Journal of Orthodontics, Vol.

40, 2013, 345351

CLINICAL
SECTION

Early interceptive treatment in the

primary dentition a case report
Mauro Cozzani1, Laura Mazzotta2 and Paolo Cozzani1
1

Private Practice, La Spezia, Italy; 2Orthodontic Department, Cagliari University, Cagliari, Italy

This article describes treatment of a patient presenting with a class II malocclusion, maxillary and mandibular crowding,
posterior crossbite and an increased deep bite, where the specific treatment goals were achieved in the early mixed dentition by
only working on the primary teeth. A Haas-type rapid maxillary expansion (RME) appliance was modified to be anchored on
the primary second molars and canines and activated once a day, with each activation equal to 0.20 mm. The appliance was
blocked after 30 days and left as a retainer. After 6 months, the RME appliance was removed and bands were cemented to the
primary second molars in order to apply traction with headgear. After complete eruption of the mandibular central and lateral
incisors, sequential slicing of the lower primary teeth was performed to transfer the leeway space from the distal to the mesial
part of the arch. When the patient had entered the permanent dentition, a dental class I relationship was achieved, the
crossbite corrected and the crowding improved. The overjet and overbite were also improved. No permanent teeth were
involved during this phase of treatment. The outcome of this case report shows that it is possible to work only on primary
teeth in the mixed dentition and this can be an effective way to correct a class II malocclusion with deep bite, posterior
crossbite and maxillary and mandibular crowding.
Key words: Deciduous teeth, early treatment, crowding, RME, sequential slicing
Received 11 March 2013; accepted 11 May 2013

Introduction
The most appropriate timing for the treatment of class
II malocclusion is controversial. Some clinicians advocate starting a first phase in the mixed dentition followed
by a second phase in the permanent dentition, because
in the early mixed dentition, the skeletal growth pattern
can be modified.1,2 Others, see no clear advantage in this
approach and recommend treatment in the late mixed or
early permanent dentition.36 The literature indicates
that very early treatment should not be thought of as the
most efficient way to treat most class II children,79
therefore any decision to undertake early intervention
should be based on specific indications for each child:
early treatment as a standard of care can only be justified
if it provides additional benefits to the patient.7 For
treatment such as rapid maxillary expansion (RME),
which is often undertaken in the early permanent
dentition, there may be a number of undesirable effects,
such as a buccal tipping,10,11 root resorption12,13 and
periodontal damage, such as gingival recession of
anchoring teeth.14 These undesirable effects can potentially be prevented by undertaking RME in the mixed
dentition: the RME appliance can be anchored to the
primary second molars and canines, teeth that will be
Address for correspondence: L. Mazzotta, Private Practice, Via
Fontevivo 21N, 19125 La Spezia, Italy.
Email: laura.mazzotta@ymail.com
# 2013 British Orthodontic Society

replaced; and by doing so, the permanent molars do not

undergo a direct force.15
Here, we report the case of a patient that presented
with a class II malocclusion, maxillary and mandibular
crowding, posterior crossbite and an increased deep bite,
where specific treatment goals were achieved following
treatment in the early mixed dentition, with the appliances only applied to the primary teeth.

Case report
AB presented as an 8-year-old Caucasian in the early
mixed dentition with a class II division I incisor
relationship, bilateral crossbite on the permanent first
molars, 9 mm overjet and 5 mm overbite. He also
showed crowding in both arches, with an 8 mm Littles
irregularity index in the mandibular arch and 13 mm in
the maxillary arch. The panoramic radiograph showed
the presence of all permanent teeth besides the maxillary
third molar tooth germs. The lateral cephalometric
radiograph showed an SNA angle of 81u, a SNPg angle
of 76u and an ANPg angle of 5u determining a skeletal
class II relationship. His health history and family
history were non-contributory (Figures 13).

DOI 10.1179/1465313313Y.0000000068

346

Cozzani et al.

Figure 1

Clinical Section

(A, B) Pre-treatment records facial photos

Figure 3

JO December 2013

Pre-treatment cephalometric radiograph

Treatment plan

Maxillary arch

The treatment plan was divided into two phases: a first

phase of early treatment to be undertaken only on the
primary teeth and a second phase of treatment with
fixed appliances in the permanent dentition.
The first phase of treatment aimed to alleviate the
crowding, achieve a class I incisor relationship, resolve
the posterior crossbite and improve the deep bite. The
second phase had the goals of leveling and aligning the
dental arches, controlling tip and torque and finishing in
the permanent dentition.

A Haas-type RME appliance16 modified for anchorage

on the primary second molars and canines was used
initially;11,15,17,18 this was activated once a day, with
each activation equal to 0.20 mm of expansion. The
appliance was blocked after 30 days and was left as a
retainer. A cervical headgear was also applied to the
primary molar bands of the RME appliance. After
6 months, the RME appliance was removed and bands
were cemented onto the second primary molars in order
to support the provision of headgear. A class I molar

Figure 2

(AE) Pre-treatment records intraoral photos

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Clinical Section

Treatment of malocclusions on primary teeth

347

Figure 4 Maxillary arch during first phase treatment. (A) RME inserted; (B) RME blocked; (C) effects of the headgear; (D) reduction of
overjet and overbite

relationship was achieved within 6 months and the

headgear was suspended (Figure 4).

Mandibular arch
After complete eruption of the permanent central and
lateral incisors, sequential slicing of the lower primary
teeth was performed as described by Rosa,19 to transfer
the leeway space from the distal to the mesial part of the
arch and therefore resolve the crowding (Figure 5).
After completion of the first phase of treatment, the
patient was monitored every 4 months until they entered
the permanent dentition.
At the beginning of the second phase of treatment, the
patient was in the permanent dentition with a class I
molar relationship, the molar crossbite had been
resolved and the upper and lower crowding improved.
Littles irregularity index had gone from 8 to 4 mm in
the mandibular arch and from 13 to 5 mm in the
maxillary arch. Overjet and overbite were also improved
(Figures 6). No permanent tooth was involved during
this early treatment. However, the patient still presented
with inferior crowding, rotations on the mandibular
incisors and an increased overbite; therefore, he was
bonded with fixed appliances in both arches at this
point.

with well aligned arches, along with a centered midline.

A class I canine and molar relationship was also
achieved together with an ideal overjet and overbite
and a mutually protected occlusion (Figures 7 and 8).
The lateral cephalometric radiograph showed an SNA
angle of 81u, a SNPg angle of 79u and an ANPg angle of

Treatment outcome
On removal of the fixed appliances, the crowding had
been completely corrected and the patient presented

Figure 5 (A, B) Mandibular arch during the first phase treatment

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Cozzani et al.

Figure 6

Clinical Section

JO December 2013

(AE) Intraoral photos at starting of phase 2 of treatment

2u, indicating a skeletal class I pattern as a result of

favourable mandibular growth (Fig. 9).
The patient was seen 4 years later and his occlusion
had remained stable, a dental class I relation on the right
and on the left were maintained and he still presented
with an ideal overjet and overbite (Figure 10). The
lateral cephalometric radiograph (Figures 11 and 12)
(Table 1) showed an SNA angle of 84u, a SNPg angle of
84.5u and an ANPg angle of 20.5u, indicating a skeletal
class I.

Discussion

Figure 7 (A, B) Post-treatment records facial photos at end

of phase 2 of treatment

Figure 8 (AE) Post-treatment records intraoral photos at

end of phase 2 of treatment

Early mechanotherapy in the mixed dentition, with

specific treatment goals may be beneficial for selected
patients.8 The patient analysed in this case report
presented at the age of 8 years with a dental and skeletal
class II relationship, maxillary and mandibular crowding, posterior crossbite and deep bite. What is known
from the literature is that posterior crossbite on the first

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Treatment of malocclusions on primary teeth

349

Figure 9 Post-treatment cephalometric radiograph

Figure 10 (AC) Post-retention intra-oral photos: 4-year follow-up

permanent molars does not generally self-correct and

that a good time for crossbite correction is the early
mixed dentition.20 Also, 45 mm of lower incisor
crowding in the mixed dentition stage of development
can usually be treated with non-extraction procedures, if
the leeway space is maintained and if treatment is
started early enough.21 Moreover, both dental class II22
and deep bite are malocclusions that do not self-correct;
in this case, if an early treatment had not been carried
out, the alternative would have been a one phase
treatment to correct the malocclusion in the permanent
dentition, with a likelihood of extractions and potential
undesired effects on the dentition. Some studies have
also shown that the trans-septal fibres are not determined by tooth anatomy, but by tooth position and
orientation within the dental arch during their development, which happens after the teeth erupt.23 There has
been some suggestion that these fibres have more

Figure 11 Post-retention cephalometric radiograph

difficulty in adapting to tooth derotation once they

have developed.24 This is one of reason why it may be
advisable to expand before eruption of the permanent
lateral incisors;18 by doing so, trans-septal fibres will
develop after the lateral incisors have erupted into the
correct position, potentially reducing relapse.
Early treatment can be justified only if it provides
additional benefits to the patient;7 in this case, the patient
had resolution of all skeletal and dental discrepancies
working on the primary teeth and then only 11 months of
fixed therapy was required in the permanent dentition.
We believe that this early intervention was therefore a
benefit.

Figure 12 Superimposition of lateral cephalograms: end of

treatment and post-retention

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Cozzani et al.

Table 1

Clinical Section

JO December 2013

Pre-treatment, post-treatment and post-retention cephalometric values.

Initial (Jan 1993)

Sagittal skeletal relations

Maxillary position: SNA
Mandibular position: S-NPg
Sagittal jaw relation: ANPg
Vertical skeletal relations
Maxillary inclination: SN/ANSPNS
Mandibular inclination: SN/GoGn
Vertical jaw relation: ANSPNS/GoGn
Dento-basal relations
Maxillary Incisor Inclination: 1 ANS-PNS
Mandibular incisor inclination: 1 GoGn
Mandibular incisor compensation: 1 APg (mm)
Dental relations
Overjet (mm)
Overbite (mm)
Interincisal angle: 1/1

Final (Feb 1997)

Post-retention (Aug 2001)

Mean

81u
76u
5u

81u
79u
2u

84u
84.5u
20.5u

823.5u
82u3.5u
22.5u

5u
31u
26u

6u
31u
25u

5u
23u
18u

83u
332.5u
256u

111u
93u
3

112u
101u
5

113u
107u
2

1106u
947u
22

9
5
130u

2
2,5
122u

2
2,5
121u

3.52.5
22.5
1326u

Conclusion
This case report has demonstrated that it is possible to
carry out early interceptive treatment on the primary
teeth in the early mixed dentition and this can be an
effective way to correct a class II malocclusion with deep
bite, posterior crossbite and crowding.

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