Orthodontics/MixedDentition

Felicity Borrie
David Bearn

Interceptive Orthodontics − Current

Evidence-Based Best Practice
Abstract: This article examines the key areas relating to interceptive orthodontics, ie crossbites, anterior and posterior; eruption
problems and impaction (including incisors and canines); poor quality first permanent molars; infra-occluded primary molar teeth; non-
nutritive sucking habits (digit and pacifier sucking) leading to anterior openbite, posterior crossbite and increased overjet; centreline
shifts related to unilateral loss of primary teeth; and increased overjet and associated risk of trauma. It aims to provide information and
recommendations.
Clinical Relevance: The GDP requires evidence to support the clinical management of common problems presenting in the mixed
dentition.
Dent Update 2013; 40: 442–450

Interceptive orthodontics is a term that is used  Crossbites, anterior and posterior; anterior crossbite in a few weeks, but this is
to encompass many treatments for different  Eruption problems and impaction only based on case reports. Fixed orthodontic
problems arising in the developing dentition. (including incisors and canines); appliances, in the form of a ‘2 x 4’ appliance
Studies have identified that between 26%  Poor quality first permanent molars; appeared to correct the crossbite within six
and 39%1−4 of children have malocclusions  Infra-occluded primary molar teeth; weeks to three months, based on cohort
that require treatment, depending on the age  Non-nutritive sucking habits (digit and studies (Figure 2). Surprisingly, no studies
range investigated. Interceptive orthodontic pacifier sucking) leading to anterior open bite, investigated the use of an upper removable
treatment potentially reduces the need posterior crossbite and increased overjet; appliance in this situation.
for complex orthodontic treatment5 and,  Centreline shifts related to unilateral loss of
therefore, may be of particular benefit to primary teeth; and
Recommendation
patients and clinicians in areas where there  Increased overjet and associated risk of
Although there is no conclusive
is limited access to specialist orthodontic trauma.
evidence as to the most effective overall
services. The GDP plays a very important
option for correcting an anterior crossbite
role in the identification and diagnosis of
orthodontic problems presenting early, and Anterior crossbite in the mixed dentition, a ‘2 x 4’ fixed appliance
or modification to incisal edges appear to be
assessing the potential for their development. Anterior crossbite occurs when
most effective in terms of treatment time.
It is believed that, if intercepted and correctly one, or more, lower incisor teeth occlude
managed during the mixed dentition, many anterior to the upper incisor teeth. If left
malocclusions can be eliminated or reduced untreated, it may cause attrition to the labial Posterior crossbite
in severity.6 The following areas, already surface of the upper incisor, fractures or
Posterior crossbite can occur
mentioned, will be explored, highlighting mobility of incisor teeth or gingival recession.
in the premolar or molar region, with one
current best practice recommendations: There is a variety of treatment options,
including removable and fixed orthodontic
appliances. A recent systematic review
Felicity R Borrie, BDS, PhD, MFDS, found little high quality evidence in this
MOrth RCSEd, Clinical Lecturer in area and suggested that the evidence does
Orthodontics and David R Bearn, BDS, not strongly support one treatment option
MSc, PhD, MOrth RCSEng, FDS(Orth) over another.7 The evidence suggests that
RCPS Glasg, Professor of Orthodontics, treatment involving modification to the upper
Dundee Dental Hospital and School, or lower incisal edges, either in the form of
Park Place, Dundee, UK. a temporary crown or composite build-up
Figure 1. Composite incisal build-up.
(Figure 1), gives correction of a single tooth
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 Orthodontics/MixedDentition

or more teeth involved. The purpose of incisors usually erupt around the age of six management of ectopic maxillary canines
treatment is usually to expand the maxillary to seven years, and prior to the eruption looking at the effect on the position of the
arch, to correct the crossbite, and eliminate of maxillary permanent lateral incisors. canine following creating space.18−21 Despite
the mandibular displacement, as the aetiology Any delay in eruption or abnormality in these studies having some methodological
is normally due to a narrow maxillary arch. eruption sequence should be viewed with flaws, they suggest that space creation
A Cochrane review entitled ‘Orthodontic suspicion and investigated. The two main increases the chance of eruption of the canine.
treatment for posterior crossbites’8 found that causes for non-eruption of the permanent Two further studies have
grinding of primary teeth to remove occlusal incisors are trauma to the primary dentition, examined the idea of space creation and the
interferences or the provision of a quadhelix or supernumerary teeth blocking the path effect of extraction of the primary canine plus
to provide maxillary arch expansion are of eruption for the permanent teeth.11 It is primary first molar, compared with extraction
effective treatment options. emphasized that radiographic examinations of only the primary canine.22,23 Both of these
Since the publication of this of all children who present clinically with studies appear to support the favourable
review, Petrén and co-workers9 have evidence of delayed permanent tooth effect of space creation in facilitating the
conducted a Randomized Controlled Trial eruption, or temporary tooth displacement eruption of the canine, but fail to mention any
(RCT). They concluded that, if unilateral (with or without a history of trauma), should long-term effect this has on crowding or any
posterior crossbite is planned to be corrected be performed.12 child-centred outcomes.
in the mixed dentition, treatment with a The Royal College of Surgeons
quadhelix is a more successful and quicker of England (RCSEng) has published Recommendations
method of treatment than an Upper guidelines on the management of unerupted Consider creating space in the
Removable Appliance (URA) expansion plate. maxillary incisors,13 which are summarized mixed dentition for the ectopic canine to
The same authors have since published three- in Table 1. These are based on the available increase its chance of eruption, whether that is
year follow-up results,10 and have shown that evidence, which consist of no controlled by primary extractions, or by arch expansion,
there is similar long-term stability regardless trials, 23 retrospective case studies and or a combination of both.
of appliance type. 4 epidemiological studies, and other low
grade evidence. Nonetheless, they give a
Recommendations recommendation for management of the First permanent molars with
Although a quadhelix appliance child, and are clearly divided into different poor prognosis
(Figure 3) corrects a posterior crossbite more stages of development of the central incisor.
First Permanent Molars (FPMs)
quickly in the mixed dentition, a URA provides It is also important to stress the importance
have the poorest long-term prognosis of all
an equally stable method. In selected cases, of maintaining space, awaiting the eruption
permanent teeth owing to their susceptibility
the crossbite may be eliminated through of the central incisor, following the loss of the
to caries in childhood, and their association
careful grinding of the primary canines. primary central incisor, something that is not
with Molar Incisor Hypomineralization
obvious from the guidelines.
(MIH).24,25 Ideal timing of extraction of FPMs
with poor prognosis can lead to an acceptable
Impacted maxillary permanent Recommendations occlusion, 26,27 with successful mesial migration
central incisors Follow RCS Guidelines (see Table 1). of the second permanent molars.
Maxillary permanent central The national guidance document,
produced by the RCSEng, assists with
Palatally ectopic maxillary treatment planning when considering
permanent canines extraction of FPMs in children.28 It stresses
The aetiology of impacted the importance of timing of the extraction of
maxillary permanent canines appears to the lower FPM, with the timing of the upper
be multifactorial, including links to small or extractions being less crucial. It is advocated
Figure 2. A ‘2 x 4’ appliance. developmentally absent lateral incisors,14 that the lower FPM should ideally be extracted
family history,15 and Class II division 2 when there is radiographic evidence of early
malocclusion.16 dentine calcification within the second molar
A Cochrane review investigating root bifurcation, usually occurring in children
the effect of extraction of primary canines on around 8−10 years.27,29
ectopic permanent canines17 identified two These guidelines discuss
RCTs. It stated that there is ‘a suggestion from compensating extractions, and recommend
the literature that extraction of the primary extraction of the upper FPM if extraction
canine may help eruption of the permanent of the lower FPM is required in Class I
canine.’ malocclusions to prevent the theoretical
Since the publication of the risk of the upper FPM overerupting and
Cochrane review, there have been several preventing the lower second molar from
Figure 3. A quadhelix. studies investigating the interceptive drifting forward. The work by Holm30 is

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 Orthodontics/MixedDentition

Age of child/Stage of development of incisor Recommendation

Children up to nine years of age with incomplete root  Remove the obstruction;
development of permanent incisor  Do not uncover bone from the unerupted incisor − maintain
integrity of the follicle;
 Create space if required;
 Monitor eruption for 18 months (80% erupt spontaneously);
 If exposure is required, expose minimally to eliminate soft tissue
obstruction;
 If the tooth is still high, expose and bond bracket.

Children above nine years of age, with complete or nearly  Remove the obstruction;
complete apex  Create space if required;
 If the permanent incisor is high monitor eruption for 12
months;
 If the tooth is still unerupted at 12 months, expose and bond
bracket as required.

Children referred late (over 10 years of age)  Remove the obstruction, expose and bond bracket at first
operation.

Table 1. RCSEng Guidelines on unerupted maxillary incisors.

used as the main source for supporting Infra-occluded second primary and the root resorption was found to be very
compensating extractions. He reviewed molars slow, especially after 12−13 years of age.36
1,119 cases involving loss of one or more The term infra-occluded
FPMs over a 10-year period, and assessed describes a tooth when it is situated below Recommendations
the proportion of cases involving loss the occlusal plane and, commonly, the term These are shown in Table 2.
of FPMs, and the patterns of extraction. ‘submerged’ has been used. Infraocclusion
He reported that the poorest outcomes can occur whether or not there is a
following orthodontic treatment were developing premolar. One recent study Malocclusion due to non-
found in cases of uncompensated extraction indicated that infra-occluded deciduous nutritive sucking habits
of lower FPMs, but there were no data second molars could be an early marker for The term ‘non-nutritive sucking
presented to support this. other dental anomalies, such as palatally habit’ (NNSH) encompasses the use of
More recently, Mejàre et al31 displaced canines and tooth agenesis, pacifiers (dummies/soothers), blankets and
have reviewed 32 patients who had lost both known to have a strong genetic digit sucking. Children with a history of a
one or more FPMs in childhood due to component.34 persistent NNSH are more likely to develop
MIH. Five patients had an uncompensated Ideally, waiting for exfoliation a malocclusion compared to children with
extraction of a lower FPM, and no-one had of the primary molar is the best treatment, no NNSH history.37−40 In addition, there
over eruption of the upper FPM noted. as early extraction can lead to space loss is evidence that the more prolonged the
Jälevik and Möller,32 in a longitudinal study, in the arch, but not all infra-occluded duration of the habit, the more severe the
reported no significant occlusal problems in molars exfoliate naturally. In a longitudinal developing malocclusion tends to be.41−43 If
children with uncompensated extractions of study35 looking at both upper and lower these problems are not diagnosed until the
lower FPMs, and recommended against the infraoccluded molars, 149 were monitored, patient is in the permanent dentition, it can
need for compensating extractions. and five required extraction. It concluded be complex, time-consuming and costly to
An RCT is currently underway in that extraction should only be performed correct the problem and, in severe cases, it
Scotland to answer the question of the need if there is deep infraocclusion, severe can even require orthognathic surgery to
to perform a compensating extraction when tipping of adjacent teeth and space loss correct the anterior openbite. There are six
extracting a lower FPM, and the protocol has has already occurred. Also recommended RCTs reporting on a range of interventions44−49
been published.33 was using the time of exfoliation on the for cessation of digit sucking. They show the
‘normal’ side of the arch as a guide. In a following treatments to be successful:
Recommendation separate study, where there was aplasia of  Psychological treatment, in the form of
Follow RCS guidelines until the successor, the infra-occluded tooth did positive reinforcement;
further evidence available. not exfoliate within the normal time range,  Aversive taste treatment, applied to the

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 Orthodontics/MixedDentition

Permanent successor? Recommendation

YES Likely that primary molar will exfoliate naturally (extraction not
usually necessary). But monitor and if below the contact point
consider extraction, particularly if there is tipping of adjacent teeth.

NO and primary molar submerging If only 1−2 mm below occlusal plane, monitor, consider occlusal
build-up. If below the contact point consider extraction,
particularly if there is tipping of adjacent teeth.

NO and no primary molar submergence If good root length and unrestored, consider long-term
maintenance. If poor long-term prognosis, consider extraction of
primary molar, but seek orthodontic opinion first as it may not be
possible to close resulting space fully.
Table 2. Management of infra-occluded primary second molars.

digit; and centrelines in many unilateral extraction cases The review identified and included eight
 The provision of a fixed habit-breaker spontaneously correct.52 Another study showed trials. From the evidence, it would appear
appliance. that, in a non-extraction group of children, a that providing early orthodontic treatment
All 11 patients who received a fixed centreline discrepancy was noted in 17% of for children with prominent upper front teeth
habit-breaker stopped sucking their thumb. them.53 A further study aimed to quantify the (a functional appliance), then providing the
effect of unilateral extraction of primary molars second phase of treatment (fixed appliances),
on the position of the incisor centreline.54 The when in the permanent dentition, is no more
Recommendation
results showed that the degree of centreline of an effective treatment than providing
A fixed habit-breaker is the most
shift was statistically significantly different one course of orthodontic treatment when
effective treatment option for stopping
between the balanced and unbalanced the child is in early adolescence (functional
persistent thumb-sucking habits where
extraction groups, and also between the appliance followed by fixed appliances). One
behaviour management techniques have
unbalanced and no extraction groups. This of the included studies showed that, at the
been unsuccessful.
study supports the theory of balancing start of the trial, 29.1% of the patients had
extractions, however, the evidence supporting already had some incisor trauma. During the
balancing primary molar and canine trial, there was an increase in trauma in all
Centreline loss due to unilateral extractions appears to be of poor quality. three groups (a control group and two groups
loss of primary teeth receiving functional appliances), but this was
The loss of the maxillary dental Recommendation not significantly greater in the control group,
centreline can have aesthetic consequences, If one primary canine is lost early for which treatment was delayed until the
and work by Johnston et al has shown that (and the contralateral canine is firm), it is permanent dentition.
lay people notice a maxillary centreline appropriate to extract the other to prevent One circumstance which may
shift of 2 mm or more.50 It is difficult once the potential for centreline shift. encourage early intervention, for a patient with
in the permanent dentition to correct a a large overjet, is when he/she is being teased.
centreline discrepancy, with often a unilateral The literature has shown that early treatment
extraction required to create space. It has Increased overjet with Twin block appliances resulted in an
been suggested that loss of centreline can be Åltun et al reported that children increase in self-confidence and a reduction of
prevented by extraction of the contralateral with an increased overjet are more than twice negative social experiences.58 Other studies
primary canine, around the time of loss of the as likely to have dental injuries than other have shown this link between increased overjet
first primary canine. children, with the incidence of traumatic and teasing/low self-esteem.59,60 The literature
The literature surrounding this dental injury highest among children aged supports the use of sports mouthguards for
topic is sparse. One paper reports that, out of six, and aged eight to ten years.55 Increased preventing trauma, particularly in patients with
approximately 200 children, 26 had a primary overjet and inadequate lip coverage increases an increased overjet, and a detailed review of
canine exfoliate due to the erupting lateral the risk and severity of incisor trauma.56 the literature61 also recommends custom-made
incisor.51 Centreline loss occurred in all of these A Cochrane review has been mouthguards rather than shop bought ones.
patients, and 25 had a delayed balancing conducted with the aim being to assess
extraction of the remaining primary canine. the effectiveness of orthodontic treatment
Nine of the patients still had a centreline shift in for prominent upper front teeth in two age Recommendation
adulthood. groups; when the child is aged seven to nine, Children with an increased overjet
One study has shown that or when he/she is in early adolescence.57 are at increased risk of dental trauma and

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 Orthodontics/MixedDentition

should be provided with a custom-made Heikinheimo KAK. Orthodontic treatment correction in the mixed dentition: a
sports mouthguard. Although orthodontic need from eight to 12 years of age in an randomized clinical trial with a 3-year
treatment can reduce the overjet, this is best early treatment oriented public health follow-up. Am J Orthod Dentofacial Orthop
started during early adolescence, unless the care system: a prospective study. Angle 2011; 139(1): e73−e81.
patient is being teased, where consideration Orthod 2005; 75(3): 344−349. 11. Johnsen DC. Prevalence of delayed
should be given for early treatment. 5. Jolley CJ, Huang GJ, Greenlee GM, emergence of permanent teeth as a
Spiekerman C, Kiyak HA, King GJ. Dental result of local factors. J Am Dent Assoc
effects of interceptive orthodontic 1977; 94(1): 100−106.
Summary of recommendations treatment in a Medicaid population: 12. Batra P, Duggal R, Kharbanda OP, Parkash
Having reviewed the often limited interim results from a randomized clinical H. Orthodontic treatment of impacted
literature for the range of malocclusions trial. Am J Orthod Dentofacial Orthop anterior teeth due to odontomas: a
where interceptive treatment is considered, 2010; 137(3): 324−333. report of two cases. J Clin Pediatric Dent
it has been possible to make clinical 6. Al Nimri K, Richardson A. Interceptive 2004; 28(4): 289−294.
recommendations. These are summarized in orthodontics in the real world of 13. Yaqoob O, O’Neill J, Gregg T, Noar J,
Table 3. community dentistry. Int J Paediatric Dent Cobourne M, Morris D. Management
2000; 10(2): 99−108. of unerupted maxillary incisors. Royal
7. Borrie F, Bearn D. Early correction of College of Surgeons of England,
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Condition Recommended Treatment

Anterior crossbites Modification to upper or lower incisor edges or’2 x 4’ fixed appliance
Posterior crossbites URA with expansion screw or a quadhelix
Impacted upper central incisors Maintain space for unerupted incisor
Follow RCSEng Guidelines (Table 1)
Ectopic maxillary permanent canines Consider space creation
Poor quality first permanent molars Refer to RCSEng Guidelines and/or seek a specialist opinion
Infra-occluded primary molar teeth Establish whether permanent successor present
Follow recommendations in Table 2
Non-nutritive sucking habits Advise parents on the use of positive reinforcement techniques,
and ‘paint’ for thumb
If unsuccessful, consider provision of a fixed habit-breaker
appliance

Unilateral loss of primary canines Extraction of remaining contralateral primary canine

Increased overjet and associated risk of trauma Provide a custom-made mouthguard where necessary and refer
patient to specialist once in permanent dentition
If teasing occurring consider early referral
Table 3. Recommendations for practice.

July/August 2013 DentalUpdate 447

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 Orthodontics/MixedDentition

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