School of Dentistry

ORTHODONTICS LECTURE 11
ORTHODONTICS IN THE MIXED DENTITION

Natal teeth
Present at birth or erupt shortly afterwards. They may be enamel pearls or properly formed
teeth.
They occur most often in the lower incisor region. Only 10% are supernumerary and they
should be left alone unless they cause feeding problems, or pose a risk to the airway if loose.
Enforced extraction of primary teeth
Remember the features of an ideal primary occlusion:
Spaced incisors
Second molars flush distally
Anthropoid spaces
and the importance of Leeway Space, or E Space as it is often called now increasingly known
as E space.
Effects of enforced extraction may be:
-

Centreline shift
Loss of space in buccal segments, with subsequent premolar impaction. Rate and
extent of space loss will depend upon:
Amount of crowding
Tooth lost
Age of patient

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Management of enforced extraction of primary teeth:

The alternatives are:
-

Extraction of unsaveable teeth only

Fortunately mass extraction of primary molars is less common than it used to be.
However, if a child has one unsaveable molar tooth it is likely that others are of poor
prognosis. When there is doubt conservation efforts should be directed towards the
second primary molars since these teeth are important for holding back the first
permanent molars.

Balance and/or compensate enforced extractions(s)

A balancing extraction is removal of a tooth from the contralateral quadrant in order to
minimise centreline shift.
A compensating extraction is removal of a tooth from the opposing quadrant in order
to preserve an even occlusion.
Balancing extractions are less common now, due to the fact that a centreline shift is
correctable with fixed appliances. E extraction should not affect the centres and is best
left unbalanced since extraction of an E always carries the greatest risk of first
permanent molar drift.

Fit a space maintainer

Fixed types are best. Removables are hard to retain in the lower arch and may use up
co-operation so that by the time that active treatment is begun the patient has already
tired of appliance wear.

Submerged primary teeth

Submergence most commonly affects lower second primary molars. It is sometimes, but not
always indicative of a missing premolar. A radiograph should be taken when submergence
begins. If the premolar is present submergence probably arises due to the fact that the wide
root spread of the primary tooth means that not all the roots are resorbed as the premolar
erupts. The primary molar then becomes ankylosed to the crest of the alveolus. As other
teeth continue to erupt the ankylosed molar is left behind.
Treatment - See handout on local factors
Supernumerary teeth
See handout on local factors
Double teeth
This is a better term than either fusion or gemination, since it avoids arguments concerning
aetiology.
Treatment - Depends chiefly on pulp chamber morphology. If there are separate root canals it
may be possible to divide the large crown. If there is one common pulp chamber
the only choice may be to extract. Do not be afraid to recommend extraction.

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Hypodontia
Most common isolated missing teeth are an upper lateral incisor and a lower second premolar
but any tooth may be missing.
Treatment for missing maxillary laterals
Close space and modify canines by grinding and composite additions
Create space for prosthetic lateral incisors

Teeth of abnormal form

Dens in dente - extract if malformation is severe.
Dilaceration - makes orthodontics difficult. May require extraction.
Abnormal tooth position
Ectopic eruption of first permanent molars leads to impaction under the second primary molar.
Both upper and lower first molars may be affected.
Methods of disimpaction

- A brass wire tightened around the contact point.

- A distally acting spring on a removable or fixed appliance.
- Insertion of a separating elastic between the contact points
- Removal of the E

Ectopic canines are considered in a separate lecture.

Sucking habits
These have already been mentioned in the Soft Tissues lecture
Serial extraction
Defined as The extraction of primary teeth, followed by the planned extraction of
permanent teeth. The idea is to create space for spontaneous relief of crowding without the
need to use appliances.
Usual extraction sequence:
Extract Cs when permanent upper laterals are half erupted
Extract Ds one year later
Extract 4s ASAP
This is now considered an outdated technique: it submits the patient to many extractions,
potentially using up cooperation. There is also no guarantee it will work: the lower canines
may erupt before the first premolars. Since distal movement of the lateral incisors will have
encroached on the canine space, the serial extraction process may worsen displacement of
the lower canines so that active alignment is needed.

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First molars of poor prognosis

First permanent molars are very important since they are the largest teeth in the mouth. They
are also the first permanent posterior teeth to erupt and their position determines buccal
occlusion. Edward Angle emphasised their importance by calling them Key Teeth.
However if one or more sixes are of poor prognosis, the removal of some of the others should
be considered as part of orthodontic treatment. Read the Royal College of Surgeons
guidelines 2009: A Guideline for the Extraction of First Permanent Molars in Children:
Class I cases
Class I cases with minimal crowding (<3mm)
Aim for extraction at the optimal time for eruption of the second molars into a good position.
Do not balance unilateral first molar extraction in either the upper or lower arches with
healthy first molars.
If the lower first molar is to be lost, compensating extraction of the upper first molar
should be considered to avoid overeruption of this tooth, unless the lower second molar
has already erupted and the upper first molar is in occlusal contact with it.
If the upper first molar is to be lost, do not compensate with extraction of the lower first
molar if it is healthy.
Class I cases with crowding
In the presence of crowding in the buccal segments, extract at the optimal time to allow
eruption of second molars into a good occlusal position and this should provide some relief of
any premolar crowding.
If the buccal segment crowding is bilateral, consider balancing extraction to provide
suitable relief and maintain the centreline.
Compensating extraction of upper first molars should be considered to prevent
over-eruption or relieve premolar crowding.
In the presence of crowding in the labial segments, little spontaneous relief is provided by first
molar extraction.
First molar extractions can be delayed until the second molars have erupted and then the
extraction space used for alignment with fixed appliances.
Alternatively, first molars can be extracted at the optimum time and the crowding treated
once in the permanent dentition. If premolar extractions are likely to be required at this
stage, the third molars should be present.
Class II cases
The extraction of first permanent molars in Class II cases can be more difficult to plan,
particularly with regard to the timing of upper first molar extraction. The main complicating
factors often involve the upper arch because of the need for space to correct the incisor
relationship.
Class II cases with minimal crowding
Lower first molar extraction should be carried out at the ideal time for successful eruption of
the second permanent molar and control of the second premolar. Compensating and
balancing extraction of healthy lower first molars are not indicated.
In the upper arch, space will often be required to correct the incisor relationship:
If the upper first permanent molars require immediate extraction, orthodontic treatment
may be instituted to correct the incisor relationship. A functional appliance or removable
appliance and headgear can be used to correct the buccal segment relationship, followed
by fixed appliances if required.
Alternatively, after extraction of the upper first permanent molars, the second permanent
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molars can be allowed to erupt and the incisor relationship corrected once this has taken
place. Correction of the malocclusion at this stage can involve any of the methods
described above. In addition, if there is radiographic evidence of third molar
development, then further space for incisor correction could be created by the loss of two
upper premolars teeth.
If the upper first permanent molars can be temporised or restored, then their extraction
can be delayed until the second permanent molars have erupted. the resultant extraction
space can then be used to correct the malocclusion with fixed appliances. If the upper
first molars are to be left unopposed, a simple removable appliance may be required to
prevent their over-eruption, whilst waiting for the second molars to erupt. Alternatively, a
functional appliance can be used immediately to correct the incisor relationship prior to
extraction of the first molars and fixed appliances.
If the upper first permanent molar is sound, elective extraction may be indicated if it is at
risk of over-erupting; however, the third molars should ideally be present
radiographically. The class II relationship can then be managed as for immediate
extraction of upper first molars with a poor prognosis. If there is no sign of upper third
molar development, an appliance to prevent the over-eruption of sound upper first molars
should be considered and the malocclusion managed following eruption of the second
molars.
Class II case with crowding.
Space will also be required in the lower arch for the relief of crowding.
If the third molars are present radiographically, lower first molars can be extracted at the
optimum time to allow second molar eruption and then premolars extracted at a later
stage for the correction of crowding. In these cases, fixed appliances will usually be
required.
Alternatively, first molars can be extracted after second molar eruption and the space
used directly for the correction of crowding with fixed appliances.
Balancing and compensating extraction of lower first molars are not generally required.
Space requirements in the upper arch can be significant - for the relief of crowding and
correction of the incisor relationship i.e. increased overjet. The upper first permanent molars
should be temporised or restored and the child referred to a specialist orthodontist whenever
possible.
If the upper first permanent molar is unopposed, at risk of over-erupting and third molars are
present radiographically, then extraction of the upper first molar may be indicated. The patient
should be counselled that additional premolar extractions in the upper arch may be required in
the future to create sufficient space for crowding relief and incisor correction.
Class III cases
Class III cases are often even more difficult to manage and ideally require the opinion of a
specialist orthodontist before any first permanent molars are extracted. As a general rule,
extraction of maxillary molars should be avoided if at all possible, whilst balancing and
compensating extractions are not recommended in class III cases.
When in doubt an orthodontic opinion should be sought before extracting sixes.
Early treatment of Class II Division I
Try to avoid this wherever possible: it is best to wait until the permanent teeth are all fully
erupted, or at least almost there.

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Early treatment of pseudo Class III

This is only indicated for those patients who are biting edge-edge and then displacing
anteriorly. The aim is to push the incisors over the bite, eliminating the displacement and thus
preventing it from being established in the permanent dentition. One or more incisors that
erupt inside the bite should be proclined as soon as there is enough overbite to maintain the
result. This treatment unlocks the bite and may prevent establishment of a genuine Class III
malocclusion.

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