AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Guideline on Management of the Developing Dentition and Occlusion in Pediatric Dentistry Originating Committee Clinical Affairs Committee – Developing Dentition Subcommittee Review Council Council on Clinical Affairs Adopted 1990 Revised 1991, 1998, 2001, 2005, 2009

Purpose Many factors can affect the management of the developing The American Academy of Pediatric Dentistry (AAPD) recog- dental arches and minimize the overall success of any treat- nizes the importance of managing the developing dentition and ment. The variables associated with the treatment of the devel- occlusion and its effect on the well-being of infants, children, oping dentition that will affect the degree to which treatment and adolescents. Management includes the recognition, diagno- is successful include, but are not limited to: sis, and appropriate treatment of dentofacial abnormalities. This 1. chronological/mental/emotional age of the patient and guideline is intended to set forth objectives for management of the patient’s ability to understand and cooperate in the developing dentition and occlusion in pediatric dentistry. the treatment; 2. intensity, frequency, and duration of an oral habit; Methods 3. parental support for the treatment; This revision is based upon a new MEDLINE search using 4. compliance with clinician’s instructions; the following parameters: Terms: ankylosis, anterior , 5. craniofacial configuration; Class II , Class III malocclusion, dental crowding, 6. craniofacial growth; ectopic eruption, impaction, obstruction sleep apnea syndrome 7. concomitant systemic disease or condition; (OSAS), occlusal development, oligodontia, oral habits, poste- 8. accuracy of diagnosis; rior crossbite, space maintenance, and tooth size/arch length 9. appropriateness of treatment. discrepancy; Field: all fields; Limits: within the last 10 years, A thorough clinical examination, appropriate pretreatment humans, English, and birth through age 18. Papers for review records, differential diagnosis, sequential treatment plan, and were chosen from this search and from references within se- progress records are necessary to manage any condition affecting lected articles. When data did not appear sufficient or were the developing dentition. inconclusive, recommendations were based upon expert and/or Clinical examination should include: consensus opinion by experienced researchers and clinicians. 1. facial analysis to: a. identify adverse transverse growth patterns includ- Background ing asymmetries (maxillary and mandibular); Guidance of eruption and development of the primary, mixed, b. identify adverse vertical growth patterns; and permanent dentitions is an integral component of com- c. identify adverse sagittal (anteroposterior) growth prehensive oral health care for all pediatric dental patients. Such patterns and dental anteroposterior (AP) occlusal guidance should contribute to the development of a perma- disharmonies; nent dentition that is in a stable, functional, and esthetically d. assess esthetics and identify orthopedic and ortho- acceptable occlusion. Early diagnosis and successful treatment dontic interventions that may improve esthetics and of developing can have both short-term and resultant self-image and emotional development. long-term benefits while achieving the goals of occlusal 2. intraoral examination to: harmony and function and dentofacial esthetics.1-4 Dentists a. assess overall oral health status; have the responsibility to recognize, diagnose, and either b. determine the functional status of the patient’s appropriately manage or refer abnormalities in the developing occlusion. dentition as dictated by the complexity of the problem and 3. functional analysis to: the individual clinician’s training, knowledge, and experience.5 a. determine functional factors associated with the malocclusion;

CLINICAL GUIDELINES 229 REFERENCE MANUAL V 33 / NO 6 11 / 12

b. detect deleterious habits; 2. establish proper sequence of treatments to achieve c. detect temporomandibular joint dysfunction, short-term and long-term objectives; which may require additional diagnostic pro- 3. assess treatment progress and update the biome- cedures. chanical protocol accordingly on a regular basis. Diagnostic records may be needed to assist in the evalua- tion of the patient’s condition and for documentation purposes. Stages of development of occlusion Prudent judgment is exercised to decide the appropriate records General considerations and principles of management: The required for diagnosis of the clinical condition.6 stages of occlusal development include: Diagnostic orthodontic records fall into 3 major catego- 1. Primary dentition: Beginning in infancy with the ries of evaluation: (1) health of the teeth and oral structures, eruption of the first tooth, usually about 6 months of (2) alignment and occlusal relationships of the teeth, and (3) age, and complete from approximately 3 to 6 years of facial and jaw proportions which includes both cephalometric age when all primary teeth are erupted. radiographs and facial photographs. Digital images rapidly are 2. Mixed dentition: From approximately age 6 to 13, replacing film, but both are acceptable as records.6 primary and permanent teeth are present in the Diagnostic records may include: mouth. 1. extraoral and intraoral photographs to: 3. Adolescent dentition: All primary teeth have exfoli- a. supplement clinical findings with oriented facial ated, second permanent molars may be erupted or and intraoral photographs; erupting, and third molars have not erupted. b. establish a database for documenting facial changes 4. Adult dentition: All permanent teeth are present and during treatment. eruptive growth is complete.7-10 2. diagnostic dental casts to: These stages may further be divided and referenced as a. assess the occlusal relationship; “early” and “late” (eg, early primary, late primary, early mixed, b. determine arch length requirements for intraarch late mixed).7-10 tooth size relationships; Evaluation and treatment of occlusal and skeletal dishar- c. determine arch length requirements for interarch monies may be initiated at various stages of dental arch tooth size relationships; development, depending on the problems, growth, parental in- d. determine location and extent of arch asymmetry. volvement, risks and benefits of treatment and of withholding 3. intraoral and panoramic radiographs to: treatment, and interest/ability of the practitioner.5 a. establish dental age; Historically, orthodontic treatment was provided mainly for b. assess eruption problems; adolescents. Interest continues to be expressed in early treatment c. estimate the size and presence of unerupted teeth; as well as in adult treatment. Treatment and timing options d. identify dental anomalies/pathology. for the growing patient, especially in the mixed dentition and 4. lateral and AP cephalograms to: early permanent dentition, have increased and continue to be a. produce a comprehensive of evaluated by the research community.9,11-13 Many clinicians seek the relative dental and skeletal components in the to modify skeletal, muscular, and dentoalveolar abnormalities anteroposterior, vertical, and transverse dimensions; before the eruption of the full permanent dentition.7 b. establish a baseline growth record for longitudinal A thorough knowledge of craniofacial growth and deve- assessment of growth and displacement of the jaws. lopment of the dentition, as well as orthodontic treatment, 5. other diagnostic views (eg, magnetic resonance ima- must be used in diagnosing and reviewing possible treatment ging, computed tomographic scans) for hard and soft options before recommendations are made to parents.9 Early tissue imaging as indicated by history and clinical treatment is beneficial for many children but may not be examination. in-dicated for every patient. A differential diagnosis and diagnostic summary are Treatment considerations: The developing dentition should completed to: be monitored throughout eruption. This monitoring at regular 1. establish the relative contributions of the dental and clinical examinations should include, but not be limited to, skeletal structures to the patient’s malocclusion; diagnosis of missing, supernumerary, developmentally defec- 2. prioritize problems in terms of relative severity; tive, and fused or geminated teeth; ectopic eruption; and space 3. detect favorable and unfavorable interactions that may and tooth loss secondary to caries. result from treatment options for each problem area; Radiographic examination, when appropriate14 and feasible, 4. establish short-term and long-term objectives; should accompany clinical examination. Diagnosis of anoma- 5. summarize the prognosis of treatment for achieving lies of primary or permanent tooth development and eruption stability, function, and esthetics. should be made to inform the patient’s parent and to plan A sequential treatment plan will: and recommend appropriate intervention. This evaluation is 1. establish timing priorities for each phase of therapy; on-going throughout the developing dentition, at all stages.6-10

230 CLINICAL GUIDELINES AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

1. Primary dentition stage: Anomalies of primary teeth crowded incisors; (4) intervention for ectopic molars and eruption may not be evident/diagnosable prior to and incisors; (5) holding of leeway space; (6) cross- eruption, due to the child’s not presenting for dental bites; and (7) adverse skeletal growth. Treatment examination or to a radiographic examination not should take advantage of high rates of growth and being possible in a young child. Evaluation, however, prevent worsened adverse dental and skeletal growth. should be accomplished when feasible. The objectives 3. Mid-to-late mixed dentition stage: Intervention for of evaluation include identification of: ectopic teeth may include extractions and space mainte- a. all anomalies of tooth number and size (as previ- nance to aid eruption and reduce the risk of need for ously noted); surgical bracket placement and orthodontic traction. b. anterior and posterior crossbites; Intervention for treatment of skeletal disharmonies c. presence of habits along with their dental and and crowding may be instituted at this stage. skeletal sequelae. 4. Adolescent dentition stage: In full permanent denti- Radiographs are taken with appropriate clinical indicators tion, final orthodontic diagnosis and treatment can or based upon risk assessment/history. provide the most functional occlusion. 2. Early mixed dentition stage: Palpation for unerupted 5. Early adult dentition stage: Third molar position or teeth should be part of every examination. Panoramic, space can be evaluated and, if indicated, the tooth occlusal, and periapical radiographs, as indicated at removed. Full orthodontic treatment should be rec- the time of eruption of the lower incisors and first ommended if needed. permanent molars, provide diagnostic information concerning: Recommendations a. anomalies of tooth numbers (eg, missing, supernu- Oral habits merary, fused, geminated); General considerations and principles of management: The b. tooth size and shape (eg, peg or small lateral habits of nonnutritive sucking, bruxing, tongue thrust swallow incisors); and abnormal tongue position, self-injurious/self-mutilating c. positions (eg, ectopic first permanent molars). behavior, and airway obstruction (OSAS) are discussed in this Space analysis can be used to evaluate arch length/ guideline. crowding at the time of incisor eruption. Oral habits may apply forces to the teeth and dentoalveolar 3. Mid-to-late mixed dentition stage: Ectopic tooth structures. The relationship between oral habits and unfavor- positions should be diagnosed, especially canines, bi- able dental and facial development is associational rather than cuspids, and second permanent molars. cause and effect.15-17 Habits of sufficient frequency, duration, 4. Adolescent dentition stage: If not instituted earlier, and intensity may be associated with dentoalveolar or skeletal orthodontic diagnosis and treatment should be plan- deformations such as increased overjet, reduced , poste- ned for Class I crowded, Class II, and Class III maloc- rior crossbite, or long facial height. The duration of force is clusions as well as posterior and anterior crossbites. more important than its magnitude; the resting pressure from Third molars should be monitored as to position the lips, cheeks, and tongue has the greatest impact on tooth and space, and parents should be informed. position, as these forces are maintained most of the time.18,19 5. Early adult dentition stage: Third molars should be Nonnutritive sucking behaviors are considered normal in evaluated. If orthodontic diagnosis has not been ac- infants and young children. Prolonged nonnutritive sucking complished, recommendations should be made as habits have been associated with decreased maxillary arch width, necessary. increased overjet, decreased overbite, anterior open bite, and Objectives: At each stage, the objectives of intervention/treat- posterior crossbite.16,18,19 As preliminary evidence indicates that ment include reducing adverse growth, preventing increasing some changes resulting from sucking habits persist past the dental and skeletal disharmonies, improving esthetics of the cessation of the habit, it has been suggested that early dental smile and the accompanying positive effects on self-image, and visits provide parents with anticipatory guidance to help their improving the occlusion. children stop sucking habits by age 36 months or younger.16,18,19 1. Primary dentition stage: Habits and posterior crossbites Bruxism, defined as the habitual nonfunctional and force- should be diagnosed and addressed as early as feasible. ful contact between occlusal surfaces, can occur while awake Parents should be informed about findings of adverse or asleep. The etiology is multifactorial and has been reported growth and developing malocclusions. Interventions/ to include central factors (eg, emotional stress,20 parasom- treatment can be recommended if diagnosis can be nias,21 traumatic brain injury,22 neurologic disabilities23) and made, treatment is appropriate and possible, and parents morphologic factors (eg, malocclusion24, muscle recruitment25). are supportive and desire to have treatment done. Reported complications include dental attrition, headaches, 2. Early mixed stage: Treatment should address: (1) temporomandibular dysfunction, and soreness of the mastica- habits; (2) arch length shortage; (3) intervention for tory muscles.20 Preliminary evidence suggests that juvenile

CLINICAL GUIDELINES 231 REFERENCE MANUAL V 33 / NO 6 11 / 12 bruxism is a self-limiting condition that does not progress to Treatment considerations: Management of an oral habit is indi- adult bruxism.26 The spectrum of bruxism management ranges cated whenever the habit is associated with unfavorable dentofacial from patient/parent education, occlusal splints, and psycho- development or adverse effects on child health or when there is a logical techniques to medications.20,22,27,28 reasonable indication that the oral habit will result in unfavorable Tongue thrusting, an abnormal tongue position and devia- sequelae in the developing permanent dentition. Any treatment tion from the normal swallowing pattern, may be associated must be appropriate for the child’s development, comprehension, with anterior open bite, abnormal speech, and anterior protru- and ability to cooperate. Habit treatment modalities include sion of the maxillary incisors.17 There is no evidence that patient/parent counseling, behavior modification techniques, intermittent short-duration pressures, created when the tongue myofunctional therapy, appliance therapy, or referral to other and lips contact the teeth during swallowing or chewing, have providers including, but not limited to, orthodontists, psycholo- significant impact on tooth position.17,18 If the resting tongue gists, myofunctional therapists, or otolaryngologists. Use of an posture is forward of the normal position, incisor displace- appliance to manage oral habits is indicated only when the child ment is likely, but if resting tongue posture is normal, a tongue wants to stop the habit and would benefit from a reminder.17 thrust swallow has no clinical significance.18 Objectives: Treatment is directed toward decreasing or elimi- Self-injurious or self-mutilating behavior (ie, repetitive acts nating the habit and minimizing potential deleterious effects that result in physical damage to the individual) is extremely rare on the dentofacial complex. in the normal child.29 Such behavior, however, has been asso- ciated with mental retardation, psychiatric disorders, develop- Disturbances in number mental disabilities, and some syndromes.30 The spectrum of Congenitally missing teeth treatment options for developmentally disabled individuals General considerations and principles of management: Hypo- includes pharmacologic management, behavior modification, dontia, the congenital absence of 1 or more permanent teeth, and physical restraint.31 Reported dental treatment modalities has a prevalence of 3.5% to 6.5%.35,36 Excluding third molars, include, among others, lip-bumper and occlusal bite appliances, the most frequently missing permanent tooth is the mandi- protective pad-ding, and extractions.29 Some habits, such as bular second premolar followed by the maxillary lateral lip-licking and lip-pulling, are relatively benign in relation to incisor.36,37 In the primary dentition, hypodontia occurs less an effect on the dentition.29 More severe lip- and tongue-biting (0.1% to 0.9% prevalence) and almost always affects the maxil- habits may be associated with profound neurodisability due to lary incisors and first primary molars.39 The chance of familial severe brain damage.31 Management options include monitor- occurrence of 1 or 2 congenitally missing teeth is to be differ- ing the lesion, odontoplasty, providing a bite-opening ap- entiated from missing lateral incisors in cleft lip/palate40 and pliance, or extracting the teeth.31 multiple missing teeth (6 or more) due to ectodermal dysplasia Research on the relationship between malocclusion and or other syndromes41 as the treatment usually differs. A conge- suggests that impaired nasal respiration may nitally missing tooth should be suspected in patients with cleft contribute to the development of increased facial height, anterior lip/palate, certain syndromes, and a familial pattern of missing open bite, increased overjet, and narrow palate, but it is not the teeth. In addition, patients with asymmetric eruption sequence sole or even the major cause of these conditions.32 or ankylosis of a primary mandibular second molar may have OSAS may be associated with narrow maxilla, crossbite, low a congenitally missing tooth. tongue position, vertical growth, and open bite. History associ- Treatment considerations: With congenitally missing perma- ated with OSAS may include snoring, observed apnea, restless nent maxillary incisor(s) or mandibular second premolar(s), sleep, daytime neurobehavioral abnormalities or sleepiness, and the decision to extract the primary tooth and close the space bedwetting. Physical findings may include growth abnormali- orthodontically versus opening the space orthodontically and ties, signs of nasal obstruction, adenoidal facies, and/or enlarged placing a prosthesis or implant depends on many factors. For tonsils.32-34 maxillary laterals, the dentist may move the maxillary canine The identification of an abnormal habit and the assessment mesially and use the canine as a lateral incisor or create space of its potential immediate and long-term effects on the craniofa- for a future lateral prosthesis or implant.17,41 cial complex and dentition should be made as early as possible. Factors that influence the decision are: (1) patient age; The dentist should evaluate habit frequency, duration, and (2) canine shape; (3) canine position; (4) child’s occlusion intensity in all patients with habits. Intervention to terminate and amount of crowding; (5) bite depth; and (6) quality and the habit should be initiated if indicated.17 quantity of bone in the edentulous area.42,43 Early extraction of Patients and their parents should be provided with infor- the primary canine and/or lateral may be needed.42,43 Opening mation regarding consequences of a habit. Parents may play a space for a prosthesis or implant requires less tooth movement, negative role in the correction of an oral habit as nagging or but the space needs to be maintained with an interim pros- punishment may result in an increase in habit behaviors; change thesis, especially if an implant is planned.41,42 Moving the canine in the home environment may be necessary before a habit can be into the lateral position produces little facial change, but the overcome.16 resultant tooth size discrepancy often does not allow a canine guided occlusion.42,44

232 CLINICAL GUIDELINES AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

For a congenitally missing premolar, the primary molar of the permanent adjacent normal incisor.52,53 Later removal of either may be maintained or extracted with subsequent placement the mesiodens reduces the likelihood that the adjacent normal of a prosthesis or orthodontically closing the space. Maintaining permanent incisor will erupt on its own, especially if the apex the primary second molar may cause occlusal problems due to is completed.47 Inverted conical supernumeraries can be harder its larger mesiodistal diameter, compared to the second pre- to remove if removal is delayed, as they can migrate deeper molar. Reducing the width of the second primary molar is a into the jaw.45 After removal of the supernumerary, clinical and consideration, but root resorption and subsequent exfoliation radiographic follow-up is indicated in 6 months to determine may occur.17 In crowded arches or with multiple missing premo- if the normal incisor is erupting. If there is no eruption after 6 lars, extraction of the primary molar(s) can be considered, to 12 months and sufficient space exists, surgical exposure and especially in mild Class III cases.17 For a single missing premolar, orthodontic extrusion is needed.47 if maintaining the primary molar is not possible, placement of Objectives: Removal of supernumerary teeth should facilitate a prosthesis or implant should be considered.17,41 Consultation eruption of permanent teeth and encourage normal alignment. with an orthodontist and/or prosthodontist may be required. In cases where normal alignment or spontaneous eruption In addition, preserving the primary tooth may be indicated in does not occur, further orthodontic treatment is indicated. certain cases. Objectives: Treatment is directed toward an esthetically pleasing Localized disturbances in eruption occlusion that functions well for the patient. Ectopic eruption General considerations and principles of management: Ectopic Supernumerary teeth (primary, permanent, and mesiodens) eruption (EE) of permanent first molars occurs due to the molar’s General considerations and principles of management: Super- abnormal mesioangular eruption path, resulting in an impaction numerary teeth, or hyperdontia, can occur in the primary or at the distal prominence of the primary second molar’s crown. permanent dentition but are 5 times more common in the EE can be suspected if asymmetric eruption is observed or if the permanent.36 Prevalence is reported in the primary and mixed mesial marginal ridge is noted to be under the distal prominence dentitions from 0.52% to 2%.36,38,46 Between 80% and 90% of of the second primary molar. EE of permanent molars can be all supernumeraries occur in the maxilla, with half in the an- diagnosed from bitewing or panoramic radiographs in the early terior area and almost all in the palatal position.36,47 A super- mixed dentition. This condition occurs in up to 0.75% of the numerary primary tooth is followed by a supernumerary population,54 but is more common in children with cleft lip and permanent tooth in one third of the cases.48 palate.554 The maxillary canine appears in an impacted position During the early mixed dentition, 79% to 91% of anterior in 1.5% to 2% of the population,56,57 while maxillary incisors permanent supernumerary teeth are unerupted.46,49 While can erupt ectopically or be impacted from supernumerary teeth more erupt with age, only 25% of all mesiodens (a permanent in up to 2% of the population.47 Incisors also can have altered supernumerary incisor located at the midline) erupt spontane- eruption due to pulp necrosis (following trauma or caries) or ously.47 Mesiodens can prevent or cause ectopic eruption of a pulpal treatment of the primary incisor.58 central incisor. Less frequently, a mesiodens can cause dilacer- EE of permanent molars is classified into 2 types. There are ation or resorption of the permanent incisor’s root. Dentigerous those that self correct or “jump” and others that remain impact- cyst formation involving the mesiodens, in addition to erupt- ed. In 66% of the cases, the molar jumps.59 A permanent molar ion into the nasal cavity, has been reported.47,50 If there is an that presents with part of its occlusal surface clinically visible asymmetric eruption pattern of the maxillary incisors, delayed and part under the distal of the primary second molar normally eruption, an overretained primary incisor, or ectopic eruption does not jump and is the impacted type.60 Nontreatment can of an incisor, a supernumerary can be suspected.36,45 Panoramic, result in early loss of the primary second molar and space loss. occlusal, and periapical radiographs all can reveal a supernu- Maxillary canine impaction should be suspected when the merary, but the best way to locate the supernumerary is 2 canine bulge is not palpable or when asymmetric canine eruption periapical or occlusal films reviewed by the parallax rule.47 is evident. Panoramic radiographs would show the canine has an Treatment considerations: Management and treatment of hy- abnormal inclination and/or overlaps the lateral incisor root. EE perdontia differs if the tooth is primary or permanent. Primary of permanent incisors can be suspected after trauma to primary supernumerary teeth normally are accommodated into the incisors, with pulpally-treated primary incisors, with asymme- arch and usually erupt and exfoliate without complications.48 tric eruption, or if a supernumerary incisor is diagnosed. Extraction of an unerupted supernumerary tooth during the Treatment considerations: Treatment depends on how severe primary dentition usually is not done to allow it to erupt; surgi- the impaction appears clinically and radiographically. For mild- cal extraction of unerupted supernumerary teeth can displace ly impacted first permanent molars, where little of the tooth or damage the permanent incisor.47 Removal of a mesiodens or is impacted under the primary second molar, elastic or metal other permanent supernumerary incisor results in eruption of orthodontic separators can be placed to wedge the permanent the permanent adjacent normal incisor in 75% of the cases.51 first molar distally.16 For more severe impactions, distal tipping Extraction of an unerupted supernumerary during the early of the permanent molar is required. Tipping action can be mixed dentition allows for a normal eruptive force and eruption accomplished with brass wires, removable appliances using

CLINICAL GUIDELINES 233 REFERENCE MANUAL V 33 / NO 6 11 / 12 springs, fixed appliances such as sectional wires with open coil and palpation. Radiographic examination also may reveal the springs, sling shot-type appliances,60 a Halterman appliance,61 loss of the periodontal ligament and bony bridging. or surgical uprighting.62 Treatment considerations: With ankylosis of a primary molar, Early diagnosis and treatment of impacted maxillary exfoliation usually occurs normally. Extraction is recommended canines can lessen the severity of the impaction and may if prolonged retention of the primary molar is noted. If a se- stimulate eruption of the canine. Extraction of the primary vere marginal ridge discrepancy develops, extraction should canine is indicated when the canine bulge cannot be palpated be considered to prevent the adjacent teeth from tipping and in the alveolar process and there is radiographic overlapping of producing space loss.3 Replacement resorption of permanent the canine with the formed root of the lateral during the mixed teeth usually results in the loss of the involved tooth.67 dentition.63 Even when the impacted canine is diagnosed at a Mildly to moderately ankylosed primary molars without later age (11 to 16), if the canine is not horizontal, extraction permanent successors may be retained and restored to function of the primary canine lessens the severity of the permanent in arches without crowding. Extraction of these molars can assist canine impaction and 75% will erupt.64 Extraction of the first in resolving crowded arches in complex orthodontic cases.65,70 primary molar also has been reported to allow eruption of first Surgical luxation of ankylosed permanent teeth with forced bicuspids and to assist in the eruption of the cuspids. This need eruption has been described as an alternative to premature can be determined from a panoramic radiograph.61,65 Bonded extraction.71 orthodontic treatment normally is required to create space or Objectives: Treatment of ankylosis should result in the conti- align the canine. Long-term periodontal health of impacted nuing normal development of the permanent dentition. Or, canines after orthodontic treatment is similar to nonimpacted in the case of replacement resorption of a permanent tooth, canines.68 appropriate prosthetic replacement should be planned. Treatment of ectopically erupting incisors depends on the etiology. Extraction of necrotic or over-retained pulpally-treated Tooth size/arch length discrepancy and crowding primary incisors is indicated in the early mixed dentition.58 General considerations and principles of management: Arch Removal of supernumerary incisors in the early mixed denti- length discrepancies include inadequate arch length and crowd- tion will lessen ectopic eruption of an adjacent permanent ing of the dental arches, excess arch length and spacing, and incisor.47 After incisor eruption, orthodontic treatment involv- tooth size discrepancy, often referred to as a Bolton discrepan- ing re-movable or banded therapy may be needed. cy. 72 These arch length discrepancies may be found in conjunc- Objectives: Management of ectopically erupting molars, canines, tion with complicating and other etiological factors including and incisors should result in improved eruptive positioning of the missing teeth, supernumerary teeth, and fused or geminated tooth. In cases where normal alignment does not occur, subse- teeth. Inadequate arch length with resulting incisor crowding quent comprehensive orthodontic treatment may be ne-cessary is a common occurrence with various negative sequelae and is to achieve appropriate arch form and intercuspation. particularly common in the early mixed dentition.73-76 Studies of arch length in today’s children compared to their parents Ankylosis and grandparents of 50 years ago indicate less arch length, General considerations and principles of management: Anky- more frequent incisor crowding, and stable tooth sizes.77-79 losis is a condition in which the cementum of a tooth’s root This implies that the problem of incisor crowding and ulti- fuses directly to the surrounding bone. The periodontal ligament mate arch length discrepancies may be increasing in numbers is replaced with osseous tissue, rendering the tooth immobile to of patients and in amount of arch length shortage.77,78 eruptive change. Ankylosis can occur in the primary and perma- Arch length and especially crowding must be considered nent dentitions, with the most common incidence involving in the context of the esthetic, dental, skeletal, and soft tissue primary molars. The incidence is reported to be between 7% relationships. Mandibular incisors have a high relapse rate and 14% in the primary dentition.49 In the permanent dentition, in rotations and crowding.73,75 Growth of the aging skeleton ankylosis occurs most frequently following luxation injuries.67 causes further crowding and incisor rotations.82 Functional Ankylosis is common in anterior teeth following trauma contacts are diminished where rotations of incisors, canines, and and is referred to as replacement resorption. Periodontal liga- bicuspids exist.83 Occlusal harmony and temporomandi-bular ment cells are destroyed and the cells of the alveolar bone joint health are impacted negatively by less functional contacts.83 perform most of the healing. Over time, normal bony activity Initial assessment may be done in early mixed dentition, results in the replacement of root structure with osseous tissue.67 when mandibular incisors begin to erupt.73 Evaluation of avail- Ankylosis can occur rapidly or gradually over time, in some cases able space and consideration of making space for permanent as long as 5 years post trauma. It also may be transient if only incisors to erupt may be done initially utilizing appropriate a small bony bridge forms that can be resorbed with subse- radiographs to ascertain the presence of permanent successors. quent osteoclastic activity.69 Comprehensive diagnostic analysis is suggested, with evalua- Ankylosis can be verified by clinical and radiographic tion of maxillary and mandibular skeletal relationships, direc- means. Submergence of the tooth is the primary recognizable tion and pattern of growth, facial profile, facial width, muscle sign, but the diagnosis also can be made through percussion balance, and dental and occlusal findings including tooth positions, arch length analysis, and leeway space.

234 CLINICAL GUIDELINES AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Derotation of teeth just after emergence in the mouth consider include: (1) specific tooth lost; (2) time elapsed since implies correction before the transseptal fiber arrangement tooth loss; (3) pre-existing occlusion; (4) favorable space analy- has been established.73,83 It has been shown that the trans- sis; (5) presence and root development of permanent successor; septal fibers do not develop until the cementoenamel junction (6) amount of alveolar bone covering permanent successor; of erupting teeth pass the bony border of the alveolar process.83 (7) patient’s health status; (8) patient’s cooperative ability; Long-term stability of aligned incisors may be increased.84 (9) active oral habits; and (10) oral hygiene.17,87 If a space analy- Treatment considerations: Treatment considerations may in- sis is required prior to the placement of a space maintainer, clude, but are not limited to: appropriate radiographs and study models should be 1. making space for permanent incisors to erupt and be- considered.96 come straight naturally through primary canine ex- The literature pertaining to the use of space maintainers traction and space/arch length maintenance; specific to the loss of a particular primary tooth type include 2. orthodontic alignment of permanent teeth as soon as expert opinion, case reports, and details of appliance design.17,88,89 erupted and feasible, expansion and correction of Treatment modalities may include, but are not limited to: arch length as early as feasible; 1. fixed appliances (eg, band and loop, crown and loop, 3. utilizing holding arches in the mixed dentition until passive lingual arch, distal shoe, Nance appliance, all permanent bicuspids and canines have erupted; transpalatal arch); 4. extractions of permanent teeth; 2. removable appliances (eg, partial dentures, Hawley 5. maintaining patient’s original arch form.83 appliance).17,88,89 Other treatment modalities may include, but are not limit- The placement and retention of space maintaining appli- ed to: (1) interproximal reduction; (2) restorative bonding; (3) ances requires ongoing compliant patient behavior. Follow-up veneers; (4) crowns; (5) implants; and (6) orthognathic surgery. of patients with space maintainers is necessary to assess inte- Objectives: Well-timed intervention can: grity of cement and to evaluate and clean the abutment teeth.91 1. prevent crowded incisors; The appliance should function until the succedaneous teeth 2. increase long-term stability of incisor positions; have erupted into the arch. 3. decrease ectopic eruption and impaction of permanent Objectives: The goal of space maintenance is to prevent loss of canines; arch length, width, and perimeter by maintaining the relative 4. reduce orthodontic treatment time and sequelae; position of the existing dentition.17,88 5. improve gingival health and overall dental health.73, 85,86 The AAPD supports controlled randomized clinical trials to determine efficacy of space maintainers as well as analysis Space maintenance of costs and side effects of treatment. General considerations and principles of management: The premature loss of primary teeth due to caries, trauma, ectopic Space regaining eruption, or other causes may lead to undesirable tooth move- General considerations and principles of management: Some of ments of primary and/or permanent teeth including loss of the more common causes of space loss within an arch are (1) arch length. Arch length deficiency can produce or increase primary teeth with interproximal caries; (2) ectopically erupting the severity of malocclusions with crowding, rotations, ectopic teeth; (3) alteration in the sequence of eruption; (4) ankylosis eruption, crossbite, excessive overjet, excessive overbite, and of a primary molar; (5) dental impaction; (6) transposition of unfavorable molar relationships.87 The dental profession has re- teeth; (7) loss of primary molars without proper space manage- commended the use of space maintainers to reduce the preva- ment; (8) congenitally missing teeth; (9) abnormal resorption lence and severity of malocclusion following premature loss of of primary molar roots; (10) premature and delayed eruption of primary teeth.17,88,89 Space maintenance may be a consideration permanent teeth; and (11) abnormal dental morphology.17,87,97 in the primary dentition after early loss of a maxillary incisor Loss of space in the dental arch that interferes with the desired when the child has an active digit habit. An intense habit may eruption of the permanent teeth may require evaluation. reduce the space for the erupting permanent incisor. Space loss may occur unilaterally or bilaterally and may Adverse effects associated with space maintainers include: result from teeth tipping, rotating, extruding, being ankylosed, (1) dislodged, broken, and lost appliances; (2) plaque accumu- or translating or from extrusion of teeth and the deepening of lation; (3) caries; (4) interference with successor eruption; (5) the curve of Spee.98 undesirable tooth movement; (6) inhibition of alveolar growth; The degree to which space is affected varies according to (7) soft tissue impingement; and (8) pain.87,90-92 Premature loss the arch affected, site in the arch, and time elapsed since tooth of a primary tooth of any type has the potential to cause loss loss. The quantity and incidence of space loss also are depen- of space available for the succeeding permanent tooth, but dent upon which adjacent teeth are present in the dental arch there is a lack of consensus regarding the effectiveness of space and their status.17,87 The amount of crowding or spacing in maintainers in preventing or reducing the severity of maloc- the dental arch will determine the degree to which space loss clusion.87,93-95 has a significant consequence.1,98 Treatment considerations: It is prudent to consider space main- Treatment considerations: Treatment modalities may include, tenance when primary teeth are lost prematurely. Factors to but are not limited to, fixed appliances or removable appliances

CLINICAL GUIDELINES 235 REFERENCE MANUAL V 33 / NO 6 11 / 12

(eg, Hawley appliance, lip bumper, headgear). Space loss and 1. equilibration; dentofacial skeletal development may dictate that space regain- 2. appliance therapy (fixed or removable); ing not be indicated. This should be determined as the result of 3. extractions; or a comprehensive analysis. The timing of clinical intervention 4. a combination of these treatment modalities to correct subsequent to premature loss of a primary molar is critical.1 the palatal constriction. Fixed or removable palatal expanders can be utilized until Objectives: The goal of space regaining intervention is the midline suture fusion occurs.101,102 Treatment decisions depend recovery of lost arch width and perimeter and/or improved on the: eruptive position of succedaneous teeth. Space regained should 1. amount and type of movement (tipping vs bodily be maintained until adjacent permanent teeth have erupted movement, rotation, or dental vs orthopedic move- completely and/or until a subsequent comprehensive ortho- ment); dontic treatment plan is initiated. 2. space available; 3. AP, transverse, and vertical skeletal relationships; Crossbites (dental, functional, and skeletal) 4. growth status; General considerations and principles of management: Ante- 5. patient cooperation. rior and posterior crossbites are malocclusions which involve Patients with crossbites and concomitant Class III skeletal one or more teeth in which the maxillary teeth occlude lin- patterns and/or skeletal asymmetry should receive comprehen- gually with the antagonistic mandibular teeth.99,100 If the mid- sive treatment as covered in the Class III malocclusion section. lines undergo a compensatory or habitual shift when the teeth Objectives: Treatment of a crossbite should result in improved occlude in crossbite, this is termed a functional shift.101 A intramaxillary alignment and an acceptable interarch occlu- crossbite can be of dental or skeletal origin or a combination sion and function.103 of both.102 A simple anterior crossbite is of dental origin if the molar Class II malocclusion occlusion is Class I and the malocclusion is the result of an General considerations and principles of management: Class II abnormal axial inclination of maxillary anterior teeth. This malocclusion (distocclusion) may be unilateral or bilateral and condition should be differentiated from a Class III skeletal involves a distal relationship of the mandible to the maxilla or malocclusion where the crossbite is the result of the basal bone the mandibular teeth to maxillary teeth. This relationship may position.100 Dental crossbites result from the tipping or rota- result from dental (malposition of the teeth in the arches), tion of a tooth or teeth. The condition is localized and does skeletal (mandibular retrusion and/or maxillary protrusion), or not involve the basal bone. Skeletal crossbites involve dishar- a combination of dental and skeletal factors.6 mony of the craniofacial skeleton. Aberrations in bony growth Results of randomized clinical trials indicate that Class II may give rise to crossbites in 2 ways: malocclusion can be corrected effectively with either a single 1. adverse transverse growth of the maxilla and mandible; or 2-phase regimen.105-108 Growth-modifying effects in some 2. disharmonious or adverse growth in the sagittal (AP) studies did not show an influence on the Class II skeletal length of the maxilla and mandible.99,101 pattern,107,109,110 while other studies dispute these findings.111,112 Such growth aberrations can be due to inherited growth pat- There is substantial variation in treatment response to growth terns, trauma, or functional disturbances that alter normal growth. modification treatments (headgear or functional appliance) Treatment considerations: Crossbites should be considered in the and no reliable predictors for favorable growth response have context of the patient’s total treatment needs. Anterior cross-bite been found.105,111 Some reports state early treatment does not correction can: (1) reduce dental attrition; (2) improve dental reduce the need for either premolar extractions or orthogna- esthetics; (3) redirect skeletal growth; (4) improve the tooth-to- thic surgery,106,107 while others disagree with these findings.113 alveolus relationship; and (5) increase arch perimeter. A simple Two-phase treatment results in significantly longer treatment anterior crossbite can be aligned as soon as the condition is time.101,106,114 noted, if there is sufficient space; otherwise, space needs to be Clinicians may decide to provide early treatment based created first. Such appliances as acrylic incline planes, acrylic on other factors.106,111 Preliminary evidence suggests that, for retainers with lingual springs, or fixed appliances all have been some children, early Class II treatment improves self-esteem effective. If space is needed, an expansion appliance also is and decreases negative social experiences.115 Incisor injury that required.99 Posterior crossbite correction can accomplish the is more severe than simple enamel fractures has been associ- same objectives and can improve the eruptive position of the ated positively with increased overjet and prognathic position succedaneous teeth. Early correction of unilateral posterior of the maxilla.116 Some studies indicate early treatment for crossbites has been shown to improve functional conditions Class II malocclusions can be initiated, depending upon pa- significantly and largely eliminate morphological and posi- tient cooperation and management.117 tional asymmetries of the mandible.103,104 Functional shifts Treatment considerations: Factors to consider when planning should be eliminated as soon as possible with early correction101 orthodontic intervention for Class II malocclusion are: (1) to avoid asymmetric growth. Treatment can be completed with: facial growth pattern; (2) amount of AP discrepancy; (3)

236 CLINICAL GUIDELINES AMERICAN ACADEMY OF PEDIATRIC DENTISTRY patient age; (4) projected patient compliance; (5) space anal- References ysis; (6) requirements; and (7) patient and parent 1. Kanellis MJ. Orthodontic treatment in the primary den- desires. tition. In: Bishara SE, ed. Textbook of . Treatment modalities include: (1) extraoral appliances Philadelphia, Pa: WB Saunders Co; 2001:248-56. (headgear); (2) functional appliances; (3) fixed appliances; (4) 2. Woodside DG. The significance of late developmental tooth extraction and interarch ; and (5) orthodontics crowding to early treatment planning for incisor crowd- with orthognathic surgery.102 ing. Am J Orthod Dentofacial Orthop 2000;117(5): Objectives: Treatment of a developing Class II malocclusion 559-61. should result in an improved overbite, overjet, and intercuspa- 3. Kurol J. Early treatment of tooth-eruption disturbances. tion of posterior teeth and an esthetic appearance and profile Am J Orthod Dentofacial Orthop 2002;121(6):588-91. compatible with the patient’s skeletal morphology. 4. Sankey WL, Buschang PH, English J, Owen AH III. Early treatment of vertical skeletal dysplasia: The hyper- Class III malocclusion divergent phenotype. Am J Orthod Dentofacial Orthop General considerations and principles of management: Class III 2000;118(3):317-27. malocclusion (mesocclusion) may be unilateral or bilateral and 5. American Academy of Pediatric Dentistry. Policy on involves a mesial relationship of the mandible to the maxilla or ethical responsibility to treat or refer. Pediatr Dent 2008; mandibular teeth to maxillary teeth. This relationship may result 30(suppl):83. from dental factors (malposition of the teeth in the arches), 6. Profitt WR, Sarver DM, Ackerman JL. Orthodontic diag- skeletal factors (asymmetry, mandibular , and/or nosis: The development of a problem list. In: Proffit WR, maxillary ), or a combination of these factors.118 Fields HW Jr, Sarver DM, eds. Contemporary Ortho- The etiology of Class III malocclusions can be hereditary, dontics. 4th ed. St. Louis, Mo: Mosby; 2007:167-233. environmental, or both. In a study of 320 orthodontic patients 7. Dale JG, Dale HC. Interceptive guidance of occlusion with in 155 sibships, the hereditary effect on molar relationship was emphasis on diagnosis. In: Graber TM, Vanarsdall RL determined to be 56%.119 Hereditary factors include clefts of the Jr, Vig KWL, eds. Orthodontics: Current Principals and alveolus and palate and other craniofacial anomalies that are part Techniques. 4th ed. St. Louis, Mo: Mosby; 2005:422-39. of a genetic syndrome. Some environmental factors are trauma, 8. Ferguson DJ. Growth of the face and dental arches. In: oral/digital habits, caries, and early childhood OSAS.120 McDonald RE, Avery DR, Dean JA, eds. Dentistry for Treatment considerations: Treatment of Class III malocclu- the Child and Adolescent. 8th ed. St. Louis, Mo: Mosby; sions is indicated to provide psychosocial benefits for the child 2004:590-6. patient by reducing or eliminating facial disfigurement and to 9. McNamara JA, Brudon WL. Dentitional development. In: reduce the severity of malocclusion by promoting compensat- Orthodontics and Dentofacial Orthopedics. Ann Arbor, ing growth. Early Class III treatment has been proposed for Mich: Needham Press, Inc; 2001:31-8. several years and has been advocated as a necessary tool in 10. Profitt WR The later stages of development. In: Proffit contemporary orthodontics.121-126 Factors to consider when WR, Fields HW Jr, Sarver DM, eds. Contemporary Ortho- planning orthodontic intervention for Class III malocclusion dontics. 4th ed. St. Louis, Mo: Mosby; 2007:107-29. are: (1) facial growth pattern; (2) amount of AP discrepancy; 11. Hunt O, Hepper P, Johnston C, Stevenson M, Burden (3) patient age; (4) projected patient compliance; (5) space D. Professional perceptions of the benefits of orthodontic analysis; (6) anchorage (headgear); (7) functional appliances; treatment. Eur J Orthod 2001;23(3):315-23. (8) fixed appliances; (9) tooth extraction; (10) interarch elastics; 12. International Symposium on Early Orthodontic Treatment. and (11) orthodontics with orthognathic surgery.127 Am J Orthod Dentofacial Orthop 2002;121(6):552-95. Objectives: Early Class III treatment may provide a more 13. Ackerman M. Evidenced-based orthodontics for the 21st favorable environment for growth and may improve occlu- century. J Am Dent Assoc 2004;135(2):162-7. sion, function, and esthetics.128 Although early treatment can 14. American Dental Association, US Dept of Health and minimize the malocclusion and potentially eliminate future Human Services. The selection of patients for dental orthognathic surgery, this is not always possible. Typically, radiographic examinations—2004. Available at: “http:// Class III patients tend to grow longer and more unpredictably www.ada.org/prof/resources/topics/radiography.asp”. and, therefore, surgery combined with orthodontics is the Accessed May 26, 2008. best alternative to achieve a satisfactory result for some 15. Proffit WR. The etiology and development of orthodon- patients.102 tic problems. In: Proffit WR, Fields HW Jr, Sarver DM, Treatment of a Class III malocclusion in a growing patient eds. Contemporary Orthodontics. 4th ed. St. Louis, Mo: should result in improved overbite, overjet, and intercuspation Mosby; 2007:130-61. of posterior teeth and an esthetic appearance and profile 16. Warren JJ, Bishara SE, Steinbock KL, Yonezu T, Nowak compatible with the patient’s skeletal morphology. AJ. Effects of oral habits’ duration on dental characteris- tics in the primary dentition. J Am Dent Assoc 2001;132 (12):1685-93.

CLINICAL GUIDELINES 237 REFERENCE MANUAL V 33 / NO 6 11 / 12

17. Dean JA. Management of the developing occlusion. In: 33. American Academy of Pediatrics. Clinical practice guide- McDonald RE, Avery DR, Dean JA, eds. Dentistry for line: Diagnosis and management of childhood obstructive the Child and Adolescent. 8th ed. St. Louis, Mo: Mosby; sleep apnea syndrome. Pediatrics 2002;109(4):704-12. 2004:631-68. 34. Ward T, Mason TB II. Sleep disorders in children. Nurs 18. Ogaard B, Larsson E, Lindsten R. The effect of sucking Clin North Am 2002;37(4):693-706. habits, cohort, sex, intercanine arch widths, and breast or 35. Brook AH. Dental anomalies of number, form, and size: bottle feeding on posterior crossbite in Norwegian and Their prevalence in British school children. J Int Assoc Swedish 3-year-old children. Am J Orthod Dentofacial Dent Child 1974;5(2):37-53. Orthop 1994;106(2):161-6. 36. Byrd ED. Incidence of supernumerary and congenitally 19. Warren JJ, Bishara SE. Duration of nutritive and nonnu- missing teeth. ASDC J Dent Child 1943;10:84-6. tritive sucking behaviors and their effects on the dental 37. Rose JS. A survey of congenitally missing teeth, excluding arches in the primary dentition. Am J Orthod Dento- third molars, in 6,000 orthodontic patients. Dent Pract facial Orthop 2002;121:347-56. Dent Rec 1966;17(3):107-14. 20. Monaco A, Ciammella NM, Marci MC, Pirro P, Gian- 38. Clayton JM. Congenital dental anomalies occurring in noni M. The anxiety in bruxer child: A case-control study. 3,552 children. J Dent Child 1956;23:206-86. Minverva Stomatol 2002;51(6):247-50. 39. Brabant H. Comparison of the characteristics and anom- 21. Weideman CL, Bush DL, Yan-Go FL, Clark GT, Gorn- alies of the deciduous and permanent dentitions. J Dent bein JA. The incidence of parasomnias in child bruxers Res 1967;46(5):897-902. vs nonbruxers. Pediatr Dent 1996;18(7):456-60. 40. Graber LW. Congenital absence of teeth: A review with 22. Ivanhoe CB, Lai JM, Francisco GE. Bruxism after brain emphasis on inheritance patterns. J Am Dent Assoc injury: Successful treatment with botulinum toxin-A. 1978;96(2):266-75. Arch Phys Med Rehabil 1997;78(11):1272-3. 41. Hobkirk JA, Brook AH. The management of patients 23. Rugh JD, Harlan J. Nocturnal bruxism and temporo- with severe hypodontia. J Oral Rehabil 1980;7(4):289-98. mandibular disorders. Adv Neurol 1988;49:329-41. 42. Riolo ML, Avery DR. Preadolescent orthodontic treat- 24. Sari S, Sonmez H. The relationship between occlusal fac- ment and orthodontic treatment during active stages of tors and bruxism in permanent and mixed dentition in growth and development. In: Essentials for Orthodontic Turkish children. J Clin Pediatr Dent 2001;25(3):191-4. Practice. Ann Arbor & Grand Haven, Mich: ESOP Press; 25. Negoro T, Briggs J, Plesh O, Nielsen I, McNeill C, Miller 2003:48-9. AJ. Bruxing patterns in children compared to intercuspal 43. Woodworth DA, Sinclair PM, Alexander RG. Bilateral con- clenching and chewing as assessed with dental models, genital absence of maxillary lateral incisors: A craniofacial electromyography, and incisor jaw tracing: Preliminary and dental cast analysis. Am J Orthod 1985;87(4):280-93. study. ASDC J Dent Child 1998;65(6):449-58. 44. Robertson S, Mohlin B. The congenitally missing upper 26. Kiesser JA, Groeneveld HT. Relationship between juve- lateral incisor. A retrospective study of orthodontic space nile bruxing and craniomandibular dysfunction. J Oral closure vs restorative treatment. Eur J Orthod 2000;22 Rehabil 1998;25(9):662-5. (6):697-710. 27. Restrepo CC, Alvarez E, Jaramillo C, Velez C, Valencia I. 45. Primosch RE. Anterior supernumerary teeth: Assess- Effects of psychological techniques on bruxism in children ment and surgical intervention in children. Pediatr Dent with primary teeth. J Oral Rehabil 2001;28(9):354-60. 1981;3(2):204-15. 28. Nissani M. A bibliographical survey of bruxism with 46. Luten JR. The prevalence of supernumerary teeth in pri- special emphasis on nontraditional treatment modalities. mary and mixed dentitions. ASDC J Dent Child 1967; J Oral Sci 2001;43(2):73-83. 34(5):346-53. 29. Christensen J, Fields HW Jr, Adair S. Oral habits. In: 47. Russell KA, Folwarczna MA. Mesiodens: Diagnosis and Pinkham JR, Casamassimo PS, McTigue DJ, Fields HW management of a common supernumerary tooth. J Can Jr, Nowak AJ, eds. Pediatric Dentistry: Infancy Through Dent Assoc 2003;69(6):362-6. Adolescence. 4th ed. St. Louis, Mo: Elsvier Saunders; 2005: 48. Taylor GS. Characteristics of supernumerary teeth in the 431-9. primary and permanent dentition. Dent Pract Dent Rec 30. Saemundsson SR, Roberts MW. Oral self-injurious be- 1972;22(5):203-8. havior in the developmentally disabled: Review and a 49. McKibben DR, Brearley LJ. Radiographic determination case. ASDC J Dent Child 1997;64(3):205-9. of the prevalence of selected dental anomalies in children. 31. Milwood J, Fiske J. Lip biting in patients with profound J Dent Child 1971;28(6):390-8. neurodisability. Dent Update 2001;28(2):105-8. 50. Humerfelt D, Hurlen B, Humerfelt S. Hyperdontia in 32. Fields HW Jr, Warren DW, Black BK, Phillips C. Rela- children below four years of age: A radiographic study. tionship between vertical dentofacial morphology and ASDC J Dent Child 1985;52(2):121-4. respiration in adolescents. Am J Orthod Dentofacial Orthop 1991;99(2):147-54.

238 CLINICAL GUIDELINES AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

51. Howard RD. The unerupted incisor. A study of the post- 69. Kokich VO. Congenitally missing teeth: Orthodontic operative eruptive history of incisors delayed in their management in the adolescent patient. Am J Orthod eruption by supernumerary teeth. Dent Pract Dent Rec Dentofacial Orthop 2002;121(6):594-5. 1967;17(9):332-41. 70. Sabri R. Management of congenitally missing second pre- 52. Tay F, Pang A, Yuen S. Unerupted maxillary anterior molars with orthodontics and single-tooth implants. Am supernumerary teeth: A report of 204 cases. ASDC J J Orthod Dentofacial Orthop 2004;125(5):634-42. Dent Child 1984;51(4):289-94. 71. Geiger AM, Brunsky MJ. Orthodontic management of 53. Witsenburg B, Boering G. Eruption of impacted perma- ankylosed permanent posterior teeth: A clinical report of nent upper incisors after removal of supernumerary three cases. Am J Orthod Dentofacial Orthop 1994; teeth. Int J Oral Surg 1981;10(6):423-31. 106(5):543-8. 54. Chintakanon K, Boonpinon P. Ectopic eruption of the first 72. Bolton WA. The clinical application of a tooth-size ana- permanent molars: Prevalence and etiology factors. Angle lysis. Am J Orthod 1962;48:504-29. Orthod 1998;68(2):153-60. 73. Dugoni SA, Lee JS, Varela J, Dugoni AA. Early mixed 55. Carr GE, Mink JR. Ectopic eruption of the first perma- dentition treatment: Postretention evaluation of stability nent maxillary molar in cleft lip and palate children. and relapse. Angle Orthod 1995;65(5):311-20. ASDC J Dent Child 1965;32:179-88. 74. Foster H, Wiley W. Arch length deficiency in the mixed 56. Grover P, Lorton L. The incidence of unerupted permanent dentition. Am J Orthod 1958;68:61-8. teeth and related clinical cases. Oral Surg Oral Med Oral 75. Little RM, Riedel RA, Stein A.. Mandibular arch length Pathol 1985;59(4):420-5. increase during the mixed dentition: Postretention evalu- 57. Ericson S, Kurol J. Radiographic examination of ectopi- ation of stability and relapse. Am J Orthod Dentofacial cally erupting maxillary canines. Am J Orthod Dentofacial Orthop 1990;97(5):393-404. Orthop 1987;91(6):483-92. 76. Little RM. Stability and relapse of mandibular anterior 58. Coll JA, Sadrian R. Predicting pulpectomy success and its alignment: University of Washington studies. Semin Or- relationship to exfoliation and succedaneous dentition. thod 1999;5(3):191-204. Pediatr Dent 1996;18(1):57-63. 77. Warren JJ, Bishara SE, Yonezu T. Tooth size-arch length 59. Young DH. Ectopic eruption of the first permanent molar. relationships in the deciduous dentition: A comparison be- ASDC J Dent Child 1957;24:153-62. tween contemporary and historical samples. Am J Orthod 60. Gehm S, Crespi PV. Management of ectopic eruption of Dentofacial Orthop 2003;123(6):614-9. permanent molars. Compend Cont Educ Dent 1997;18 78. Warren JJ, Bishara SE. Comparison of dental arch meas- (6):561-9. urements in the primary dentition between contemporary 61. Halterman CW. A simple technique for the treatment of and historic samples. Am J Orthod Dentofacial Orthop ectopically erupting first permanent molars. J Am Dent 2001;119(3):211-5. Assoc 1982;105(6):1031-3. 79. Moorrees CF. Register of longitudinal growth studies of 62. Terry BC, Hegtvedt AK. Self-stabilizing approach to sur- facial and dental development. J Dent Res 1967;46(6): gical uplifting of the mandibular second molar. Oral 1206-7. Surg Oral Med Oral Pathol 1993;75(6):674-6. 80. Moorrees CF, Burstone CJ, Christiansen RL, Hixon EH, 63. Fernandez E, Bravo LA, Canteras M. Eruption of the Weinstein S. Research related to malocclusion. A “state-of- permanent upper canine: A radiographic study. Am J the-art” workshop conducted by the Oral-Facial Growth Orthod Dentofacial Orthop 1998;113(4):414-20. and Development Program, The National Institute of 64. Olive RJ. Orthodontic treatment of palatally impacted Dental Research. Am J Orthod 1971;59(1):1-18. maxillary canines. Aust Orthod J 2002;18(2):64-70. 81. Turpin DL. Where has all the arch length gone? (editorial) 65. D’Amico RM, Bjerklin K, Kurol J, Falahat B. Long-term Am J Orthod Dentofacial Orthop 2001;119(3):201. results of orthodontic treatment of impacted maxillary 82. Behrents, RG. Growth in the aging craniofacial skeleton. canines. Angle Orthod 2003;73(3):231-8. Monograph 17. Craniofacial Growth Series. Ann Arbor, 66. McTigue DJ. Managing traumatic injuries in the young Mich: University of Michigan, Center for Human Growth permanent dentition. In: Pinkham JR, Casamassimo PS, and Development; 1985. McTigue DJ, Fields HW Jr, Nowak AJ, eds. Pediatric 83. Zachrisson BU. Important aspects of long-term stability. J Dentistry: Infancy Through Adolescence. th4 ed. St Louis, Clin Orthod 1997;31(9):562-83. Mo: Elsevier Saunders; 2005:593-607. 84. Kusters ST, Kuijpers-Jagman AM, Maltha JC. An experi- 67. Andreasen JO, Andreasen FM. , general prog- mental study in dogs of transseptal fiber arrangement nosis. In: Essentials of Traumatic Injuries to the Teeth. between teeth which have emerged in rotated and non- Copenhagen, Denmark: Munksgaard; 1994:111. rotated positions. J Dent Res 1991;70(3):192-7. 68. Andreasen JO, Andreasen FM. Avulsion injuries: Pattern 85. Ericson S, Kurol J. Radiographic assessment of maxillary of injury and diagnosis. In: Essentials of Traumatic Injuries canine eruption in children with clinical signs of erup- to the Teeth. Copenhagen, Denmark: Munksgaard; 1994: tion disturbances. Eur J Orthod 1986;8(3):133-40. 115-20.

CLINICAL GUIDELINES 239 REFERENCE MANUAL V 33 / NO 6 11 / 12

86. Ericson S, Kurol J. Early treatment of palatally erupting 102. Proffit WR, Fields HW Jr, Sarver DM. Orthodontic treat- maxillary canines by extraction of the primary canines. ment planning: Limitations, controversies, and special Eur J Orthod 1988;10(4):283-95. problems. In: Contemporary Orthodontics. 4th ed. St. 87. Brothwell DJ. Guidelines on the use of space maintainers Louis, Mo: Mosby; 2007:268-327. following premature loss of primary teeth. J Can Dent 103. Sonnesen L, Bakke M, Solow B. Bite force in preorthodon- Assoc 1997;63(10):753-66. tic children with unilateral crossbite. Eur J Orthod 2001; 88. Ngan P, Alkire RG, Fields HW Jr. Management of space 23(6):741-9. problems in the primary and mixed dentitions. J Am Dent 104. Pinto AS, Bushang PH, Throckmorton GS, Chen P. Assoc 1999;130(9):1330-9. Morphological and positional asymmetries of young chil- 89. Terlaje RD, Donly KJ. Treatment planning for space dren with functional unilateral posterior crossbites. Am J maintenance in the primary and mixed dentition. J Dent Orthod Dentofacial Orthop 2001;120(5):513-20. Child 2001;68(2):109-14. 105. Ghafari J, Shofur FS, Jacobsson-Hunt U, Markowitz 90. Dincer M, Haydar S, Unsal B, Turk T. Space maintain- DL, Laster LL. Headgear vs functional regulator in the er effects on intercanine arch width and length. J Clin early treatment of Class II, division 1 malocclusion: A Pediatr Dent 1996;21(1):47-50. randomized clinical trial. Am J Orthod Dentofacial 91. Qudeimat MA, Fayle SA. The longevity of space main- Orthop 1998;113(1):51-61. tainers: A retrospective study. Pediatr Dent 1998;20(4): 106. Tulloch JF, Proffit WR, Phillips C. Benefit of early Class 267-72. II treatment: Progress report of a two-phase randomized 92. Cuoghi OA, Bertoz FA, de Mendonca MR, Santos EC. clinical trial. Am J Orthod Dentofacial Orthop 1998;113 Loss of space and dental arch length after the loss of the (1):62-72. lower first primary molar: A longitudinal study. J Clin 107. Keeling SD, Wheeler TT, King GJ, et al. Anteroposterior Pediatr Dent 1998;22(2):117-20. skeletal and dental changes after early Class II treatment 93. Rajab LD. Clinical performance and survival of space with bionators and headgear. Am J Orthod Dentofacial maintainers: Evaluation over a period of 5 years. ASDC Orthop 1998;113(1):40-50. J Dent Child 2002;69(2):156-60. 108. Tulloch JF, Phillips C, Proffit WR. Outcomes in a 2-phase 94. Owen DG. The incidence and nature of space closure randomized clinical trial of early Class II treatment. Am J following the premature extraction of deciduous teeth: A Orthod Dentofacial Orthop 2004;125(6):657-67. literature survey study. Am J Orthod Dentofacial Orthop 109. Chen JY, Will LA, Niederman R. Analysis of efficacy 1971;59(1):37-49. of functional appliances on mandibular growth. Am J 95. Kisling E, Hoffding J. Premature loss of primary teeth. Part Orthod Dentofacial Orthop 2002;122(5):470-6. IV, a clinical control of Sannerud’s space maintainer, type I. 110. O’Brien K, Wright J, Conboy F, et al. Effectiveness of ASDC J Dent Child 1979;46(2):109-13. early orthodontic treatment with the twin-block ap- 96. Qudeimat MA, Fayle SA. The use of space maintainers at pliance: A multicenter, randomized, controlled trial. Part a UK pediatric dentistry department. ASDC J Dent Child 1: Dental and skeletal effects. Am J Orthod Dentofacial 1999;66(6):383-6. Orthop 2003;124(3):234-43. 97. Christensen JR, Fields HW Jr. Space maintenance in the 111. McNamara JA, Brookstein FL, Shaughnessy TG. Skeletal primary dentition. In: Pinkham JR, Casamassimo PS, and dental changes following regulatory therapy on Class McTigue DJ, Fields HW Jr, Nowak AJ, eds. Pediatric II patients. Am J Orthod Dentofacial Orthop 1985;88(2); Dentistry Infancy Through Adolescence. 4th ed. St Louis, 91-110. Mo: Elsevier Saunders; 2005:423-30. 112. Toth LR, McNamara JA Jr. Treatment effects produced 98. Profitt WR, Fields HW Jr, Sarver DM. Orthodontic by the twin-block appliance and the FR-2 appliance of treatment planning: From problem list to specific plan. Frankel compared with untreated Class II sample. Am J In: Contemporary Orthodontics. 4th ed. St. Louis, Mo: Orthod Dentofacial Orthop 1999;116(6):597-609. Mosby; 2007:234-67. 113. Carapezza L. Early treatment vs late treatment Class II closed 99. Richards B. An approach to the diagnosis of different mal- bite malocclusion. Gen Dent 2003;51(5):430-4. occlusions. In: Bishara SE, ed. Textbook of Orthodontics. 114. Von Bremen J, Pancherz H. Efficiency of early and late Philadelphia, Pa: Saunders Co; 2001:157-8. Class II division 1 treatment. Am J Orthod Dentofacial 100. Bishara SE, Staley RN. Maxillary expansion: Clinical Orthop 2002;121(1):31-7. implications. Am J Orthod Dentofacial Orthop 1987;91 115. O’Brien K, Wright J, Conboy F, et al. Effectiveness of (1):3-14. early orthodontic treatment with the twin-block appli- 101. Kluemper GT, Beeman CS, Hicks, EP. Early orthodontic ance: A multicenter, randomized, controlled trial. Part 2: treatment: What are the imperatives? J Am Dent Assoc Psychosocial effects. Am J Orthod Dentofacial Orthop 2000;131(5):613-20. 2003;124(5):488-95.

240 CLINICAL GUIDELINES AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

116. Kania MJ, Keeling SD, McGorray SP, Wheeler TT, King 122. Kim JH, Viana MA, Graber TM, Omerza FF, BeGole GJ. Risk factors associated with incisor injury in ele- EA. The effectiveness of protraction face mask therapy: A mentary school children. Angle Orthod 1996;66(6): meta-analysis. Am J Orthod Dentofacial Orthop 1999; 423-31. 115(6):675-85. 117. Baccetti T, Franchi L, McNamara JA Jr, Tollaro I. Early 123. Jager A, Braumann B, Kim C, Wahner S. Skeletal and dentofacial features of Class II malocclusion: A longi- dental effects of maxillary protraction in patients with tudinal study from the deciduous through the mixed Angle class III malocclusions. A meta-analysis. 2001;62 dentition. Am J Orthod Dentofacial Orthop 1997;111 (4):275-84. (5):502-9. 124. Page DC. Early orthodontics: 5 new steps to better care. 118. Staley RN. Orthodontic diagnosis and treatment plan- Dent Today 2004;23(2):1-7. ning: Angle’s classification system. In: Bishara SE, ed. 125. Stahl F, Grabowski R. Orthodontic findings in the decidu- Textbook of Orthodontics. Philadelphia, Pa: Saunders Co; ous and early mixed dentition: Inferences for a preventive 2001:102-3. strategy. J Orofac Orthop 2003;64(6):401-16. 119. Cassidy KM, Harris EF, Tolley EA Keim RG. Genetic 126. Ricketts RM. A statement regarding early treatment. Am J influences on dental arch in orthodontic patients. Angle Orthod Dentofacial Orthop 2000;117(5):556-8. Orthod 1998;68(5):445-54. 127. Profitt WR, Sarver DM. Combined surgical and ortho- 120. Staley RN. Etiology and prevalence of malocclusion. In: dontic treatment. In: Profitt WR, Fields HW Jr, Sarver Bishara SE, ed. Textbook of Orthodontics. Philadelphia, DM, eds. Contemporary Orthodontics. 4th ed. St. Louis, Pa:Saunders Co; 2001:84. Mo: Mosby; 2007:686-718. 121. Campbell PM. The dilemma of Class III treatment. Early 128. Toffol LD, Pavoni C, Baccetti T, Franchi L, Cozza P. or late? Angle Orthod 1983;53(3):175-91. Orthopedic treatment outcomes in Class III malocclusion. Angle Orthod 2008;78(3)561-73.

CLINICAL GUIDELINES 241