International Journal of Applied Dental Sciences 2019; 5(4): 374-381

ISSN Print: 2394-7489

ISSN Online: 2394-7497
IJADS 2019; 5(4): 374-381 Too much too soon, rather than in too little too late:
© 2019 IJADS
www.oraljournal.com
Orthodontic in mixed dentition
Received: 25-08-2019
Accepted: 27-09-2019
Dr. Yashi Andley, Dr. Bhavna Gupta Saraf, Dr. Neha Sheoran and Dr. Nisha
Dr. Yashi Andley
PG Student, Department of Abstract
Paedodontics and Preventive When it comes to treatment planning in orthodontics “Timing is everything”. It is suggested that almost
Dentistry, Sudha Rustagi College all types of malocclusion could be benefited from early treatment. The aim of “early” orthodontic
of Dental Sciences and Research, treatment is to correct existing or developing skeletal, dentoalveolar, and muscular imbalances to
Faridabad, Haryana, India improve the orofacial environment before the permanent teeth eruption is complete. The “epitome of
dynamic orthodontic approach” is the beginning of the treatment in the deciduous dentition. It is here we
Dr. Bhavna Gupta Saraf
have growth to assist us, hard tissues are highly responsive to forces applied and soft tissue shows a
Professor and HOD, Department
higher degree of adaptability, thereby enhancing the stability of results. Early intervention can simplify or
of Paedodontics and Preventive
Dentistry, Sudha Rustagi College eliminate the need for later treatment. Mixed dentition treatment also may ensure normal development of
of Dental Sciences and Research, the teeth and jaws. The functional improvement coupled with the psychological benefit gives a
Faridabad, Haryana, India significant advantage for treating potentially challenging mixed dentition problems.

Dr. Neha Sheoran Keywords: Orthodontic treatment, mixed dentition, correction of malocclusion
Professor, Department of
Paedodontics and Preventive 1. Introduction
Dentistry, Sudha Rustagi College
of Dental Sciences and Research,
Dental neglect of primary dentition is principal cause of malocclusion in the permanent
Faridabad, Haryana, India dentition. Mixed dentition period is period of dental development starting with eruption of first
permanent molar and ending with complete replacement of deciduous teeth. Average period is
Dr. Nisha 6-8 years and coincides with rapid growth of craniofacial skeleton [1].
PG Student, Department of Primary aim of mixed dentition treatment are to eliminate functional interference, correct
Paedodontics and Preventive
Dentistry, Sudha Rustagi College
dental arch irregularities, and occlusal relation abnormalities and to intercept or correct
of Dental Sciences and Research, malocclusions that would otherwise become progressively more complex in the permanent
Faridabad, Haryana, India dentition or result in skeletal anomalies. Such treatments may be described as preventive or
interceptive [1].

Some of the factors for early intervention [2]

 Greater ability to modify skeletal growth;
 improved patient self-esteem and parental satisfaction
 better and more stable result
 less extensive therapy required later;
 minimise potential for iatrogenic tooth damage such as trauma

This review article emphasis that the goal of orthodontic treatment is to get “the achievable
normal occlusion which is aesthetically pleasing and functionally stable.” Factors which
influence orthodontic goal are not only the type of malocclusion, but also mechanotherapy or
the type and duration of retention; but timing of treatment is equally important.

Discussion
Orthodontic intervention in the mixed dentition does not always prevent orthodontic treatment
Corresponding Author: in the permanent dentition; however, there can be significant advantages to early intervention.
Dr. Bhavna Gupta Saraf
Identifying certain problems at an early age offers a possibility either to redirect skeletal
Professor and HOD, Department
of Paedodontics and Preventive growth or to improve the occlusal relationship. The main objective of managing orthodontic
Dentistry, Sudha Rustagi College problems in the mixed dentition stage is to intercept or correct malocclusions that would
of Dental Sciences and Research, otherwise become progressively more complex in the permanent dentition or result in skeletal
Faridabad, Haryana, India anomalies [3].
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According to American association of orthodontists every  Results must be stabilised with retainers until all the
child must have an orthodontic examination by the age of permanent teeth have replaced the deciduous teeth after
seven. By then, maxillary and mandibular first molars, lateral correcting transverse malocclusion at an early age,
incisors and central incisors should have erupted. It has been
suggested that almost all types of malocclusion could be Permanent teeth erupt on average beginning at 6 years of age
benefited from early treatment [3]. (lower central incisors, upper and lower first molars) and
other than third molars is complete by 12 years of age [8].
Early treatment presents opportunity to [3]
 Influence jaw growth in a positive manner Mixed dentition period is classified into 3 phases [9]
 Harmonize width of the dental arches 1. First transitional period = emergence of first permanent
 Lower risk of trauma to protruded upper incisors molars and exchange of deciduous incisors with
 Improve airway/speech problems permanent incisors.
 Correct harmful oral habits 2. Inter-transitional period = maxillary and mandibular
 Preserve/gain space for erupting permanent teeth arches consists of sets of deciduous and permanent teeth.
 Improve eruption patterns-less likelihood of impacted Between the permanent incisors and first permanent
permanent teeth molars are deciduous molars and canines. This is
 Improve aesthetics and self-esteem relatively stable phase and no change occurs.
 Simplify and shorten treatment time for later corrective 3. Second transitional period = replacement of deciduous
orthodontics. molars and canine by premolars and permanent Cuspids
respectively [9].
Mixed dentition analysis forms an essential part of an
orthodontic assessment because it helps to determine amount Most common eruption sequence is 6-1-2-3-4-5-7 in lower
of space available (whether mandibular or maxillary arch) for arch and 6-1-2-4-5-3-7 in upper arch [8].
accommodation of the incremental permanent teeth, and for First permanent molars are guided into the dental arch by the
the transitional changes occurring in the mixed dentition stage distal surface of the second deciduous molars. The mesio-
[4]
. distal relation between the distal surfaces of the upper and
lower second deciduous molars can be of 3 types
Consequently following should be highlighted A flush terminal plane (Fig 1).
 All transverse alterations should be treated as soon as B Distal step (Fig 2).
possible, ideally during mixed dentition C Mesial step (Fig 2).
 If transverse alteration is skeletal, treatment should be
even earlier, as soon as first upper permanent molars
erupt
 If transverse problem is dentoalveolar then treatment can
be delayed until permanent dentition, but only while
patients are still growing.
 If transverse alteration is accompanied by a vertical or
anterior-posterior malocclusion, transverse alteration
must be treated first. Fig 1: Early Shift & Late Shift

Flush terminal plane Distal step terminal plane Mesial step terminal plane
Fig 2

Incisal Liability occurs during the exchange of incisors in

which the difference in the amount of space needed for the
accommodation of the incisors and amount of space available
for this is called Incisal Liability. Incisal liability is roughly
about 7 mm in maxillary arch and about 5 mm in mandibular
arch.

Incisal liability is overcome by following factors

1. Utilizing interdental space seen in primary dentition
2. Increase in inter canine width
3. Change in incisor inclination
Fig 3: Leeway Space of Nance
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Transition from primary incisors to permanent incisors In the early mixed dentition years after incisor transition,
possible because the incisors normally exhibit
1. Interdental spacing of primary teeth if available - Baume 1. On average, 1.6 mm. of lower incisor “crowding”, S.D.
Type I [8]. of ±1 mm. (i.e. slight “crowding” normal) [8].
2. Primate spaces – allows incisor transition with less than 2. On average, no spacing or crowding in the upper incisor
mean average of 1 to 2 mm [8]. segment (S.D. of ±1 mm.). Overjet ideally is no overjet
3. Incisor crowding. Larger basal arch size. If not available, with incisal contact, range is 0 - 3 mm.
much more likely to end up with crowding at above 3. Overbite is about 2 mm. or 30 - 50% vertical overlap, two
average levels [8]. S.D. range is 0 – 5 mm [8].
4. Intercanine arch width during incisor eruption increases
and “growth” transition” [8]. Permanent molar transition positioning influenced by [8]
5. Increase in lower intercanine width - mean of 2.4 mm.  Relationship of Primary molar terminal plane.
with range of 0 to 5 mm [8].  As first molars erupt Primary spacing is closed by “early
6. Intercanine arch width stabilizes after incisor eruption is mesial shift”.
complete at 8 years of age [8].  The difference in size between primary C-D-E and
7. Permanent canines will erupt at same arch width as permanent 3-4-5 teeth (i.e. leeway space) results in “late
primary canines occupied [8]. mesial shift” of first molars when second primary molar
8. Increase in upper intercanine width - mean of 3.0 mm. exfoliates
with range of 0 to 6.5 mm [8].  On average, leeway space is +0.9 mm in upper & is +1.7
mm. in lower per quadrant.
Another increase of about 2 mm. will occur in maxillary  Relative A-P positioning is affected by the Mandibular
width when canines erupt at age 12 years [8]. growth and differential growth.
Buccal segments undergo transition with eruption in the lower
arch of the canines around 10 years of age, eruption of upper Permanent Molar Relationships in the Mixed Dentition
and lower first premolars approximating age 11-11.5 years,  Class I (Fig 5)
eruption of upper and lower second premolars at age 11.5-12  End-on Class II (Fig 6)
years and eruption of upper canines at age 12+ years [8].  Full Class II (Fig 7)
 Class III.
Leeway Space of Nance (Fig 3)
The combined mesio-distal width of the permanent canine and
premolars is usually less than that of the deciduous canines
and molars. The surplus space is called leeway space of
Nance [9].
The amount of leeway space is greater in the mandibular arch
than in the maxillary arch.it is about 1.8mm (0.9 mm on each
side of the arch) in the maxillary arch and about 3.4mm
(1.7mm on each side of the arch) in the mandibular arch. The
excess space available after the exchange of the deciduous Fig 5: Class I
molars and canines is utilized for mesial drift of the
mandibular molars to establish class I molar relation [9].
Ugly duckling Stage (Fig 4) a self-correcting malocclusion is
seen in the maxillary incisor region between 8-9 years of age.
This situation is seen during the eruption of the permanent
canines. This condition has been described by Broadbent as
the ugly duckling stage as children tend to look ugly during
this phase of development. This condition usually corrected
by itself when the canines erupt and the pressure is transferred
from the roots to the coronal area of the incisors [9]. The Fig 6: CLASS II
“Ugly duckling” stage is normal transitional appearance with
“splayed” maxillary incisors under influence of eruptive
positions of adjacent incisors and canines [8].

Fig 7: Full Class II

Management of the mixed dentition occlusion by

1. Space supervision
2. Guidance of Eruption
3. Preventive Orthodontics
Fig 4: Ugly duckling stage 4. Interceptive Orthodontics

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Goals of Mixed Dentition Management of the Occlusion [8] Indication [10]

 Incisor integrity: Satisfactory alignment of anterior teeth 1. Preserving arch length following premature loss of a
without significant midline discrepancy, excessive primary tooth/teeth,
protrusion, lingual malpositioning, open bite or excessive 2. Allows permanent tooth to erupt without hindrance into
deep bite. proper alignment and occlusion.
 Development of Dentition without functional problems:
Elimination of functional posterior and anterior cross A space maintainer should fulfil the following criteria [10]
bites, deleterious oral habits and temporomandibular 1. Maintain entire mesio-distal space created by a lost tooth.
dysfunction (TMD). 2. Must restore function as far as possible and prevent over
 Optimal tooth eruption: Correction of eruption anomalies eruption of opposing teeth.
such as ectopic molars and canines, over-retained 3. Be simple in construction.
primary teeth, delayed permanent tooth eruption, 4. Be strong enough to withstand the functional forces.
ankylosis, supernumerary teeth. 5. Not exert excessive stress on adjoining teeth.
 Avoiding unnecessary extraction of permanent teeth: 6. Must permit maintenance of oral hygiene.
Optimal use of leeway space and arch perimeter with 7. Normal growth and development and natural adjustments
symmetrical molar positioned without symptomatic space that take place during the transition from deciduous to
loss. permanent dentition must not be restricted.
8. Should not come in the way of other function.
Preventive orthodontic procedures [9]
1. Parent education Planning for Space Maintenance depends on
2. Caries control 1. Time elapsed since loss
3. Care of deciduous dentition 2. Dental age of the patient
4. Management of ankylosed tooth 3. Amount of bone covering the unerrupted tooth
5. Maintenance of quadrant wise tooth shedding time table. 4. Sequence of eruption of teeth
6. Check-up for oral habits and habit braking appliance if 5. Delayed eruption of the permanent tooth
necessary. 6. Congenital absence of the permanent tooth
7. Occlusal equilibration if there are anterior occlusal 7. Presentation of problems to parents
prematurity’s
8. Prevention of damage to occlusion eg. Milwaukee braces. Classification of space maintainers [9]
9. Extraction of supernumerary teeth According to Hitchcock
10. Space maintenance 1. Removable or Fixed or Semi fixed
11. Management of deeply locked first permanent molar 2. with bands or without Bands
12. Management of abnormal frenal attachment. 3. Functional or Non Functional
4. Active or Passive
Interceptive orthodontic procedures [9] 5. Certain combination of the above
Serial extraction = Dewel method, tweed method, Moyers
method. According to Raymond C. Thurow

Dewel Method

According to Hinrichsen
1. Fixed space maintainer
Moyers Method Class 1
a) Non-functional types
1. Correction of developing crossbite I) bar type
2. Control of abnormal habits II) Loop type
3. Space regaining b) Functional types
4. Muscle exercise I) Pontic types
5. Interception of skeletal malrelation II) Lingual arch type
6. Removal of soft tissue or bone barrier to enable eruption Class 2
of teeth Cantilever type (distal shoe, band & loop)

Space maintenance & maintainers 2. Removable space maintainers

Space maintenance = preservation of space left by primary Acrylic partial dentures
incisors, primary canines, and primary molars and sometimes
the primate spaces [10]. Some commonly used removable space maintainers.
Space maintainers = device used to maintain the space created 1. Acrylic partial denture
by the loss of a deciduous tooth [10]. 2. Full or complete denture
3. Removable Distal Shoe space maintainer

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Some commonly used fixed space maintainers

1. Band and loop space maintainer
2. Band and loop space maintainer with occlusal rest
3. Crown and loop appliance.
4. The lingual arch space maintainer
5. Palatal arch appliance
 Nance arch holding appliance
 Transpalatal arch
6. Esthetics anterior space maintainers
7. Band and bar type space maintainer
8. Pin and tube space maintainer Fig 10: Distal Shoe
9. Gerber space maintainer
10. EZ space maintainer
11. Distal shoe space maintainer

Space maintenance in anterior segment

1. Removable partial denture
2.
Fixed Appliances
3. Groper Appliance

Space maintenance in buccal segment

1. Removable appliances
2. Fixed Space Maintainers Fig 11: Lingual arch
 Band and loop appliances (Fig 8)
 crown and loop ( Fig 9)
 Mayne Space Maintainer- Designed by W R Mayne,
 Distal shoe - Intra-alveolar appliance- It was introduced
by Gerber and extended by Croll. (Fig 10)
 Band and Bar
 Glass Fiber-reinforced Composite Resin
 Fixed lingual arch –popularised by Burstone, (Fig 11)
 Nance palatal arch appliance - developed by H.N. Nance
in 1947, (Fig 12)
 Transpalatal arch- Originally described by Robert
Goshgarian in 1972,
Fig 12: Nance Palatal Arch

Correction of mandibular anterior crowding, following

eruption of mandibular lateral incisors [6].
1. Stripping of teeth to resolve crowding
2. Lingual arch
3. Mandibular expansion
4. Extraction treatment
5. Lower incisor extraction treatment
6. Second molar extractions in the lower arch:
7. Lower first molar extractions
8. Mandibular lip bumper
9. Vestibular screen
Fig 8: Band and Loop
Correction of developing crossbites
Various treatment methods proposed such as [20]
1. reversed stainless steel crowns,
2. tongue blades
3. fixed acrylic planes
4. bonded resin-composite slopes
5. reverse pull facemask
6. Removable acrylic appliances with finger springs.
7. fixed inclined bite planes
8. Bruckl appliance
9. Hawley appliance with a lingual shield
10. Hawley appliance with midline expansion screw
11. coffin spring
Fig 9: Crown and Loop

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Maxillary biomechanics / Maxillary expansion appliances  Removable ACCO appliance are examples modalities.
[8]

1. Cross-arch elastics Mandibular space regaining:

2. Removable Schwarz Plate  lip bumper
3. W-arch / Quad-helix (0.036 S.S. wires)  “active” lingual arch,
4. Palatal Expander/Hyrax  Removable split-saddle.
5. Hass expander Space gaining methods
 proximal stripping
Space Regaining  expansion
 Gerber space regainer  extraction
 space regainers using jack screw  distalization
 space regaining using cantilever spring  uprighting the molars
 derotation of molars
Maxillary space regaining  proclination of anterior
 Extraoral headgear,
 Fixed molar “distalizing” appliances (e.g. Distal jet), Interception of skeletal malrelations

Defined as biomechanical treatment directed at altering relationships of the jaws and activity patterns of orofacial muscles to affect changes in
facial proportions.
1. Skeletal class II malocclusion due to maxillary prognathism Restrict maxillary growth using headgear
Myofunctional appliances to promote mandibular
2. Skeletal class II malocclusion due to mandibular retrognathism
growth
3. Skeletal class II malocclusion due to mandibular retrognathism
Headgear + myofunctional appliance
and maxillary prognathism
4. Skeletal class III malocclusion due to mandibular prognathism Chin cup therapy to restrict mandibular growth
Myofunctional appliance to promote maxillary growth
5. Skeletal class III malocclusion due to maxillary retrognathism
and face mask therapy
6. Skeletal class III malocclusion due to maxillary retrognathism Facemask therapy and chin cup to restrict mandibular
and mandibular prognathism growth.

Anteroposterior Class II malocclusion with Retrusive minimal.

Mandible > Functional Appliances
Promote growth of mandible by advancing mandible with Anteroposterior Class II malocclusion with acceptable A-
protrusive bite appliance, restrain maxillary forward P skeletal / profile relationships
development for “catch-up” [8]. Promote corrective changes by restraining or distalizing upper
dentition, protracting lower dentition.
Correction by [8] 1. Class II elastics: requires Edgewise appliances.
a) Moving (or restricting) upper teeth backward - moving 2. Distalized maxillary posterior segments (e.g. headgear,
the lower teeth forward. distal jets, ACCO, springs, etc.).
b) Restraining maxillary skeletal growth (i.e., so-called 3. May incorporate selective permanent tooth extractions to
“headgear effect”). camouflage A-P discrepancy.

Examples of functional advancement appliances [8] Control of excess vertical facial development
1. Bionator / orthopedic corrector 1. Maxillary restraint with high-pull headgear
2. Activator 2. Maxillary restraint with full coverage functional
3. Frankel appliances (Combine Activator-Headgear)
4. Herbst
Anteroposterior Class III Malocclusion
Anteroposterior Class II Malocclusion with Protrusive  Restrain mandibular growth with Chin-cup therapy
Maxilla > Directed Headgear  Protract the maxillary complex with extraoral reverse-
Headgear promotes restraint of maxillary dental and skeletal pull headgear (facemask)
forward and vertical development, distalized upper dentition,
and allows normal mandibular growth. Orthodontic and There are many orthodontic problems that need
orthopedic effects are possible with directed headgear in evaluation for treatment in the mixed dentition [8]
growing patients [8].  Class II malocclusion and Class III malocclusions with
a. Cervical-pull Headgear: Optimize molar distalization, midface discrepancies
redirect vertical development, and influence maxillary  Anterior crossbites and posterior crossbites
skeletal growth, decrease overbite, promoting molar  Midline discrepancies, associated to early loss of a
extrusion, distalization of crowns. Average 3 mm. /year deciduous cuspid
distalization.  Overjet over 6-7mm
b. High-pull Headgear: Optimize orthopedic restraint of  Crowding up to 4mm
maxillary growth and minimize vertical eruptive  Deep overbite associated with palatal impingement
development, enhance overbite, promotes horizontal and  Ectopically erupting Cuspids and molars
bodily movement of molars, distalization effects are  Mucogingival problems

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 Premature loss of deciduous molars Review Dr. Narmadha Sudhakar Dr. Saravana Dinesh
 Missing permanent teeth or supernumerary teeth IOSR Journal of Dental and Medical Sciences (IOSR-
JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861. Volume
Conclusion 12, Issue 4 (Nov.- Dec. 2013), PP 47-50
Early intervention can simplify or eliminate need for later 18. Orthodontic treatment for posterior crossbites (Review)
treatment. Treatment in mixed dentition opens doors for an Jayne E Harrison, Deborah Ashby the Cochrane Library,
orthodontist and a pedodontist to apply his judgment and 2001, 1.
experience. Proper diagnosis and treatment planning can 19. Interceptive Orthodontics-Current Evidence Maen H.
produce most satisfying results during the mixed dentition Zreaqat
stage. On other hand, lack of careful planning can lead to 20. Diagnosing Early Interceptive Orthodontic Problems —
disastrous results. It should be remembered that there is Part 2 A Peer-Reviewed Publication Written by Michael
generally greater danger in: “Too much too soon, rather than Florman,; Rob Veis,; Mark Alarabi and Mahtab Partovi,
in too little too late.” 21. Isaacson RJ, Ingram AH. Forces produced by rapid
maxillary expansion: II. Forces present during treatment.
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