensive oral health care for all pediatric dental patients. a. assess overall oral health status; and
Such guidance should contribute to the development of a b. determine the functional status of the patient’s
permanent dentition that is in a stable, functional, and esthe- occlusion.
tically acceptable occlusion and normal subsequent dentofacial
development. Early diagnosis and successful treatment of
developing malocclusions can have both short-term and long- ABBREVIATIONS
term benefits while achieving the goals of occlusal harmony AAPD: American Academy Pediatric Dentistry. AP: Anteroposterior.
CBCT: Cone-beam computed tomography. EE: Ectopic eruption.
and function and dentofacial esthetics.3-5 Dentists have the OSAS: Obstructive sleep apnea syndrome. PFE: Primary failure of
responsibility to recognize, diagnose, and manage or refer eruption. TMD: Temporomandibular joint dysfunction.
abnormalities in the developing dentition as dictated by the

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3. Functional analysis to: 3. detect favorable and unfavorable interactions that may
a. determine functional factors associated with the result from treatment options for each problem area.
malocclusion; 4. establish short-term and long-term objectives.
b. detect deleterious habits; and 5. summarize the prognosis of treatment for achieving
c. detect temporomandibular joint dysfunction stability, function, and esthetics.
(TMD), which may require additional diagnostic A sequential treatment plan will:
procedures. 1. establish timing priorities for each phase of therapy.
2. establish proper sequence of treatments to achieve
Diagnostic records may be needed to assist in the evaluation short-term and long-term objectives.
of the patient’s condition and for documentation purposes. 3. assess treatment progress and update the biomechan-
Prudent judgment is exercised to decide the appropriate records ical protocol accordingly on a regular basis.
required for diagnosis of the clinical condition.7
Diagnostic orthodontic evaluations fall into three major Stages of development of occlusion
categories: (1) health of the teeth and oral structures, (2) General considerations and principles of management: The
alignment and occlusal relationships of the teeth, and (3) stages of occlusal development include:
facial and jaw proportions.7 1. Primary dentition: Beginning in infancy with the
Diagnostic records may include: eruption of the first tooth, usually about six months
1. Extraoral and intraoral photographs to: of age, and complete from approximately three to
a. supplement clinical findings with oriented facial six years of age when all primary teeth are erupted.
and intraoral photographs; and 2. Mixed dentition: From approximately age six to 13,
b. establish a database for documenting facial primary and permanent teeth are present in the
changes during treatment. mouth. This stage can be divided further into early
2. Diagnostic dental casts to: mixed and late mixed dentition.
a. assess the occlusal relationship; 3. Adolescent dentition: All succedaneous teeth have
b. determine arch length requirements for intraarch erupted, second permanent molars may be erupted
tooth size relationships; or erupting, and third molars have not erupted.
c. determine arch length requirements for interarch 4. Adult dentition: All permanent teeth are present.7,8
tooth size relationships; and
d. determine location and extent of arch asymmetry. Historically, orthodontic treatment was provided mainly for
3. Intraoral and panoramic radiographs to: adolescents. Interest continues to be expressed in the concept
a. establish dental age; of interceptive (early) treatment as well as in adult treatment.
b. assess eruption problems; Treatment and timing options for the growing patient have
c. estimate the size and presence of unerupted teeth; increased and continue to be evaluated by the research com-
and munity.9,10 Many clinicians seek to modify skeletal, muscular,
d. identify dental anomalies/pathology. and dentoalveolar abnormalities before the eruption of the
4. Lateral and AP cephalograms to: full permanent dentition.
a. produce a comprehensive cephalometric analysis A thorough knowledge of craniofacial growth and develop-
of the relative dental and skeletal components in ment of the dentition, as well as orthodontic treatment, must
the AP, vertical, and transverse dimensions; be used in diagnosing and reviewing possible interceptive
b. establish a baseline growth record for longitudinal treatment options before recommendations are made to parents.
assessment of growth and displacement of the Treatment is beneficial for many children, but may not be
jaws; and indicated for every patient with a developing malocclusion.
c. determine dental maturity relative to skeletal
maturity and chronological age. Treatment considerations: The developing dentition should
5. Other diagnostic views (e.g., magnetic resonance be monitored throughout eruption. This monitoring at regular
imaging, cone-beam computed tomographic images clinical examinations should include, but not be limited to,
[CBCT]) for hard and soft tissue imaging as diagnosis of missing, supernumerary, developmentally de-
indicated by history and clinical examination. fective, and fused or geminated teeth; ectopic eruption; space
and tooth loss secondary to caries; and periodontal and pulpal
A differential diagnosis and diagnostic summary are health of the teeth.
completed to: Radiographic examination, when necessary11 and feasible,
1. establish the relative contributions of the soft tissue should accompany clinical examination. Diagnosis of anomalies
and dental and skeletal structures to the patient’s of primary or permanent tooth development and eruption
malocclusion. should be made to inform the patient’s parent and to plan
2. prioritize problems in terms of relative severity. and recommend appropriate intervention. This evaluation is
ongoing throughout the developing dentition, at all stages.7,8

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1. Primary dentition stage: Anomalies of primary teeth 1. Primary dentition stage: Habits and crossbites should
and eruption may not be evident/diagnosable prior be diagnosed and, if predicted not likely to be self-
to eruption, due to the child’s not presenting for correcting, they should be addressed as early as feasible
dental examination or to a radiographic examination to facilitate normal occlusal relationships. Parents
not being possible in a child due to age or behavior. should be informed about findings of adverse
Evaluation, however, should be accomplished when growth and developing malocclusions. Interventions/
feasible. The objectives of evaluation include identi- treatment can be recommended if diagnosis can be
fication of: made, treatment is appropriate and possible, and
a. all anomalies of tooth number and size (as parents are supportive and desire to have treatment
previously noted); done.
b. anterior and posterior crossbites; 2. Early mixed dentition stage: Treatment consideration
c. presence of habits along with their dental and should address:
skeletal sequelae; a. habits;
d. openbite; and b. arch length shortage;
e. airway problems. c. intervention for crowded incisors;
Radiographs are taken with appropriate clinical indi- d. intervention for ectopic teeth;
cators or based upon risk assessment/history. e. holding of leeway space;
2. Early mixed dentition stage: The objectives of evalu- f. crossbites;
ation continue as noted for the primary dentition g. openbite;
stage. Palpation for unerupted teeth should be part h. surgical needs; and
of every examination. Panoramic, occlusal, and peria- i. adverse skeletal growth.
pical radiographs, as indicated at the time of eruption Intervention for ectopic teeth may include extrac-
of the lower incisors and first permanent molars, tions of primary teeth and space maintenance/
provide diagnostic information concerning: regaining to aid erupting teeth and reduce the risk
a. unerupted teeth; of need for permanent tooth extraction or surgical
b. missing, supernumerary, fused, and geminated teeth; bracket placement for orthodontic traction. Treat-
c. tooth size and shape (e.g., peg or small lateral ment should take advantage of the child’s growth
incisors); and should be aimed at prevention of adverse dental
d. positions (e.g., ectopic first permanent molars); relationships and skeletal growth.
e. developing skeletal discrepancies; and 3. Late mixed dentition stage: Intervention for treat-
f. periodontal health. ment of skeletal disharmonies and crowding may be
Space analysis can be used to evaluate arch length instituted at this stage.
at the time of incisor eruption. 4. Adolescent dentition stage: In full permanent denti-
3. Late mixed dentition stage: The objectives of the tion, orthodontic diagnosis and treatment can provide
evaluations remain consistent with the prior stages, the most functional, stable, and esthetic occlusion.
with an emphasis on evaluation for ectopic tooth 5. Early adult dentition stage: Third molar position or
positions, especially canines, premolars, and second space can be evaluated and, if indicated, the tooth/
permanent molars. teeth removed. Full orthodontic treatment should be
4. Adolescent dentition stage: If not instituted earlier, recommended if needed.
orthodontic diagnosis and treatment should be
planned for Class I crowded, Class II, and Class III Recommendations
malocclusions as well as posterior and anterior Oral habits
crossbites. Third molars should be monitored as to General considerations and principles of management: The
position and space, and parents should be informed habits of nonnutritive sucking, bruxing, tongue thrust swallow
of the dentist’s observations. and abnormal tongue position, self-injurious/self-mutilating
5. Early adult dentition stage: Third molars should be behavior, and OSAS are discussed in these recommendations.
evaluated. If orthodontic diagnosis has not been Oral habits may apply negative forces to the teeth and
accomplished, recommendations should be made as dentoalveolar structures. The relationship between oral habits
necessary. and unfavorable dental and facial development is associational
rather than cause and effect.12,13 Habits of sufficient frequency,
Treatment objectives: At each stage, the objectives of duration, and intensity may be associated with dentoalveolar
intervention/treatment include managing adverse growth, or skeletal deformations such as increased overjet, reduced
correcting dental and skeletal disharmonies, improving esthe- overbite, openbite, posterior crossbite, or increased facial height.
tics of the smile and the accompanying positive effects on The duration of force is more important than its magnitude14;
self-image, and improving the occlusion. the resting pressure from the lips, cheeks, and tongue has the

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greatest impact on tooth position as these forces are main- Research on the relationship between malocclusion and
tained most of the time.15,16 mouth breathing suggests that impaired nasal respiration
Nonnutritive sucking behaviors are considered normal in may contribute to the development of increased facial height,
infants and young children. Long-term nonnutritive sucking anterior open bite, increased overjet, and narrow palate, but it
habits (e.g., pacifier use, thumb/finger sucking) have been is not the sole or even the major cause of these conditions.34
associated with anterior open bite and posterior crossbite.12,15-19 OSAS may be associated with narrow maxilla, crossbite,
Some evidence indicates that changes resulting from sucking low tongue position, vertical growth, increased overjet, and
habits persist past the cessation of the habit; therefore, it has openbite. 35-37 History associated with OSAS may include
been suggested that early dental visits provide parents with snoring, observed apnea, restless sleep, daytime neurobehavioral
anticipatory guidance to help their children stop sucking abnormalities or sleepiness, and bedwetting. Physical findings
habits by age 36 months or younger.12,15,16 may include growth abnormalities, signs of nasal obstruction,
Bruxism, defined as the habitual nonfunctional and force- adenoidal facies, and enlarged tonsils.34,38,39
ful contact between occlusal surfaces, can occur while awake The identification of an abnormal habit and the assessment
or asleep. The etiology is multifactorial and has been reported of its potential immediate and long-term effects on the cra-
to include central factors (e.g., emotional stress,20 parasomnias,21 niofacial complex and dentition should be made as early as
traumatic brain injury,22 neurologic disabilities23) and morpho- possible. The dentist should evaluate habit frequency, duration,
logic factors (e.g., malocclusion24, muscle recruitment25). The and intensity in all patients with habits. Intervention to
occlusal wear that may result from bruxism is important to terminate the habit should be initiated if indicated, and
differentiate from other forms of occlusal loss of enamel parents should be provided with information regarding con-
(e.g., erosion caused by diet or gastroesophageal reflux).26 sequences of a habit as well as tools to help in elimination of
Reported complications of bruxism include dental attrition, the habit.12,13
headaches, TMD, and soreness of the masticatory muscles.20
Evidence indicates that juvenile bruxism is self-limiting and Treatment considerations: Management of an oral habit is
does not persist in adults.27 The spectrum of bruxism man- indicated whenever the habit is associated with unfavorable
agement ranges from patient/parent education, occlusal splints, dentofacial development or adverse effects on child health or
and psychological techniques to medications.21,22,28,29 when there is a reasonable indication that the oral habit will
Tongue thrusting, an abnormal tongue position and result in unfavorable sequelae in the developing permanent
deviation from the normal swallowing pattern, may be asso- dentition. Any treatment must be appropriate for the child’s
ciated with anterior open bite, abnormal speech, and ante- development, comprehension, and ability to cooperate. Habit
rior protrusion of the maxillary incisors.30 There is no evidence treatment modalities include patient/parent counseling, be-
that intermittent short-duration pressures, created when havior modification techniques, myofunctional therapy,
the tongue and lips contact the teeth during swallowing or appliance therapy (extraoral and intraoral), or referral to
chewing, have significant impact on tooth position.15,30 If the other providers including, but not limited to, orthodontists,
resting tongue posture is forward of the normal position, psychologists, myofunctional therapists, or otolaryngologists.
incisor displacement is likely, but if resting tongue posture is The child’s desire to stop the habit is beneficial for managing
normal, a tongue thrust swallow has no clinical significance.15 oral habits.13
Self-injurious or self-mutilating behavior (i.e., repetitive
acts that result in physical injury to the individual) is ex- Treatment objectives: Treatment is directed toward decreasing
tremely rare in the normal child. Such behavior, however, is or eliminating the habit and minimizing potential deleterious
a chronic condition more frequently seen in special needs effects on the dentofacial complex.
populations, having been associated with developmental delay
or disabilities, psychiatric disorders, traumatic brain injuries, Disturbances in number
and some syndromes.31,32 The spectrum of treatment options Congenitally missing teeth
for developmentally disabled individuals includes pharmaco- General considerations and principles of management: Hypo-
logic management, behavior modification, and physical dontia, the congenital absence of one or more permanent
restraint. 33 Dental treatment modalities include, among teeth, has a prevalence of 3.5 to 6.5 percent.40 Excluding third
others, lip-bumper and occlusal bite appliances, protective molars, the most frequently missing permanent tooth is the
padding, and extractions. Some habits, such as lip-licking and mandibular second premolar followed by the maxillary lateral
lip-pulling, are relatively benign in relation to an effect on the incisor.40 In the primary dentition, hypodontia occurs less fre-
dentition. Severe lip- and tongue-biting habits may be quently (0.1 to 0.9 percent prevalence) and almost always
associated with profound neurodisability due to severe brain affects the maxillary incisors and first primary molars.41 The
damage.33 Management options include monitoring the lesion, chance of familial occurrence of one or two congenitally missing
odontoplasty, providing a bite-opening appliance, or extracting teeth is to be differentiated from missing lateral incisors in
the teeth.33 cleft lip/palate42 and multiple missing teeth (six or more) due
to ectodermal dysplasia or other syndromes43 as the treatment

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usually differs. A congenitally missing tooth should be sus- permanent.44 Prevalence is reported in the primary dentition
pected in patients with cleft lip/palate, certain syndromes, and from 0.3-0.8 percent and the mixed dentition from 0.52 to
a familial pattern of missing teeth. In addition, patients with two percent.52-55 Between 80 and 90 percent of all super-
asymmetric eruption sequence, over-retained primary teeth, or numeraries occur in the maxilla, with half in the anterior
ankylosis of a primary mandibular second molar may have a area and almost all in the palatal position.52 A supernumerary
congenitally missing tooth.42,44,45 primary tooth is followed by a supernumerary permanent
tooth in one-third of the cases.56 Supernumerary teeth are
Treatment considerations: With congenitally missing perma- classified according to their form and location.52,57
nent maxillary incisor(s) or mandibular second premolar(s), During the early mixed dentition, 79 to 91 percent of
the decision to extract the primary tooth and close the space anterior permanent supernumerary teeth are unerupted.45,53
orthodontically versus opening the space orthodontically and While more erupt with age, only 25 percent of all mesiodens
placing a prosthesis or implant depends on many factors. For (a permanent supernumerary incisor located at the midline)
maxillary laterals, the dentist may move the maxillary canine erupt spontaneously.52 Mesiodens can prevent or cause ectopic
mesially and use the canine as a lateral incisor or create space eruption of a central incisor. Less frequently, a mesiodens can
for a future lateral prosthesis or implant.13,46 cause dilaceration or resorption of the permanent incisor’s
Factors that influence the decision are: (1) patient age; (2) root. Dentigerous cyst formation involving the mesiodens, in
canine size and shape; (3) canine position; (4) child’s occlu- addition to eruption into the nasal cavity, has been reported.52
sion and amount of crowding; (5) bite depth; (6) profile; If there is an asymmetric eruption pattern of the maxillary
(7) smile line; and (8) quality and quantity of bone in the incisors, delayed eruption, an overretained primary incisor, or
edentulous area.46,47 Early extraction of the primary canine and/ ectopic eruption of an incisor, a supernumerary tooth can be
or lateral may be needed.46 Opening space for a prosthesis or suspected.41,42,53 Panoramic, occlusal, and periapical radiographs
implant requires less tooth movement, but the space needs to all can reveal a supernumerary tooth. To determine the super-
be maintained with an interim prosthesis, especially if an numerary tooth’s position, either a cone beam radiograph or
implant is planned. 43,46 Moving the canine into the lateral two periapical or occlusal films reviewed by the parallax rule is
position produces little facial change, but the resultant tooth recommended.52,54
size discrepancy often does not allow a canine guided occlu-
sion.45,46 Patients generally prefer space closure over implants.47 Treatment considerations: Management and treatment of
For a congenitally missing premolar, the primary molar hyperdontia differs if the tooth is primary or permanent. Pri-
may either be maintained or extracted with placement of a mary supernumerary teeth normally are accommodated into
prosthesis, autotransplantation, or orthodontic space closure.48-54 the arch and usually erupt and exfoliate without complications.56
Maintaining the primary second molar may cause occlusal Surgical extraction of unerupted anterior supernumerary teeth
problems due to its larger mesiodistal diameter, compared during the primary dentition can displace or damage the per-
to the second premolar.46 Reducing the width of the second manent incisor.52 Removal of an erupted mesiodens or other
primary molar is a consideration, but root resorption and permanent supernumerary incisor results in eruption of the
subsequent exfoliation may occur.13,46 In crowded arches or permanent adjacent normal incisor in 75 percent of the cases.52
with multiple missing premolars, extraction of the primary Extraction of an unerupted supernumerary during the early
molar(s) can be considered, especially in mild Class III mixed dentition (i.e., at age six to seven years when the
cases. 13,46,50 For a single missing premolar, if maintaining permanent crown has formed completely and the root length
the primary molar is not possible, placement of a prosthesis, is less than the crown height) allows for a normal eruptive
autotransplantation, or implant should be considered.13,47,50 force and eruption of the adjacent normal permanent in-
Preserving the primary tooth may be indicated in certain cisor.52-54,58 Later removal of the mesiodens reduces the likeli-
cases. However, maintaining a submerged/ankylosed tooth hood that the adjacent normal permanent incisor will erupt
may increase the likelihood of an alveolar defect which can on its own, especially if the apex is completed.52 Inverted conical
compromise later implant success. 50,51 Consideration for supernumerary teeth can be harder to remove if removal is
extraction and space maintenance may be indicated.50,51 Con- delayed, as they can migrate deeper into the jaw.53 After removal
sultation with an orthodontist and/or prosthodontist may be of the supernumerary tooth, clinical and radiographic follow-up
considered. is indicated in six months to determine if the normal incisor
is rupting. If there is no eruption after six to 12 months and
Treatment objectives: Treatment is directed toward an esthe- sufficient spaceexists, surgical exposure and orthodontic
tically pleasing occlusion that functions well for the patient. extrusion may be needed.52,59,60

Supernumerary teeth (primary, permanent, and mesiodens) Treatment objectives: Removal of supernumerary teeth should
General considerations and principles of management: Super- facilitate eruption of permanent teeth and encourage normal
numerary teeth, or hyperdontia, can occur in the primary or alignment. In cases where normal alignment or spontaneous
permanent dentition but are five times more common in the eruption does not occur, further orthodontic treatment is
indicated.

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Localized disturbances in eruption such as sectional wires with open coil springs,74 sling shot-type
Ectopic eruption appliances,75 or a Halterman appliance.76
General considerations and principles of management: Early diagnosis and treatment of impacted maxillary canines
Ectopic eruption (EE) of permanent first molars occurs due to can lessen the severity of the impaction and may stimulate
the molar’s abnormal mesioangular eruption path, resulting in eruption of the canine. Extraction of the primary canine is
an impaction at the distal prominence of the primary second indicated when the canine bulge cannot be palpated in the
molar’s crown.61,62 EE can be suspected if asymmetric eruption alveolar process and there is radiographic overlapping of the
is observed or if the mesial marginal ridge is noted to be canine with the formed root of the lateral during the mixed
under the distal prominence of the second primary molar.61,62 dentition.67,77,78 The use of rapid maxillary expansion alone79,80
EE of permanent molars can be diagnosed from bitewing or with cervical pull headgear81 in the early mixed dentition
or panoramic radiographs in the early mixed dentition.61,62 has been shown to increase the potential for eruption of
This condition occurs in up to three percent of the popula- palatally-displaced maxillary canines. When the impacted ca-
tion.61 EE of first permanent molars has been associated with nine is diagnosed at a later age (11 to 16 years), if the canine
transverse and sagittal crowding and is more common in the is not horizontal, extraction of the primary canine lessens the
maxillary arch and in children with cleft lip and palate. 62-64 severity of the permanent canine impaction and 75 percent
EE of second permanent molars occurs infrequently.65 EE of will erupt. 82 Extraction of the first primary molar also has
permanent molars is classified into two types. There are those been reported to allow eruption of first premolars and to assist
that self-correct and others that remain impacted. Previous in the eruption of the canines.83 This need can be determined
data suggested that 66 percent of EE permanent molars self- from a panoramic radiograph,84,85 although CBCT will provide
correct by age seven; 45,62 however, a recent cohort study greater localization of the impacted canine.86 Bonded ortho-
demonstrated that 71 percent self-correct by age nine.66 In dontic treatment normally is required to create space or
some cases, definitive treatment is indicated to manage and/ align the canine. Long-term periodontal health of impacted
or avoid early loss of the primary second molar and space canines after orthodontic treatment is similar to nonimpacted
loss. 61,62 Increased magnitude of impaction, increased canines, and there is insufficient data to conclude the best
resorption of the primary tooth, and bilateral occurrence were type of surgical technique.87,88
positively associated with irreversible ectopic eruption and Treatment of ectopically erupting incisors depends on the
may indicate the need for early intervention.66 etiology. Extraction of necrotic or over-retained pulpally-
The maxillary canine appears in an impacted position in treated primary incisors is indicated in the early mixed denti-
1.5 - 2 percent of the population.67 Maxillary canine impaction tion.73 Removal of supernumerary incisors in the early mixed
should be suspected when the canine bulge is not palpable, dentition will lessen ectopic eruption of an adjacent permanent
asymmetric canine eruption is evident, or peg shaped lateral incisor. 52 After incisor eruption, orthodontic treatment
incisors are present.67-71 Panoramic radiographs may demon- involving removable or banded therapy may be needed.
strate that the canine has an abnormal inclination and/or over-
laps the lateral incisor root. Additional potential radiographic Treatment objectives: Management of ectopically erupting
signs of maxillary canine impaction include enlarged follicular molars, canines, and incisors should result in improved
sac, lack of root resorption of primary canines, and presence eruptive positioning of the tooth. In cases where normal
of premolar impaction.69,70,72 alignment does not occur, subsequent comprehensive ortho-
Maxillary incisors can erupt ectopically or be impacted from dontic treatment may be necessary to achieve appropriate
supernumerary teeth in up to two percent of the population.57 arch form and intercuspation.
Incisors also can have altered eruption due to pulp necrosis
(following trauma or caries) or pulpal treatment of the primary Ankylosis
incisor. 73 EE of permanent incisors can be suspected after General considerations and principles of management:
trauma to primary incisors, with pulpally-treated primary Ankylosis is a condition in which the cementum of a tooth’s
incisors, with asymmetric eruption, or if a supernumerary root fuses directly to the surrounding bone.89 The periodontal
incisor is diagnosed.67,71 ligament is replaced with osseous tissue, rendering the tooth
immobile to eruptive change.89 An ankylosed tooth stays at
Treatment considerations: Treatment for ectopic molars the same vertical level, yet in a growing child appears to sub-
depends on how severe the impaction appears clinically and merge as the other teeth continue to erupt. Ankylosis can
radiographically. For mildly impacted first permanent molars, occur in the primary and permanent dentitions, with the most
where little of the tooth is impacted under the primary second common incidence involving primary molars. The incidence
molar, elastic or metal orthodontic separators can be placed is reported to be between seven and 14 percent in the primary
to wedge the permanent first molar distally.61 For more severe dentition.90 In the permanent dentition, ankylosis occurs most
impactions, distal tipping of the permanent molar is re- frequently following luxation injuries.91
quired.61 Tipping action can be accomplished with brass Ankylosis is common in anterior teeth following trauma
wires, removable appliances using springs, fixed appliances and is referred to as replacement resorption. Periodontal

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ligament cells are destroyed, and the cells of the alveolar bone ankylosis in that eruption fails to occur due to an imbalance
perform most of the healing. Over time, normal bony activity in resorptive and appositional factors related to tooth erup-
results in the replacement of root structure with osseous tion.108,109 Teeth with PFE are not initially ankylosed but may
tissue.90,91 Ankylosis can occur rapidly or gradually over time, become ankylosed when orthodontic forces are applied.110 A
in some cases as long as five years post trauma. It also may systematic review demonstrated 85 percent of patients with
be transient if only a small bony bridge forms then is resorbed PFE have another family member with the condition.100 PFE
with subsequent osteoclastic activity.92 has variable expression and has been associated with mutations
Ankylosis can be verified by clinical and radiographic means. in the autosomal dominant parathyroid hormone receptor
Submergence of the tooth is the primary recognizable sign, (PTH1R) gene.110-113 A sample of blood or saliva deoxyri-
but the diagnosis also can be made through percussion and bonucleic acid (DNA) can be used to test for mutations in
palpation.93 Radiographic examination also may reveal the loss PTH1R.112,114
of the periodontal ligament and bony bridging.89
Treatment considerations: Diagnosis of PFE should be based
Treatment considerations: With ankylosis of a primary molar, on a combination of clinical, radiographic, and genetic infor-
exfoliation usually occurs normally. Extraction is recommended mation.108-110 A positive family history also supports a diagnosis
if prolonged retention of the primary molar is noted. If a of PFE.102 Other than a few anecdotal reports, PFE is strongly
severe marginal ridge discrepancy develops, extraction should associated with the failure of orthodontically assisted eruption
be considered to prevent the adjacent teeth from tipping and or tooth movement.108,109 To that point, early orthodontic inter-
producing space loss 4,93 or vertical occlusal discrepancies. 94 vention of the affected teeth should be avoided.103,108,109,114 To
Replacement resorption of permanent teeth usually results in date there are no established mechanotherapeutic methods of
the loss of the involved tooth.90 modifying dentoalveolar growth for these patients.103,108,109,114
Mildly to moderately ankylosed primary molars without Space maintenance, up-righting adjacent teeth that have tipped
permanent successors may be retained and restored to function into the sites, prevention of supra-eruption in opposing arch,
in arches without crowding.94 Extraction of these molars can or modification of lateral tongue thrust habits may be addi-
assist in resolving crowded arches in complex orthodontic tional considerations.103,114 Once growth is complete, multi-
cases.95 Surgical luxation of ankylosed permanent teeth with disciplinary treatment options such as single tooth or segmental
forced orthodontic eruption has been described as an alternative osteotomies with immediate traction, or selective extractions
to premature extraction.96,97 followed by implants can be considered to create a function-
ing occlusion.108 Early extraction of first molars allowing the
Treatment objectives: Treatment of ankylosis should result in second molars to drift forward has also been suggested.103
the continuing normal development of the permanent denti-
tion. In the case of replacement resorption of a permanent Treatment objectives: Since best available evidence does not
tooth, appropriate prosthetic replacement should be planned. support early orthodontic intervention, treatment objectives
of PFE should involve reassurance and education about the
Primary failure of eruption eruption disorder and preparation for future prosthetic rehabil-
General considerations and principles of management: Primary itation.103 In some cases, early extraction can improve normal
failure of eruption (PFE) is an eruption disorder characterized development of the alveolus and permanent dentition.103
by partial or complete non-eruption of permanent teeth in the Objectives include space and intra-arch maintenance in
absence of any mechanical obstruction or syndrome.98 Failure preparation for future implants, prosthetic rehabilitation, or
in eruptive mechanisms prevent permanent successors from corticotomy-assisted tooth movement.103
following the eruption path after the exfoliation of deciduous
teeth.99 Posterior teeth are most commonly affected and one or Tooth size/arch length discrepancy and crowding
all four quadrants may be involved.100 Although typically associ- General considerations and principles of management:
ated with permanent teeth, examples in the primary dentition Arch length discrepancies include inadequate arch length and
have been noted.101 Two main phenotypes of PFE have been crowding of the dental arches, excess arch length and spacing,
identified: (1) All teeth distal to the most mesial non-erupted and tooth size discrepancy, often referred to as a Bolton dis-
tooth are affected, or (2) unerupted teeth do not follow the crepancy.115 These arch length discrepancies may be found in
pattern that all teeth distal to the most mesial involved tooth conjunction with complicating and other etiological factors
are also affected.102 Hallmark features of PFE include poste- including missing teeth, supernumerary teeth, and fused or
rior open bite in the presence of normal vertical growth, infra- geminated teeth. Inadequate arch length with resulting incisor
occlusion of affected teeth, and the inability to move affected crowding is a common occurrence with various negative
teeth orthodontically.103 sequelae and is particularly common in the early mixed denti-
The reported incidence of PFE is between 0.01 and 0.06 tion.116-119 Studies of arch length in today’s children compared
percent;104,105 however, some data suggests PFE may be mis- to their parents and grandparents of 50 years ago indicate less
diagnosed as infra-occlusion or ankylosis.106,107 PFE differs from arch length, more frequent incisor crowding, and stable tooth

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 BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION

sizes.120-122 This implies that the problem of incisor crowding 2. increase long-term stability of incisor positions.
and ultimate arch length discrepancies may be increasing in 3. decrease ectopic eruption and impaction of perma-
numbers of patients and in amount of arch length shortage.121-123 nent canines.
Arch length and especially crowding must be considered in 4. reduce orthodontic treatment time and sequelae.
the context of the esthetic, dental, skeletal, and soft tissue 5. improve gingival health and overall dental health.116,128,129
relationships. Mandibular incisors have a high relapse rate in
rotations and crowding.116,118 Growth of the aging skeleton causes Space maintenance
further crowding and incisor rotations.124 Functional contacts General considerations and principles of management: The
are diminished where rotations of incisors, canines, and premature loss of primary teeth due to caries, infection, trauma,
premolars exist.125 Occlusal harmony and temporomandibular ectopic eruption, or crowding deviates from the normal exfolia-
joint health are impacted negatively by less functional contacts.125 tion pattern and may lead to loss of arch length. Arch length
Initial assessment may be done in early mixed dentition, deficiency can produce or increase the severity of malocclusions
when mandibular incisors begin to erupt.116 Evaluation of avail- with crowding, rotations, ectopic eruption, crossbite, excessive
able space and consideration of making space for permanent overjet, excessive overbite, and unfavorable molar relation-
incisors to erupt may be done initially utilizing appropriate ships.130 Whenever possible, restoration of carious primary teeth
radiographs to ascertain the presence of permanent successors. should be attempted to avoid malocclusions that could result
Comprehensive diagnostic analysis is suggested, with evaluation from their extraction.131 The use of space maintainers to reduce
of maxillary and mandibular skeletal relationships, direction the prevalence and severity of malocclusion following prema-
and pattern of growth, facial profile, facial width, muscle ture loss of primary teeth should be considered.13,132,133
balance, and dental and occlusal findings including tooth Adverse effects associated with space maintainers include:
positions, arch length analysis, and leeway space. (1) dislodged, broken, and lost appliances; (2) plaque accumu-
Derotation of teeth just after emergence in the mouth implies lation; (3) increase in microorganisms and increase in perio-
correction before the transseptal fiber arrangement has been dontal index scores; (4) caries; (5) damage or interference with
established.116,125 It has been shown that the transseptal fibers successor eruption; (6) undesirable tooth movement; (7)
do not develop until the cementoenamel junction of erupting inhibition of alveolar growth; (8) soft tissue impingement; and
teeth pass the bony border of the alveolar process.125 Therefore, (9) pain.130,134-140 Premature loss of a primary tooth, especially
long-term stability of aligned incisors may be increased.126 in crowded dentitions, has the potential to cause loss of space
available for the succeeding permanent tooth, but there is a
Treatment considerations: Treatment considerations may lack of consensus or evidence regarding the effectiveness of
include, but are not limited to: space maintainers in preventing or reducing the severity of
1. gaining space for permanent incisors to erupt and malocclusion.130,135,136,141-150
become straight naturally through primary canine
extraction and space/arch length maintenance with Treatment considerations: It is prudent to consider space
holding arches. Extraction of primary or permanent maintenance when primary teeth are lost prematurely. Factors
teeth with the aim of alleviating crowding should to consider include: (1) specific tooth lost; (2) time elapsed since
not be undertaken without a comprehensive space tooth loss; (3) occlusion and space assessment; (4) dental age;
analysis and a short- and long-term orthodontic treat- (5) presence and root development of permanent successor;
ment plan. (6) amount of alveolar bone covering permanent successor;
2. orthodontic alignment of permanent teeth as soon (7) patient’s health history and medical status; (8) patient’s
as erupted and feasible, expansion and correction of cooperative ability; (9) active oral habits; and (10) oral
arch length as early as feasible. hygiene.13,130,131
3. utilizing holding arches in the mixed dentition until The literature pertaining to the use of space maintainers
all permanent premolars and canines have erupted. specific to the loss of a particular primary tooth type include
4. maintaining patient’s original arch form.125 expert opinion, case reports, and details of appliance design.13,
5. interproximal stripping of the enamel of mandibular 132,133
Space maintainers can be designed as fixed unilateral
primary canines to allow alignment of crowded lower (band and loop, crown and loop, distal shoe), fixed bilateral
permanent lateral incisors.127 (lower lingual holding arch, Nance appliance, transpalatal arch),
or removable (partial dentures, Hawley type appliance). Vari-
Additional treatment modalities may include, but are not ations of these appliances have been described. Unilateral
limited to: (1) interproximal reduction; (2) restorative bond- space maintainer kits as well as direct bonded techniques
ing; (3) veneers; (4) crowns; (5) implants; and (6) orthognathic eliminate laboratory involvement and allow for single visit
surgery. delivery; however, the literature describes mixed results on the
longevity of these options compared to success rates of custom
Treatment objectives: Well-timed intervention can: appliances.152-155
1. prevent crowded incisors.

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The placement and retention of space maintaining appli- Crossbites (dental, functional, and skeletal)
ances requires ongoing compliant patient behavior. Follow-up General considerations and principles of management: Cross-
of patients with space maintainers is necessary to assess inte- bites are defined as any abnormal buccal-lingual relation
grity of cement and to evaluate and clean the abutment between opposing incisors, molars, or premolars in centric
teeth.139 The appliance should function until the succedaneous relation.159-161 If the mid lines undergo a compensatory or
teeth have erupted into the arch. However, adjustment or new habitual shift when the teeth occlude in crossbite, this is
appliances may be necessary with continued development and termed a functional shift.157 A crossbite can be of dental or
changes in the dentition. skeletal origin or a combination of both.157
A simple anterior crossbite is of dental origin if the molar
Treatment objectives: The goal of space maintenance is to occlusion is Class I and the malocclusion is the result of an
prevent loss of arch length, width, and perimeter by main- abnormal axial inclination of maxillary and/or mandibular
taining the relative position of the existing dentition.13,132 anterior teeth. This condition should be differentiated from a
The AAPD recognizes the need for controlled randomized Class III skeletal malocclusion where the crossbite is the result
clinical trials to determine efficacy of space maintainers as well of the basal bone position.159 Posterior crossbites may be the
as analysis of costs and side effects of treatment. result of bilateral or unilateral lingual position of the maxillary
teeth relative to the mandibular posterior teeth due to tipping
Space regaining or alveolar discrepancy, or a combination. Most often, uni-
General considerations and principles of management: Some lateral posterior crossbites are the manifestation of a bilateral
of the more common causes of space loss within an arch are crossbite with a functional mandibular shift.161 Dental crossbites
(1) primary teeth with interproximal caries; (2) ectopically may be the result of tipping or rotation of a tooth or teeth. In
erupting teeth; (3) alteration in the sequence of eruption; (4) this case, the condition is localized and does not involve the
ankylosis of a primary molar; (5) dental impaction; (6) trans- basal bone. In contrast, skeletal crossbites involve disharmony
position of teeth; (7) loss of primary molars without proper of the craniofacial skeleton.161,162 Aberrations in bony growth
space management; (8) congenitally missing teeth; (9) abnor- may give rise to crossbites in two ways:
mal resorption of primary molar roots; (10) premature and 1. adverse transverse growth of the maxilla and mandible.
delayed eruption of permanent teeth; and (11) abnormal dental 2. disharmonious or adverse growth in the sagittal (AP)
morphology.13,130,133,156,157 Therefore, loss of space in the dental length of the maxilla and mandible.160,163
arch that interferes with the desired eruption of the perma-
nent teeth may require evaluation. Such growth aberrations can be due to inherited growth
The degree to which space is affected varies according to patterns, trauma, or functional disturbances that alter normal
the arch, site in the arch, and time elapsed since tooth loss.158 growth.161-163
The quantity and incidence of space loss are dependent upon
which adjacent teeth are present in the dental arch and their Treatment considerations: Crossbites should be considered
status.13,130 The amount of crowding or spacing in the dental in the context of the patient’s total treatment needs. Anterior
arch will determine the consequence of space loss.157 crossbite correction can: (1) reduce dental attrition; (2) improve
dental esthetics; (3) redirect skeletal growth; (4) improve the
Treatment considerations: Space can be maintained or regained tooth-to-alveolus relationship; (5) increase arch perimeter, (6)
with removable or fixed appliances.130,132 Some examples of help avoid periodontal damage, and (7) prevent the potential
fixed space regaining appliances are active holding arches, pen- for TMD.162,164 If enough space is available, a simple anterior
dulum appliances, Halterman-type appliances, and Jones jig. crossbite can be aligned as soon as the condition is noted.
Examples of removable space regaining appliances are Hawley Treatment options include acrylic incline planes, acrylic re-
appliance with springs, lip bumper, and headgear.132 If space tainers with lingual springs, or fixed appliances with springs.
regaining is planned, a comprehensive analysis should be If space is needed, an expansion appliance also is an option.160
completed prior to any treatment decisions. Some factors that Posterior crossbite correction can accomplish the same objec-
should be considered in the analysis include: dentofacial devel- tives and can improve the eruptive position of the succedaneous
opment, age at time of tooth loss, tooth that has been lost, teeth. Early correction of posterior crossbites with a mandibular
space available, and space needed.130,132 functional shift has been shown to improve functional condi-
tions significantly and largely eliminate morphological and
Treatment objectives: The goal of space regaining intervention positional asymmetries of the mandible.30,165,166 Contemporary
is the recovery of lost arch width and perimeter and/or im- evidence indicates a need for long-term studies to assess the
proved eruptive position of succedaneous teeth. Space regained possibility for spontaneous crossbite correction, as current
should be maintained until adjacent permanent teeth have proof is conflicting.167 Functional shifts should be eliminated
erupted completely and/or until a subsequent comprehensive as soon as possible with early correction163 to avoid TMD and/
orthodontic treatment plan is initiated. or asymmetric growth.161,167 Treatment can be completed with:
1. equilibration.

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2. appliance therapy (fixed or removable). in excess of three millimeters is associated with an increased
3. extractions. risk of incisor injury, with large overjets (>8 millimeters)
4. a combination of these treatment modalities to resulting in trauma in more than 40 percent of children.186,187
correct the alveolar constriction.167
Treatment considerations: Factors to consider when planning
Skeletal expansion with fixed or removable palatal expand- orthodontic intervention for Class II malocclusion are: (1)
ers can be utilized until mid line suture fusion occurs.157,159 facial growth pattern; (2) amount of AP discrepancy; (3) patient
Treatment decisions depend on the: age; (4) projected patient compliance; (5) space analysis; (6)
1. amount and type of movement (tipping versus bodily anchorage requirements; and (7) patient and parent desires.
movement, rotation, or dental versus orthopedic Treatment modalities include: (1) extraoral appliances head-
movement); gear; (2) functional appliances; (3) fixed appliances; (4) tooth
2. space available; extraction and interarch elastics; and (5) orthodontics with
3. AP, transverse, and vertical skeletal relationships; orthognathic surgery.157
4. growth status; and
5. patients cooperation. Treatment objectives: Treatment of a developing Class II mal-
occlusion should result in an improved overbite, overjet, and
Patients with crossbites and concomitant Class III skeletal intercuspation of posterior teeth and an esthetic appearance
patterns and/or skeletal asymmetry should receive compre- and profile compatible with the patient’s skeletal morphology.
hensive treatment as covered in the Class III malocclusion
section. Class III malocclusion
General considerations and principles of management: Class
Treatment objectives: Treatment of a crossbite should result III malocclusion (mesio-occlusion) involves a mesial relation-
in improved intramaxillary alignment and an acceptable ship of the mandible to the maxilla or mandibular teeth to
interarch occlusion and function.165 maxillary teeth. This relationship may result from dental
factors (malposition of the teeth in the arches), skeletal factors
Class II malocclusion (asymmetry, mandibular prognathism, and/or maxillary re-
General considerations and principles of management: Class trognathism), anterior functional shift of the mandible, or a
II malocclusion (distocclusion) may be unilateral or bilateral combination of these factors.188
and involves a distal relationship of the mandible to the The etiology of Class III malocclusions can be hereditary,
maxilla or the mandibular teeth to maxillary teeth. This rela- environmental, or both. Hereditary factors can include clefts
tionship may result from dental (malposition of the teeth in of the alveolus and palate as well as other craniofacial ano-
the arches), skeletal (mandibular retrusion and/or maxillary malies that are part of a genetic syndrome.189,190 Some environ-
protrusion), or a combination of dental and skeletal factors.6 mental factors are trauma, oral/digital habits, caries, and early
Results of randomized clinical trials indicate that Class II childhood OSAS.191
malocclusion can be corrected effectively with either a single
or two-phase regimen.168-171 Growth-modifying effects in some Treatment considerations: Treatment of Class III malocclu-
studies did not show an influence on the Class II skeletal sions is indicated to provide psychosocial benefits for the
pattern,171-173 while other studies dispute these findings.174,175 child patient by reducing or eliminating facial disfigurement
There is substantial variation in treatment response to growth and to reduce the severity of malocclusion by promoting
modification treatments (headgear or functional appliance) compensating growth.192 Interceptive Class III treatment has
and no reliable predictors for favorable growth response have been proposed for years and has been advocated as a necessary
been found.168,174 Some reports state interceptive treatment tool in contemporary orthodontics, with initiation in the
does not reduce the need for either premolar extractions or primary-early mixed dentition recommended.193-202 Factors to
orthognathic surgery,169,171 while others disagree with these consider when planning orthodontic intervention for Class
findings.176 Two-phase treatment results in significantly longer III malocclusion are: (1) facial growth pattern; (2) amount of
treatment time163,169,177 although the time spent in full bonded AP discrepancy; (3) patient age; (4) projected patient compli-
appliance therapy in the permanent dentition can be signifi- ance; and (5) space analysis.
cantly less.178
Clinicians may decide to provide interceptive treatment Treatment objectives: Interceptive Class III treatment may
based on other factors.169,174 Evidence suggests that, for some provide a more favorable environment for growth and may
children, interceptive Class II treatment may improve self- improve occlusion, function, and esthetics.203 Although inter-
esteem and decreases negative social experiences, although the ceptive treatment can minimize the malocclusion and poten-
improvement may not be different longterm.174,179 Early Class tially eliminate future orthognathic surgery, this is not always
II correction may improve facial convexity and/or reduce possible. Typically, Class III patients tend to grow longer and
incidence of maxillary anterior tooth trauma.180-185 An overjet more unpredictably and, therefore, surgery combined with

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378 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY