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CLINICAL

PRACTICE

MANAGEMENT OF SPACE PROBLEMS IN THE PRIMARY AND MIXED DENTITIONS


PETER NGAN, D.M.D.; RANDY G. ALKIRE, D.D.S., M.S.; HENRY FIELDS JR., D.D.S., M.S., M.S.D.

Background. According to the Third National Health and Nutrition Examination Survey, crowding and irregularity remain a consistent problem for children. Management of space problems continues to play an important role in a dental practice. It also represents an area of major interaction between the primary provider and the specialists. This article attempts to update clinicians on the current knowledge of space management. Description of Condition. Proper management of space in the primary and mixed dentitions can prevent unnecessary loss in arch length. Diagnosing and treating space problems requires an understanding of the etiology of crowding and the development of the dentition to render treatment for the mild, moderate and severe crowding cases. Most crowding problems with less than 4.5 millimeters can be resolved through preservation of the leeway space,

regaining space or limited expansion in the late mixed dentition. In cases with 5 to 9 mm of crowding, some can be approached with expansion after thorough diagnosis and treatment planning. Most of these cases will require extraction of permanent teeth to preserve facial esthetics and the integrity of the supporting soft tissue. Serial extraction or guidance of eruption is reserved for treatment of severe tooth-size/arch-size discrepancies. Due to variations in the timing and extraction sequence depending on the diagnosis, serial extraction should be reserved for those who can complete the treatment successfully. Clinical Implications. The recommended timing of referring patients with moderate crowding to specialists for treatment is in the late mixed-dentition stage of development. Patients with severe crowding will require earlier evaluation for serial extraction.

Crowding and irregularity are the most preva-

lent components of a malocclusion in dental patients. Surveys conducted by the U.S. Public Health Service in the 1960s1,2 found in a sample of 8,000 that 40 percent of children (aged 6 to 11 years) and 85 percent of youths (aged 12 to 17 years) have crowding problems. The data from the Third National Health and Nutrition Examination Survey, or NHANES III,3 which was conducted by the National Center for Health Statistics from 1988 to 1991, also indicate that crowding and irregularity remain a consistent problem for children and adults. Space management is an area of major interaction between primary dental care providers and specialists. A recent survey of general dentists in
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Ohio4 found that 77 percent performed space maintenance and 32 percent incorporated some form of interceptive orthodontics into their practice. On the other hand, a survey of the orthodontists in the same state found that only 63 percent felt that general dentists were referring patients to their offices at the appropriate age for evaluation.4 The remaining 37 percent felt that patients were referred too late. Diagnosing space problems and treating cases of mild, moderate and severe crowding requires an understanding of the etiology of crowding and of the development of the dentition. This article attempts to update clinicians on the current knowledge of space management. Proper space management in the primary and mixed dentitions

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CLINICAL PRACTICE
can prevent unnecessary loss in arch length.
CROWDING: DEFINITION AND ETIOLOGY

SIGNS OF A TRUE HEREDITARY TOOTH-SIZE/ JAW-SIZE DISCREPANCY.*


dMaxillary mandibular alveolodental protrusion without interproximal spacing dCrowded mandibular incisor teeth dA midline displacement of the permanent mandibular incisors, resulting in the premature exfoliation of the primary canine on the crowded side dA midline displacement of the permanent mandibular incisors with the lateral incisors on the crowded side blocked out, usually lingually but occasionally labially dA crescent area of external resorption on the mesial aspect of the roots of the primary canines, caused by crowded permanent lateral incisors dBilateral primary mandibular canine exfoliation, resulting in an uprighting of the permanent mandibular incisors; this, in turn, increases the overjet, the overbite or both dA splaying out of the permanent maxillary or mandibular incisor teeth due to the crowded position of the unerupted canines dGingival recession on the labial surface of the prominent mandibular incisor dEctopic eruption of the permanent maxillary first molars, which indicates a lack of development in the tuberosity area and results in the premature exfoliation of the primary second molars dA vertical palisading of the permanent maxillary first, second and third molars in the tuberosity area * Based on information in Dale.8

Definition. The problem of crowding has been broken down into two categories: simple and complex.5 Simple crowding is defined as disharmony between the size of the teeth and the space available in the alveolus with no skeletal, muscular, or occlusal functional features. It is most frequently associated with a Class I malocclusion, although it may be found with Class II malocclusions with maxillary dental protrusion and a normal skeletal pattern.5 Complex crowding is defined as crowding caused by skeletal imbalance, abnormal lip and tongue functioning, and/or occlusal dysfunction as well as disharmony between the sizes of the teeth and the available space.5 Fields6 categorized crowding as an alignment problem based on the amount of crowding. Etiology. The exact cause of crowding or malocclusion in general is unknown. Several researchers have suggested that the problem is hereditary and is associated with the evolutionary development of modern humans.7 These investigators attributed the main cause of crowding to a progressive reduction in the jaw size as compared with tooth size. Another author8 believed there are true signs of hereditary and environmentally induced tooth-size/jaw-size discrepancyas indicated in the boxes Signs of a True Hereditary Tooth-Size/Jaw-Size Discrepancy and Environmental Factors Causing Crowding. Given the size of these lists, the etiology of crowding must be

ENVIRONMENTAL FACTORS CAUSING CROWDING.*


dAn aberration in the eruptive pattern and sequence of the permanent teeth dTransposition of teeth dUneven resorption of primary teeth dPremature loss of primary teeth, resulting in the reduction of arch length due to subsequent drifting of permanent teeth dReduction of arch length due to interproximal caries in the primary teeth dProlonged retention of primary teeth * Based on information in Dale.8

considered multifactorial.
DEVELOPMENT OF THE DENTITION

Primary dentition. In a

classic article, Baume9 found that the primary dentition can be either spaced or closed. Primary spacing, according to Baume, occurs in the maxilla in
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CLINICAL PRACTICE
permanent molars does not change appreciably during the primary-dentition period. Mixed dentition. In a longitudinal study, Moorrees and Reed11 found that arch length decreases 2 to 3 mm between the ages of 10 and 14 years, when primary molars are replaced by permanent premolars. These authors also found a reduction in arch circumference of approximately 3.5 mm in the mandible in boys and 4.5 mm in girls during the mixed-dentition period. If crowding is evident in the early mixed-dentition years, it will not improve with further growth and development. Mesial shift. In patients with a spaced primary dentition and a flush or straight terminal plane, the eruption of the permanent mandibular first molars at approximately 6 years of age closes the space distal to the primary canines (primate space) and transforms the molar relationship into a Class I relationship. This has been referred to as early mesial shift.9 In patients with a closed primary dentition (no primate space) and a straight terminal plane, the transformation into a Class I molar relationship may not occur until the exfoliation of the primary molars. At approximately 11 years of age, the permanent first molars migrate forward to close up the excess leeway space provided by the difference in size between the primary molars and the succedaneous premolars (Figure 1). This has been called late mesial shift.9 The transformation into a Class I molar relationship depends on a number of dental and facial skeletal changes, both genetic and environmental, that interact to achieve (or not achieve) a normal occlusion. Several factors may prevent the establishment of a normal posterior occlusion. Extensive interproximal caries or ectopic eruption of the maxillary first molars may result in premature loss of primary second molars and a subsequent loss of arch length. Periapical pathology of primary teeth may hasten the eruption of their permanent successors. Tumors and supernumerary teeth may impede the course of eruption. Prolonged retention of primary teeth may disturb the eruption sequence. Leeway space. The difference in size between the primary molars and the succedaneous premolars is termed leeway space. This varies greatly from person to person, according to a longitudinal study by Bishara and colleagues.12 The average leeway space in that study was 2.2 mm (1.1 mm per side) in the maxilla and 4.8 mm (2.4 mm per side) in the mandible. The differences in the leeway spaces between the maxillary and mandibular arches were 1.3 mm for male subjects and 1.1 mm for female subjects. The range in the amount of leeway space between people is quite remarkable and can exceed the above amounts. Incisor liability. The size differential between the primary and permanent incisors is called incisor liability. In the anterior segment, the four permanent maxillary incisor teeth are, on average, 7.6 mm larger than the primary incisors. In the mandibular arch, the permanent incisors are 6.0 mm larger than the corresponding primary teeth.13 Incisor liability varies greatly from person to person. The spacing of the primary

Figure 1. Late mesial shift: the permanent first molars migrate forward and close up the excess leeway space. Leeway space is the difference in the mesiodistal dimension of the teeth in the molar area from the primary to the permanent dentition.

70 percent of children and in the mandible in 63 percent of children. The intercanine distance is 1.7 millimeters and 1.5 mm more in spaced dentitions than in closed dentitions, respectively in the maxillas and mandibles. A primary dentition without spacing is followed by crowding in approximately 40 percent of cases. Contrary to a widely held misconception, arch length is reduced after the premature loss of the primary incisor.9 This is particularly true if the incisor is lost very early. It is also true if there is no primary spacing in the dentition, if there is a tendency toward a Class II molar relationship, or if the incisors have a deep overbite relationship. Overbite is related to the growth of the jaws and to the rate of eruption of the incisor teeth. It decreases from the primary to the permanent dentition in only 10 percent of cases; it remains unchanged in 43 percent of cases and increases in 47 percent of cases.10 The arch dimension anterior to the first
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CLINICAL PRACTICE
anterior teeth; lateral and even possibly distal shifting of the primary canines; and facial positioning of the incisors all contribute to the incisor liability. All of these factors will increase the arch perimeter and help the mouth accommodate the larger permanent teeth. Eruption sequence. In a study by Lo and Moyers,14 the most favorable sequence of eruption to obtain a normal molar relationship was as follows: first molar, central incisor, lateral incisor, first premolar, second premolar, canine, second molar in the maxilla and first molar, central incisor, lateral incisor, canine, first premolar, second premolar, second molar in the mandible. The most unfavorable sequence in the maxilla was that in which second molar erupted earlier than either the premolars. The most unfavorable sequence in the mandible was that in which the canines erupted later than the premolars.
DIAGNOSIS OF CROWDING PROBLEMS

Diagnosis of crowding problems should take into account any jaw discrepancies, muscle imbalance and the environmental influences listed in the Box, Environmental Factors Causing Crowding. The amount of intraarch crowding can be calculated in part by performing one of several space analyses. Conventional space analysis. The conventional or canine space analysis was first proposed by Nance in 1947.15 This analysis consists of comparing the amount of space available for the alignment of the teeth to the amount of space required for proper alignment. dThe space available is estimated by measuring the arch

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Figure 2. Pretreatment photographs of a 4-year-old patient with premature loss of primary maxillary incisors and unrestorable teeth nos. B, I, L and S. A. Anterior view. B. Maxillary occlusal view. C. Mandibular occlusal view.

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CLINICAL PRACTICE
perimeter from the mesial contact of the permanent first molar from one side of the dental arch to the mesial contact of the permanent first molar on the opposite side of the dental arch. This can be accomplished either by separating the dental arch into segments that can be measured as straight-line approximations of the arch or by contouring a piece of wire to the line of occlusion and then straightening out the wire for measurement. dThe space required is the summation of the mesiodistal widths of the erupted mandibular permanent incisors and the estimated mesiodistal widths of the unerupted permanent canines and premolars. The size of the unerupted permanent teeth can be estimated using one of the following methods: measuring the teeth on a radiograph and adjusting for the magnification by use of a simple proportional relationship16; estimating the size of the unerupted teeth from a prediction table; or using a combination of both methods. Tanaka and Johnston analysis. The Tanaka and Johnston method17 is recommendable as a predictive technique because it has reasonable accuracy, does not require radiographs, requires no prediction tables and predicts the sizes of the unerupted permanent canines and premolars in maxillary and mandibular teeth. The Tanaka and Johnston analysis is completed by taking one-half of the mesiodistal widths of the four lower incisors and adding 10.5 mm, which is equal to the estimated width of the mandibular canines and premolars in one quadrant. Also, one-half of the

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Figure 3. Posttreatment photographs of the same patient shown in Figure 2. Teeth nos. B, I, L and S were extracted. Maxillary Nance appliance with prosthesis and mandibular band and loop appliances with occlusal rest on the canines were used for space maintenance. A. Anterior view. B. Maxillary occlusal view. C. Mandibular occlusal view.

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CLINICAL PRACTICE
mesiodistal width of the four lower incisors plus 11.0 mm equals the estimated width of the maxillary canine and premolar in one quadrant. However, one must be cautioned that neither conventional space analysis nor the Tanaka and Johnston method takes into account the axial inclination of the mandibular anterior teeth, the effects of the curve of Spee, innate prediction bias, ethnic group biases or facial profile, all of which can affect the amount of crowding and space required in the analyses. The total space analysis developed by Merrifield18 took into account the tooth measurement, cephalometric correction and softtissue modification. This method also indicated the exact area (anterior, middle or posterior) where the crowding occurred. The severity of space problems can be categorized into mild crowding (space shortage of less than 2 mm), moderate crowding (space shortage of 2 to 4 mm), severe crowding (space shortage of 5 to 9 mm) and extremely severe crowding (space shortage of 10 mm or more).
MANAGEMENT OF MILD CROWDING PROBLEMS

Figure 4. A distal shoe space maintenance appliance for early loss of a second primary molar before the eruption of the permanent first molar. A stainless steel crown is fitted on the primary first molar. A stainless steel extension is soldered to the crown and extended to the former distal contact of the primary second molar to guide the eruption of the permanent first molar.

Space maintenance. Early loss of primary teeth is most commonly attributable to caries.19,20 Caries, if left untreated, will lead to loss in arch length. Space maintenance is indicated when there is a loss of one or more primary teeth, there is no loss in arch perimeter and there is a favorable prediction from the space analysis if it can be completed. Early loss of a primary incisor as a result of caries or trauma usually results in very little change in the dentition. Space mainte-

nance is not necessary unless esthetic concerns warrant the replacement. If one or more primary anterior teeth are lost prematurely, the teeth can be replaced using either a removable or fixed partial denture. The fixed partial denture actually is a lingual arch with prosthetic teeth attached (Figures 2 and 3). Premature loss of primary canines. Premature loss of primary canines in the mandibular arch usually is a result of large succedaneous permanent incisors and ectopic eruption. A lateral shift of the incisor teeth usually accompanies the loss of the primary canine, resulting in a midline discrepancy. A fixed lingual holding arch with soldered spurs can be used to maintain arch integrity and prevent lingual tipping of the mandibular incisors. Early loss of primary first molars. Early loss of primary first molars can cause distal drifting of the primary canine if the loss occurs during the active

eruption of the permanent lateral incisors. Early loss of primary second molars is a problem because these teeth serve as a guide for the erupting permanent first molars. Early loss of a primary second molar, especially in the maxillary arch, results in arch length reduction due to mesial migration of permanent molars.21,22 If the first permanent molar has fully erupted, then a band and loop can be placed on either the first permanent molar running mesial to the primary first molar or on the primary first molar running distal to the mesial aspect of the first permanent molar. A distal shoe appliance should be used if the primary second molar is lost before the permanent first molar erupts (Figure 4). There are, however, some drawbacks to the use of this appliance.23 These complications include difficulty in the accurate construction of the appliance, the presence of a constant foreign body in a sensitive area in the mouth, and a pos1335

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CLINICAL PRACTICE
exhibits resorption of the distobuccal root. In most instances, these primary molars can last until normal exfoliation. For ectopic molars that are not selfcorrecting, some type of intervention is warranted. When the impacted molar is clinically accessible, some type of separation can be used for disimpaction.25,26 With reciprocal anchorage, either a brass wire, a spring-type deimpactor or an elastic separator can be used. When the degree of impaction or inaccessibility of the first permanent molar prevents separation, active appliance therapy can be used to disimpact the tooth.27 The appliance consists of a band cemented to the second primary molar with an active spring or arm soldered to the band. The arm extends distally and bonds to the occlusal surface of the permanent first molar (Figure 5). The arm is activated every three or four weeks using a three-prong plier or optical plier until the ectopically erupted molar has cleared the distal surface of the primary second molar, as seen in radiographs. Alternatively, a wire extension can be soldered to the primary molar band and an elastomeric chain is used for distal traction to disimpact the permanent first molar. When the resorption on the distal surface of the primary molar is extensive, the amount of entrapment of the first permanent molar may approach onehalf of the clinical crown. Resorption may extend into the pulp of the primary molar, and the tooth may be mobile. In these cases, the tooth should be extracted and a plan for regaining space should be formulated. Use of leeway space to resolve transient crowding. There are situations in which, on arch length analysis, there is no space deficiency but the permanent incisors are crowded, sometimes to an extent greater than 2 mm. This is usually the result of large permanent incisors and primary molars in combination with small premolars. Moorrees and colleagues,28 Moorrees and Chadha29 and Baume30 found that up to 2 mm of incisor crowding may resolve spontaneously with no treatment required. In children whose succedaneous premolars are smaller than the primary molars they replace, the leeway space can be used to unravel anterior crowding by maintaining the arch length. A study by Gianelly31 showed that crowding of 4.5 mm could be resolved without active treatment in 77 percent of cases if leeway space was used. Methods such as disking of the primary incisors or extracting the primary canines are reserved for situations in which the permanent mandibular incisors are severely crowded. If either of these methods is used for crowded arches and the leeway space is used to relieve the crowding, adjustment of the molar relationships may require subsequent use of headgear or interarch elastics.
MANAGEMENT OF MODERATE CROWDING PROBLEMS

Figure 5. Active appliance therapy to disimpact ectopically erupted permanent first molar. An orthodontic band is cemented on the primary second molar and an active arm soldered to the band. The arm extends distally and bonds to the occlusal surface of the permanent first molar. A three-prong plier is used to activate the arm until the ectopically erupted molar clears the distal surface of the primary molar.

sible route of infection between intraoral and submucosal areas. If multiple primary posterior teeth are missing, the distal shoe should be incorporated in a removable partial denture. Ectopically erupted permanent first molars. The permanent maxillary first molars may erupt ectopically underneath the distal surface of the primary second molars, causing pathological resorption of the roots.24 This path of ectopic eruption leads to loss of arch length and should be monitored for major arch length deficiency or be treated as needed. Spontaneous self-correction of the impacted first permanent molar occurs in 66 percent of cases. In these cases, the second primary molar
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Moderate crowding problems usually are the result of an inherent lack of space or a loss of space. In the maxillary arch, early space loss usually is manifested as mesial tipping or mesial-lingual rotation32 of the permanent first molars. Space can be regained or expanded by

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CLINICAL PRACTICE
and mandibular arches or extraction of primary and, ultimately, permanent teeth may be the only possible method of reducing the discrepancy between tooth mass and arch length. Maxillary expansion could be orthodontic or orthopedic in nature. Orthodontic expansion involves lateral movement of teeth in alveolar bone. Orthopedic expansion involves the movement of basal bone such as the palatal halves of the maxilla. One study shows that every millimeter of transpalatal width increase in the premolar region, created with the use of a rapid palatal expansion appliance, produces a 0.7-mm increase in available arch perimeter.39 However, the ability of this treatment modality to reduce the need for extraction of permanent teeth remains controversial. One reason is the lack of welldesigned long-term studies of the stability of maxillary expansion. Most of the published long-term studies are case reports lacking comparison with control groups.40-42 The possibility of expansion in the mandibular arch also is limited because of the lack of a midline suture and the need for surgical intervention. Space supervision may be an alternative method of guiding the eruption of permanent teeth in a crowded situation. However, the goal of space supervision is in keeping with Stemms43 recommendation of timely extractions, a sequence of extracting primary teeth but not permanent teeth. The goal of this approach is to squeeze all permanent teeth into minimal space. The indications, timing and sequence for timed extractions are presented in an article
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Figure 6. Molar distalization in the maxillary arch using a Nance appliance as anchorage and a segmental arch wire with a nickel-titanium coil spring.

distal tipping or bodily distalization of the permanent first molars. Regaining space is easier in the maxillary arch because of the increased anchorage afforded by the palate. A transpalatal arch can be used to correct molar rotations and a certain degree of distal molar movement. Cetlin and Ten Hoeve33 showed a high degree of success in regaining space using a removable appliance in combination with headgear. In the late mixed dentition after the upper premolars have erupted, a Nance appliance may be banded or bonded to the premolars as anchorage. Maxillary molars can be distalized using several appliances such as the pendulum appliance,34 Jones Jig (American Orthodontics Corp.)35 or nickel-titanium, open-coil springs.36 Most of these appliances are supported by a Nancetype lingual arch to obtain palatal anchorage (Figure 6). Space can be regained or expanded in the mandibular arch using a lip bumper if the space loss is bilateral.37 This appliance functions by tipping

the lower molars distally while at the same time removing lip pressure from the lower incisors. It provides forward movement of the lower incisors due to increased tongue pressure. Unilateral space loss may be corrected by using a removable lingual holding arch. The lingual arch has a loop that, if opened, places a distal force on the lower first molars. Alternatively, a lingual arch that supports a segmental arch wire and a coil spring to the mesially drifted permanent molar (a variant of the maxillary segmental appliance supported by a Nance arch) can be used. A Schwarz appliance may be used if crowding is up to 3 mm in the lower anterior region and there is a significant amount of lingual tipping of the posterior molars.38
MANAGEMENT OF SEVERE CROWDING PROBLEMS

The decision whether to regain space or resign oneself to extraction is a difficult one. When crowding problems are severe, expansion of maxillary

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by Musselman and Chadha.44
MANAGEMENT OF EXTREMELY SEVERE CROWDING PROBLEMS

In the case of space shortages of 10 mm or more, there is no doubt that the size of the permanent teeth when compared with the amount of space available indicates a deficiency significant enough to warrant extraction of permanent teeth. Serial extraction45 or guidance of eruption46 involves the sequential removal of primary and, ultimately, permanent teeth to resolve toothsize/arch-length problems. In serial extraction, a sequence of extractions begun in the early mixed dentition eventually culminates in the extraction of the permanent first premolars, with the goal of the distal movement of the canine and general alleviation of tooth-size/arch-length discrepancy. The decision to extract maxillary and mandibular first or second premolars is made early, depending on the type of malocclusion. Many articles have been written about serial extraction since its inception in the 1930s in Europe.47-52 Dale8 provided a detailed discussion on the subject of serial extraction for both Class I and Class II occlusions. The timing of extractions should be based on the stage of development of the erupting permanent tooth and should coincide with its phase of active eruption. Fanning49 found that the rate of formation of the permanent premolar did not change after the extraction of its primary precursor. However, an immediate eruption spurt occurred following extraction of the primary molar regardless of its stage of development and the age of the child.52 The findings of
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Fanning49coupled with those of Gron,50 who found that premolars emerge when one-half to three-quarters of their roots are formedprovided good guidelines for the timing of tooth removal during serial extraction. The ideal guidelines for serial extractions are as follows: dabsence of skeletal discrepancies; dlarge (greater than 10 mm) arch-length deficiency; dnormal overbite; d(usually) Class I malocclusion; da commitment on the practitioners part to finishing the case. Ideally, the extraction sequence begins with removal of the primary canines as the permanent lateral incisors erupt. Then, the primary first molars are extracted to speed the eruption of the first premolars. Next, the permanent first premolars are removed to allow the permanent canines to erupt in the first premolar space. As mentioned earlier, there are variations in the timing and sequence of extractions, depending on the diagnosis. Mayne51 stated that diagnosis in the mixed dentition is the clinicians most challenging task and that serial extraction should be practiced only by those who could complete the treatment successfully.
TIMING OF TREATMENT TO RESOLVE CROWDING

would have adequate space if a lip bumper was used to move the mandibular first molars 1 mm distally. Even if extraction treatment is necessary at that time, the permanent first premolars are available for extraction. Gianelly concluded that late mixed-dentition stage of development is a favorable time to start treatment to resolve crowding. It is recommended, therefore, that patients with moderate crowding be referred to specialists for treatment if they are in a later stage of development than the late mixed-dentition stage. Patients with severe crowding will require earlier evaluation to determine if serial extraction is an appropriate treatment.
CONCLUSIONS

Gianelly31 examined 100 patients in the mixed-dentition stage of development to determine the incidence and quantity of incisor crowding. He found that 77 percent of the patients would have adequate space to accommodate an aligned dentition if leeway space was preserved; 84 percent

Management of space problems continues to play an important role in a dental practice. An understanding of the dental development in the primary and mixed dentitions can help in deciding when and how to intercept the malocclusion if crowding is detected. Space maintenance in the developing dentition can prevent unnecessary loss in arch length. Most of the crowding problems caused by a space shortage of less than 4.5 mm can be resolved starting in the late mixed-dentition stage by preserving the leeway space, regaining space or accomplishing limited expansion. In cases with 5 to 9 mm of space shortage, maxillary expansion can be attempted after thorough diagnosis and treatment planning. Most of these cases will require extraction of permanent teeth to preserve facial esthetics and the integrity of the supporting soft tissue. Serial extraction or guidance of eruption is

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CLINICAL PRACTICE
reserved for treatment of severe tooth-size/arch-size discrepancy. Due to the variations in the timing and extraction sequence depending on the diagnosis, serial extraction should be practiced only by those who can complete the treatment successfully. The recommended timing of referring patients with crowding to the specialists for treatment is in the late mixed-dentition stage of development. s
Dr. Ngan is professor and chair, West Virginia University, School of Dentistry, Department of Orthodontics, Health Science Center North, P.O. Box 9480, Morgantown, W.V. 26506. Address reprint requests to Dr. Ngan. Dr. Alkire is in private practice in Albuquerque, N.M. Dr. Fields is professor and dean, The Ohio State University, College of Dentistry, Columbus. 1. Kelly JE, Sauchey M, VanKirk LE. An assessment of the occlusion of teeth of children. Washington, D.C.: National Center for Health Statistics; 1973. Department of Health Education and Welfare publication number (HRA) 74-1612. 2. Kelly JE, Harvey C. An assessment of the teeth of youths 12-17 years. Washington, D.C.: National Center for Health Statistics; 1977. Department of Health Education and Welfare publication (HRA) 77-1644. 3. Brunelle JA, Bhat M, Lipton JA. Prevalence and distribution of selected occlusal characteristics in the U.S. population, 198891. J Dent Res 1996;75(special issue):706-13. 4. Ngan P, Amini H. Self-confidence of general dentists in diagnosing malocclusion and referring patients to orthodontists. J Clin Orthod 1998;32(4):241-5. 5. Moyers RE. Handbook of orthodontics. 4th ed. Chicago:Mosby-Year Book Medical Publishers; 1988:442-3. 6. Fields HW. Treatment of nonskeletal problems in preadolescent children. In: Proffit WR, ed. Contemporary orthodontics. 2nd ed. St. Louis: Mosby-Year Book; 1993:376-99. 7. Wolpoff MH. Paleoanthropology. New York: Knopf; 1980. 8. Dale JG. Guidance of occlusion: serial extraction. In: Graber TM, Swain BF, eds. Orthodontics: Current principles and techniques. St. Louis: Mosby; 1985:259-366. 9. Baume LJ. Physiological tooth migration and its significance for the development of occlusion. I. The biogenetic course of the deciduous teeth. J Dent Res 1950;29:123-32. 10. Baume LJ. Physiological tooth migration and its significance for the development of occlusion. IV. The biogenesis of overbite. J Dent Res 1950;29:331-7. 11. Moorrees CF, Reed RB. Changes in the dental arch dimensions expressed on the basis of tooth eruption as a measure of biologic age. J Dent Res 1965;44:129-41. 12. Bishara SE, Hoppens BJ, Jakobsen JR, Kohout FJ. Changes in the molar relationship between the deciduous and permanent dentitions: a longitudinal study. Am J Orthod Dentofacial Orthop 1988;93:19-28. 13. Mayne WR. Serial extraction. In: Graber TM, Swain BF, eds. Current orthodontic concepts and techniques. 2nd ed. Philadelphia: Saunders; 1975:259-364. 14. Lo RT, Moyers RE. Studies in the etiology and prevention of malocclusion. I. The sequence of eruption of the permanent dentition. Am J Orthod Dentofacial Orthop 1953;39:460-7. 15. Nance HN. The limitations of orthodontic treatment. I. Mixed dentition diagnosis and treatment. Am J Orthod Dentofacial Orthop 1947;33:177-223. 16. Staley RN, Kerber PE. A revision of the Hixon and Oldfather mixed-dentition prediction method. Am J Orthod 1980;78:296-302. 17. Tanaka MM, Johnston LE. The prediction of the size of the unerupted canines and premolars in a contemporary orthodontic population. JADA 1974;88:798-801. 18. Merrifield LL. Differential diagnosis with total space analysis. J Charles H Tweed Foundation 1978;6:10-5. 19. Northway WM. Antero-posterior arch dimension changes in French-Canadian children: A study of the effects of dental caries and premature extractions (master s thesis). Montreal, Quebec: University of Montreal; 1977. 20. Ronnerman A. Early extraction of deciduous molars: effect on dental development and need for orthodontic treatment. Sven Tandlak Tidskr 1974;67:327-37. 21. Davey KW. Effect of premature loss of primary molars on the anteroposterior position of maxillary first permanent molars and other maxillary teeth. J Dent Child 1967;34:383-94. 22. Posen AL. The effect of premature loss of deciduous molars on premolar eruption. Angle Orthod 1965;35:249-52. 23. Lee KP. Behavior of erupting crowded lower incisors. 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