Space supervision and guidance of eruption in

management of lower transitional crowding: A

non-extraction approach
Ronald A. Bell, DDS, MEd, and Andrew Sonis, DMD

Mandibular incisor crowding in the mixed dentition is one of the most common
problems presenting to the orthodontist. Asymmetry of alignment, premature
loss of primary canine(s), and disruption in arch integrity are all early
benchmarks of a tooth size/arch length discrepancy in the transitional dentition
that can occur independent of any skeletal discrepancy. Space supervision and
guidance of eruption refer to treatment interventions during the early to mid-
mixed dentition periods that influence the eruption patterns and positioning of
the permanent teeth during their transition. Generally considered applicable to
individuals with adequate overall arch dimensions to accommodate a normal
complement of permanent teeth with an acceptable esthetic and functioning
occlusion, guidance of eruption involves the implementation of directed
interventions to optimize the eruption and alignment patterns of the
permanent teeth as part of a non-extraction protocol. (Semin Orthod 2014;
20:16–35.) & 2014 Elsevier Inc. All rights reserved.

T he concept of an early phase of treatment

intervention with guidance of eruption
procedures to correct mandibular incisor
crowding is not a new one. Space supervision,
guidance of eruption, pre-orthodontic guidance, and
interceptive orthodontics are all terms that have been
used to refer to the treatment of crowding dis-
crepancies presenting during the early to mid-
mixed dentition (Nance, 19471; Popovich, 19622;
Hotz, 19703; Ackerman and Proffit, 19804; Moyer,
19885). While considerable debate has ensued as
to the proper terminology, the definitions are far
less important than the concepts of intervention.
The authors have elected to utilize Hotz’s3 term
guidance of eruption in referring to “treatment
procedures that influence the eruption patterns
Department of Pediatric Dentistry and Orthodontics, James B.
Edwards College of Dental Medicine, Medical University of South
Carolina, Charleston, SC; Children0 s Hospital Boston, Boston, MA;
Department of Developmental Biology, Harvard School of Dental
Medicine, Boston, MA.
Address correspondence to Ronald A. Bell, DDS, MEd, Depart-
ment of Pediatric Dentistry and OrthodonticsJames B. Edwards
College of Dental Medicine, Medical University of South Carolina, 30
Bee St MSC126, Charleston, SC 29425. E-mail: bellr@musc.edu
& 2014 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2013.12.003
and positioning of the permanent teeth during
the transition from the primary dentition
through the mixed dentition.” The effective-
ness of preserving “leeway space” with a lingual
arch to resolve mandibular crowding was
reported by Nance1 in a presentation to the
Southern Society of Orthodontics in 1946 and in
an article in the American Journal of Ortho-
dontics in 1947. Nance describes a series of cases
dating back to 1934 that were successfully treated
with passive lingual arches in the mixed
dentition. A similar approach to preserving
arch length was described by Hotz3 in 1970
and later by Singer6 in 1974. These opinion
articles and case series were later substantiated in
clinical studies by Wagers,7 Arnold,8 Gianelly,9
DeBaets and Chiarini,10 Dugoni et al.,11
Gianelly,12,13 Rebellato et al.,14 Brennan and
Gianelly,15 Villalobos,16 Gianelly,17 and Bell.18
Despite these positive reports, opponents of early
intervention have argued that a second phase of
therapy is frequently necessary, resulting in both
increased length of treatment time and cost.
While this opinion is frequently mentioned in the
literature, there is scant research to substantiate
such a conclusion. Wagers7 reported in a survey
of 100 patients undergoing mixed dentition
treatment a 0.2-month difference in treatment

16 Seminars in Orthodontics, Vol 20, No 1 (March), 2014: pp 16–35

 Space supervision and guidance of eruption
time over those patients treated in the permanent
dentition (21.6 months vs. 21.4 months). Popowich
et al.19 reported very similar results of patients
treated in the mixed dentition with average
treatment durations of 20.25 months in non-
extraction Class I cases.
The short-term and long-term dental health
benefits of early mandibular incisor alignment
also remain unclear and unsubstantiated.
Empirically, one would think that well-aligned
teeth are easier to clean and thus less prone to
plaque-mediated dental disease, namely caries
and periodontal disease. Yet clinical studies fail
to consistently demonstrate a causal relationship.
A 2007 review by Burden20 entitled “Oral Health-
Related Benefits of Orthodontic Treatment” in
this same publication concluded that “ortho-
dontists today could not claim to prevent caries by
orthodontic intervention” and that “orthodontic
treatment confers neither harm nor benefit in
terms of long-term periodontal health.” A more
recent systematic review of the literature by Hafez
et al.21 arrived at this same conclusion.
If not for overall dental health benefits and
with questions regarding multiple-phase effi-
ciency, then why treats crowding in the mixed
dentition? Proponents of early treatment argue
long-term lower incisor positional stability is
better in patients treated during this period.
The study by Dugoni et al.11 is often cited as
evidence supporting such early guidance
intervention. However, while the abstract of
this study shows impressive results with 19 of
25 (76%) patients showing clinically satisfactory
lower anterior alignment 10 years post-retention,
a close review of the study suggests the reader
may be misled by the abstract. Although it is
unclear as to how patients were selected for
the study and while no patients were stated to
receive lower Edgewise treatment, it is clear the
patients received more than just a passive lingual
arch to maintain leeway space. Quoting the
article, “In most cases the lingual arch was
removed and a lower fixed canine-to-canine
retainer was placed” for a period of time. In
addition, 16 (64%) patients had circumferential
fiberotomies and 18 (72%) had interproximal
enamel stripping. In contrast, while the classic
10-year post-retention follow-up study of first
premolar extraction cases by Little et al.22 found
satisfactory incisor alignment to be less than
30%, no circumferential fiberotomies were per-
17
formed on any of the patients, and presumably
none had interproximal enamel stripping. Con-
sequently, to suggest that incisor alignment exhi-
bited better long-term stability in the Dugoni
et al.11 study compared to the first premolar
extraction cases reported by Little et al.22 may be
somewhat misleading. Unfortunately, in another
study by Little et al.23 that examined post-rete-
ntion stability in non-extraction cases treated in
the mixed dentition that involved an increase in
lower arch length, patients treated with lee-
way space preservation were specifically exclu-
ded from the study. The study results involving
mixed dentition arch dimensional expansion did
demonstrate an instability and high relapse
potential even when small amounts of expansion
were utilized to resolve incisor crowding. Con-
sequently, it is unclear whether one can con-
clude resolution of lower crowding via leeway
space preservation is any more stable than either
premolar extractions or mixed dentition arch
expansion. In addition to “relapse” of incisor
alignment, some of the recurrence in crowding is
likely related to normal physiologic changes as
those observed in untreated individuals. The results
of the Belfast longitudinal studies24,25 showed a
mean decrease in crowding of about 1 mm between
7 and 11 years of age; the crowding increased an
average of 2.3 mm from 13 to 18 years.
Given the information available suggesting
post-treatment lower incisor stability is likely
comparable with any of these approaches, the
clinician might again ask—why bother with early
treatment? In an essay entitled “Timing of early
treatment: An overview,” Proffit26 suggested the
indications for considering early treatment
basically involve two issues—the effectiveness
and the efficiency of treatment. The authors of
the present article would argue that two
“guidance of eruption” concepts meet these
effectiveness and efficiency requirements: the
utilization of E-space just prior to exfoliation of
the mandibular second primary molar and the
sequential utilization of leeway space for the
relief of mixed dentition lower incisor crowding.
An understanding of normative eruption pat-
terns and arch dimensional changes in relation
to the primary to mixed dentition transitional
stages is imperative in understanding the
rationale for the various treatment approaches
that will be discussed under the general concept
of “guidance of eruption.”
18 Bell and Sonis
Normative transitional dimensional
changes and anticipatory guidance
Recognition of an impending tooth size–arch
length discrepancy is often first evident in the
primary dentition. The significance of spacing in
the primary dentition (both generalized and
primate spaces) and its relationship to potential
crowding of the permanent incisors is well illus-
trated by the longitudinal study by Leighton,27 the
work of Baume,28–30 and the work of Moorees and
co-workers.31–34 Observing 200 children during
the transition from full primary dentition to
permanent dentition, Leighton27 noted a direct
relationship between the amount of spacing in
the primary dentition and subsequent crowding
of the permanent incisors. Specifically, those
children having 6 mm or more of spacing in
the primary dentition had well-aligned perma-
nent incisors, while approximately two-thirds of
those with no spacing experienced significant
crowding of the permanent incisors. Baume29
also observed a similar relationship, where 44% of
subjects lacking interdental spacing in the
primary dentition exhibited significant crowd-
ing in the permanent dentition while those with
generalized primary spacing transitioned into
normally aligned lower permanent incisors.
The retrospective assessment of adolescents
with well-aligned permanent dentitions by Moo-
rees and Chadha32 showed that the individuals
expressed generalized spacing in the primary
dentition at 5 years of age. There is also some
historical evidence that impending malalignment
of permanent incisors may be seen radiographi-
cally well prior to their eruption.35 Thus, the
clinician seeing children in the primary dentition
can inform parents of potential crowding con-
cerns based on clinical observations supported by
timely radiographs.
On eruption of the lower lateral permanent
incisors, there is a normative increase in lower
intercanine arch width of 2–3 mm, with a range
from 0 to 5 mm.29,32 After lower permanent
incisor transition is complete by 8 years of age,
the normative amount of lower incisor crowding
in the mid-mixed dentition approximates an in-
cisor liability of about 1.5–2 mm, with a standard
deviation of ⫾1 mm.37,38 These dimensional
parameters indicating lower incisor crowding of
1–4 mm are expressed in the vast majority of
children at 8–9 years of age after permanent
lower incisor eruption is complete. Studies of
transitional arch dimensional changes further
document that no future increase in lower
intercanine width will occur after the incisor
eruption is complete.29,32,36,39 These findings
suggest that normative transverse arch dimen-
sional changes do not compensate for the relief
of any malalignment that might be present in the
mid-mixed dentition as the intercanine width is
established by 8 years of age (Fig. 1). Relative to
arch length changes, studies assessing dimen-
sional changes occurring over the course of the
transitional dentition show arch length decre-
ases on average of about 2–3 mm per lower
quadrant.14,33,34,39,40 A slight decrease of about
1 mm, as the first permanent molars erupt and
close any available posterior primary dentition
spaces (i.e., early mesial shift), is mostly offset by
more forward incisor positioning during the
incisor transition. The arch length is generally
stable over the course of the mid- to late-mixed
dentition, but shows a significant average
decrease of 2–3 mm as the final buccal segment
transition occurs with the exfoliation of the
second primary molar and late mesial shift of the
permanent first molars (Fig. 2). Concurrently
with the late transition period and subsequently
into the adolescent years, an additional decrease
in arch length may be associated with uprighting
of the lower incisors as the overbite and overjet
are defined.14 The lack of width increase in the
lower anterior segment after lower lateral
incisors have erupted and the decrease in arch
length concurrent with buccal segment transition
and incisor uprighting combine to result in a
notable decrease in mandibular arch perimeter
as the mixed dentition transitions into the young
permanent occlusion. This arch perimeter
decrease is on the order of 4–6 mm in the
lower arch during this period and helps explain
why mixed dentition incisor crowding either
remains the same or typically worsens more
during the transition to the full permanent den-
tition. As noted, the majority of lower arch peri-
meter reduction occurs as the second primary
molars exfoliate, and the residual space secon-
dary to the size differential between this tooth
and the succedaneous second premolar (i.e.,
“E-space”) is eliminated due to “late” mesial shift
adjustments of the first molars. Prior to this,
minimal arch length change and the increase in
arch width during incisor eruption actually
 Space supervision and guidance of eruption 19

Figure 1. Dimensional changes show an average increase in lower intercanine width of 2–3 mm (range of 0–
5 mm) during incisor transition, with no other increases in the lower intercanine width noted after the lower lateral
incisors have fully erupted by 8 years of age. The normative finding is a resulting average lower incisor crowding of
1.5 mm, with a SD of ⫾1 mm. Thus, lower crowding in the range of 1–4 mm should be expected in the majority of
mixed dentition children at 8–9 years of age.

produce an increased arch perimeter through
the majority of the mid-mixed dentition. The
arch perimeter changes in the mixed to adoles-
cent dentition period are illustrated in Fig. 3
After the lower permanent incisors have
erupted and intercanine width changes have
been realized in terms of anterior space dimen-
sions, any crowding of the incisors should be
considered an established dimensional reality
with no “self-improvement” anticipated through
future growth changes.41 Since arch circumfer-
ence decreases anterior to the first permanent
molars during normal development and with
“space loss” often complicating alignment when
arch integrity has been disrupted by premature
loss of primary molars,42 it is often desirable to
supervise the eruption sequence and positioning
of the permanent teeth during the transitional
occlusion. The review of normative arch dimen-
sional changes revealed that extra space is actu-
ally available within the overall arch prior to
the transition of the buccal dentition as represen-
ted by the size difference between the primary
canines and molars vs. the permanent canines
and premolars.1 This “leeway space” represents a
þ1.7-mm space on average in each lower qua-
drant (overall þ3.4 mm) and provides some
potential for the relief of lower incisor
crowding. Gianelly,9 in a study of 100 mixed
dentition children presenting for orthodontic
needs, reported that 85 patients showed lower
incisor crowding on an average of 4.4 mm, a level
of crowding notably greater than the normative
average of about 2 mm. Gianelly9 calculated via
space analysis that leeway space would provide
adequate room to accommodate an aligned
dentition in 72% of the cases presenting with
incisor crowding. It is important to note that
leeway space is most directly related to the
size difference between second primary molars
and the successor second premolars. This
“E-space” approximates to 2–3 mm in compara-
tive widths, and these are the last teeth to nor-
mally transition in the lower buccal segment eru-
ption sequence.43 Thus, the control of leeway/
E-space through space supervision and guidance

Figure 2. Lower arch length decreases significantly on exfoliation of the lower second primary molar as the
permanent first molars shifts forward toward the available “E-space.” The decrease of 2–3 mm in each lower
quadrant translates to an arch perimeter decrease of 4–6 mm during this late “mesial shift” transition period.
20 Bell and Sonis

Figure 3. An increase in lower arch perimeter during the 2-year incisor eruption period (Inc—age 6–8 years) is
related to increase in intercanine width associated with incisor transition and counter-balanced arch length
adjustments. A stable period of arch dimensions follows during the mid-mixed dentition (8–11 years) until a
dramatic decrease in arch length of 2–3 mm per side is associated with turnover of the buccal dentition, specifically
second primary molar exfoliation. The resultant decrease in arch perimeter associated with the late mesial shift
period (LMS—11–12 years of age) is on the order of 4–5 mm.

of eruption techniques offers potential oppor-
tunities for the clinician to significantly improve
tooth size–arch size adjustments for the relief of
typical levels of dental arch crowding that present
in the mixed dentition age child. Given this
potential, diagnostic procedures to evaluate the
overall space should be instituted to determine
treatment alternatives whenever lower incisor
alignment is disrupted by a lack of lower anterior
space. Perhaps the most widely accepted
diagnostic procedure used to evaluate available
space is the use of a mixed dentition space
analysis. While numerous mixed dentition ana-
lyses have been reported in the literature, studies
by Luu et al.44 and Irwin et al.45 would suggest
that little clinically significant differences exist
between the different methods. If a selected
space analysis indicates the overall arch peri-
meter could accommodate or be within 2–3 mm
of relieving the presented incisor crowding, the
clinician should consider several options to faci-
litate dentition adjustments through a sequenced
and staged guidance of eruption plan with the
timely use of available posterior leeway space.
Stage 1—Eruption guidance in the
mandibular incisor segment (6–9 years
of age)
Disking of primary canines
The first option considered when lower incisor
crowding is in the range of 2–4 mm is disking of
the primary canines to reduce their mesiodistal
diameter in providing additional space to
improve the position of the adjacent permanent
incisors. The technique of reducing the width of
primary canines to provide space for incisor
alignment was likely first introduced in 1851 by
Linderer46 and re-introduced by Hotz3 in the
1960s. Other clinicians have subsequently
presented the concepts of disking both mesial
and distal surfaces of the primary canines to
enhance the space dimensions for lower incisor
alignment.47–51 The disking procedures work
best when the malpositioned permanent incisors
are displaced lingual to the anterior arch form
(Fig. 4). The disking of the mesiolingual corner
of the primary canines provides a “sluiceway” for
the lingually positioned incisors to slide forward
under the muscular pressure of the tongue.
Bilateral disking of the mesiolingual aspect of the
primary canines readily provides space of 1 mm
and up to 2 mm per side for incisor “unraveling”
(2–4 mm overall). With proper slicing of the
mesiolingual corner of the primary canine at the
gingival contact area with the lateral incisor,
there is the potential for no measurable encro-
achment on the overall leeway space in the
quadrant. Labial movement of the lingual dis-
placed incisors may actually increase the midline
arch length and overall arch circumference as
the arch form is rounded out in a forward
direction by the action of the tongue.51
While some clinicians disk the distal surfaces
of the primary canines as well as mesial surfaces
 Space supervision and guidance of eruption 21

Figure 4. Disking the mesiolingual angle of lower primary canines provides additional space for an improved
alignment of the permanent incisors without overly encroaching on leeway space. Two examples of primary canine
mesiolingual disking and the favorable response in terms of incisor alignment are shown. Top images shows one-
time disking using #169 tapered fissure bur and response at 1-year follow-up. Bottom images represents two
sequential disking procedures—first at initial presentation and second at the child0 s 6-month recall visit.

to allow more displacement of the intercanine primary canine width adequately—another

distance, this tends to result in encroachment on
the leeway space as a long-term consideration. In
the case of labial malpositioned incisors, while
disking may provide additional room for incisor
alignment, the lips are a more significant factor
in the balance between muscular forces such that
the result is a lingual flattening of the anterior
segment rather than improved incisor position-
ing and an associated decrease in overall arch
space. In addition to lingual displacement of the
incisors and crowding in the range of 2–4 mm as
indicators for a favorable disking outcome, the
general guidelines and recommended proce-
dures for successful disking of primary canines
are as follows:
1. Local anesthesia (block, infiltration, or topical
anesthetic compound) may be required as the
canine must be sliced subgingivally to com-
pletely free the contact area. Disking just the
crown is not adequate as the contact area is
subgingival. Placement of a wedge is some-
times necessary to protect the lateral incisor
and access the contact area. Thirdly, dentin
exposure is usually necessary to reduce the
indicator for local anesthesia or nitrous oxide
support. Coordinating with restorative work
requiring anesthesia in the area may be
beneficial in treatment planning.
2. A tapered fissured bur (#699 or #169) to
allow effective tooth reduction and access
without injury to adjacent permanent teeth is
recommended. Re-approximating diamond
disks or strips at this stage of development is
not recommended due to risk of soft tissue
injury. Emphasis on the mesiolingual corner
of the primary canine rather than the straight
mesial surface is facilitated with tapered
fissure burs.
3. Timing is critical to allow ease of access and
optimal tooth positioning response. Given the
normative intercanine width increases during
lateral incisor eruption, disking should be
delayed until “wedging” effects of erupting
incisors and arch width increases are realized.
Disking is best around 7 ½ to 8 ½ years of age
in proximity to the completion of lateral
incisor eruption. The primary canine roots
should be relatively intact without ectopic
resorption changes from the erupting lateral
22 Bell and Sonis

incisors or due to the eruption timing of the
lower permanent canines.
Extraction/ectopic loss of primary canines
Most often manifest in a significant tooth size–
arch size discrepancy of 4 mm or more in the
incisor segment, early “ectopic” loss of a single
lower primary canine or even bilateral canine
loss through displaced eruption of permanent
lateral incisors is a significant indicator for a
thorough orthodontic evaluation (Fig. 5). The
ectopic loss of a lower primary canine unilaterally
is frequently followed by lingual and distal
movement of the incisor segment with shifting
of the dental midline toward the side of the pre-
mature primary canine tooth loss. The disruption
in arch integrity further compounds normal
space use for eruption of the permanent cani-
nes and premolars in subsequent development.
The early bilateral loss of both lower primary
canines may allow maintenance of midline
and arch symmetry, but ultimately results in
significant lingual retroclination of permanent
incisors, deepening of overbite, increased
overjet, and bilateral loss of arch length over
time.52–54
If one primary canine is lost ectopically during
incisor eruption, it is usually desirable to extract
the contralateral primary canine to maintain
arch symmetry.52–56 While extraction of the
contralateral primary canine may improve inci-
sor alignment and midline integrity otherwise
distorted by the asymmetric anterior space, the
early loss of both primary canines will mimic the
response seen when bilateral primary canines are
ectopically lost. The result will be lingual retro-
clination of the permanent incisors, deepening
of the overbite, increased overjet, and bilateral
loss of arch length. In either scenario of unilat-
eral or bilateral loss, alignment problems pro-
ducing ectopic loss of primary canines are strong
indicators of a significant incisor liability and
arch length deficiency that will likely become
grossly evident upon permanent canine and
premolar eruption. Much more frequent than
ectopic loss of lower primary canines, the canines
most often remain in the mixed dentition
arrangement with the permanent incisors
erupted with a crowded malposition. While

Figure 5. Unilateral ectopic loss of a lower primary canine typically results in an asymmetric space loss as the
incisors shift toward the side of loss and move lingually (A and B). Bilateral ectopic loss of lower primary canines (C
and D) allows maintenance of arch symmetry, but results in significant lingual retroclination and supraeruption of
the lower incisors, increased overjet, deepened overbite, and reduction in overall lower arch dimensions.
 Space supervision and guidance of eruption 23

Figure 6. Extraction of lower primary canines. (A) Lingually positioned lateral incisors, dental shift to right,
retained left primary lateral. Decision made to extract the primary canines. (B) A year later—symmetry of incisor
alignment achieved at expense of arch length and perimeter through lingual and distal movement of the incisors.

disking of the primary canines as described is the
procedure of first choice, elective extraction of
the primary canines in an attempt to maintain
arch symmetry, coincident midlines, and incisor
positional integrity can be considered under cer-
tain circumstances. Such intervention becomes
more viable when the incisor crowding and lia-
bility is greater than 4 mm or when the eruptive
alignment and dental midline is significantly
skewed toward one side with a totally blocked
incisor from the arch form (Fig. 6). The objective
of lower primary canine extraction is to provide
space in the arch for an improved incisor align-
ment and to maintain midline symmetry with
the thought that negative effects on the occlusion
(i.e., lingual inclination of incisors, deepened
overbite, increased overjet, and additional space
loss) can be overcome through later orthodontic
tooth movement.50,54,56,57 This same concept is
followed if a primary canine is lost unilaterally
during incisor eruption and the contralateral
primary canine is removed in an effort to main-
tain midline symmetry.53,54 The clinician must
remember that early extraction of lower primary
canines will mimic what happens with bilateral
ectopic loss and will likely result in notable lower
anterior arch collapse.55–57 Therefore, the
extraction of primary canines should not be
undertaken without parental understanding of
the consequences and ideally, orthodontic con-
sideration of the long-term implications to the
occlusion. Some clinicians recommend the use of
a lingual holding arch to control the incisor
positioning and prevent encroachment on per-
manent canine positions when lower primary
canines are lost prematurely (Fig. 7). However,
the displacement of the incisors attendant with
ectopic loss or early extraction of lower primary
canines typically contradicts the passive place-
ment of a lingual holding arch at this stage
without first aligning the incisors with active
appliance therapy. Early selective extraction of

Figure 7. Loss of primary canines—what about a lingual holding arch? Usually not that simple as incisors tend to
align along LHA wire shaped to the most lingual position, i.e., loss of arch length as incisors drift distal and lingual
along lingual wire into the canine space.
24 Bell and Sonis
primary canines goes beyond a simple first step in
guidance of eruption and actually represents the
start of either a phased early treatment proto-
col with arch expansion or a serial extraction
program. In the context of a non-extraction
treatment plan as part of first-phase arch devel-
opment, a 2  4 Edgewise setup to decompensate
displacements and position the lower incisors
forward into the proper arch form may be indi-
cated. The goal of such 2  4 treatment in Phase
1 is to establish coincident midlines, normative
overjet and overbite with the maxillary incisors,
and increase arch dimensions for eruption of the
buccal segment dentition to optimize the poten-
tial for a long-term non-extraction treatment
plan. After the incisor alignment has achieved
the proper anterior positioning with the first-
phase mechanics, a lingual holding arch can be
placed as a “retainer” for the achieved incisor
antero-posterior (A-P) positioning (Fig. 8).
Stage 2—Guidance in mandibular canine/
first premolar segment (age 10–11 years)
In patients aged 10–11 years, panoramic evalu-
ation of the exfoliation and eruption patterns of
the posterior segment provides a particular site of
assessment for timely mandibular guidance of
eruption procedures. The clinician should take
note of resorption patterns in the premolar area
as well as desired molar adjustments and leeway
space usage needed to achieve optimal align-
ment while maintaining stable occlusal rela-
tionships. In the usual eruption sequencing, the
lower canine and first premolar frequently erupt
at approximately the same time frame of 10–11
years of age. Since most of the leeway space is
located in the size difference between the second
primary molar and second premolar area, the
canine and first premolar are forced toward a
mesial eruption path.10,41 The resultant align-
ment finds the permanent lower canines posi-
tioned labial to the contact area of the lateral
incisors with exacerbation of any anterior mala-
lignment. To allow distal placement and to
minimize malpositioning of the canine labial to
the lateral incisor, extraction of the primary first
molar (and primary canine if exfoliating impro-
perly) is considered around this time. Disking of
the mesial surface of the second primary molar
may provide additional space for distal position-
ing of the erupting canine and first premolar.
One can utilize up to 2–3 mm of “E-space” with
coordinated disking of the primary canines,
selective extraction of primary canines and first
primary molars, and disking of the mesial surface
of the second primary molars (Fig. 9). This
second stage of intervention continues
the guidance concept of unraveling lower
anterior crowding toward the available posterior
“E-space.” As long as the second primary molars
are maintained in position as abutments against
the fully erupted first permanent molars during
lower canine and first premolar eruption, no
measurable arch length changes should occur
through mesial movement of the first permanent
molars.33,34 As discussed, the major decrease in
lower arch length occurs concurrent with exfo-
liation of the second primary molar as the first
molar shifts forward (i.e., “late” mesial shift) into
the available “E-space.” This forward shift of the
molars upon loss of the second primary molars
typically results in a decrease in lower arch length
of 2–3 mm per mandibular quadrant. Particularly
under the impact of erupting second permanent
molars, the arch length decrease occurs rapidly
from back to front before more anterior teeth
can distalize into the available “leeway” space.
Stage 3—Guidance in mandibular second
premolar/molar segment (age 11–12 years)
Hopefully, the eruption sequence has followed a
normal canine-first premolar-second premolar
pattern so the clinician has had the opportunity
to perform the suggested Stage 1 and Stage 2
guidance procedures with guided canine and
first premolar distal positioning along with relief
of incisor malpositioning. The next critical tim-
ing sequence in a staged guidance program
occurs around 11–12 years of age in association
with the projected exfoliation of the second
primary molars. The second premolars fre-
quently take a path of eruption along the distal
root of the second primary molar and eruption
transition problems may occur. Occasionally,
extraction of the second primary molar is indi-
cated to allow normal eruption of the second
premolar if such atypical patterns are noted. In
addition to assessing the transitional patterns of
the second premolars, consideration should be
given to the placement of a lingual holding arch
or a lip bumper concurrent with removal of the
second primary molars (Fig. 10). If the available
 Space supervision and guidance of eruption 25

Figure 8. Phase 1 2  4 arch development—pre-treatment (upper left): arch changes associated with bilateral
ectopic loss of lower primary canines and narrowed maxillary arch form. Upper 2  4 arch development supported
by E-spyder expander to emphasize fan-like anterior expansion of maxillary arch (upper right). Tieback of NiTi
archwires restrained upper incisors and resulted in some retraction. Lower 2  4 arch development using AW lock
stopped sequential archwires (0.016 NiTi, 0.020 NiTi, and 0.020 SS) to advance lower incisors, correct midline
discrepancy, and increase arch perimeter to accommodate leeway space adjustments (at 4 months). Active
appliances removed at 7-month treatment time (lower left). Retention with upper transpalatal bar and lower
lingual holding arch at 18 months post-treatment maintained achieved arch width and arch length changes. Note
facial profile changes influenced by correcting initial excessive overjet and lip interpositioning.
 26
Bell and Sonis
Figure 9. Removal of primary first molars concurrent with disking the mesial surfaces of second primary molars enhances distal eruptive positioning of the
permanent canine and first premolar as illustrated above on upper left. The case on the lower right had primary canines disked at 8 years and 4 months of age.
After exfoliation of primary canines and first primary molars, lower second primary molars were disked at 10 years and 8 months as the canines and first premolars
erupted. This continued the guidance concept of unraveling anterior crowding toward available leeway/E-space.
 Space supervision and guidance of eruption
Figure 10. Control of late lower arch length decrease using lingual holding arches and selected extraction of second primary molars allows alignment of crowded
lower incisors on the order of 3–4 mm as the buccal dentition (canines and premolars) erupt more distally into the leeway space maintained by the LHA.

27
28 Bell and Sonis
buccal segment space is tight, if the optimal use
of leeway/E-space for crowding is desirable, and/
or if the second permanent molars are erupting
before the second premolars, a lingual arch or lip
bumper may be a critical element in controlling
lower arch dimensions at this point. In the
Gianelly article9 on the value of leeway space
as to treatment timing, lower crowding with an
average discrepancy of 4.4 mm could be
theoretically accommodated in 72% of the
cases that presented with incisor crowding
when the leeway space was calculated into a
space analysis. Subsequent to that article,
treatment-based articles have documented dra-
matic and positive alignment effects in the timely
use of passive lingual holding arches (LHA) for
control of lower leeway space in the late-mixed
dentition.10,11,14–16 These LHA studies, individ-
ually reviewed and presented chronologically,
consistently show that a passive lingual holding
arch placed in conjunction with selected removal
of second primary molars will stabilize perma-
nent first molars from forward mesial drift,
minimize lingual movement of lower incisors,
and allow canines and premolars to erupt distally
as much as 1–2 mm into the held leeway space.
Such leeway space control has been shown to
result in reductions of up to 2–4 mm in lower
incisor irregularity as a consistent finding.
DeBaets and Chiarini10 reported on arch
changes in 39 mixed dentition cases with lower
anterior crowding treated with passive lingual
arch therapy and selected removal of primary
molars. Changes over a 4-year period were
compared to a matched group of 60 untreated
children with similar crowding who received no
space supervision. In untreated subjects, lower
canine and premolar mesial displacement
occurred upon eruption with resulting overlap of
the already crowded lower incisors that worsened
the anterior displacement. In lingual arch sub-
jects, lower anterior crowding decreased an
average of 3–4 mm through the period of second
permanent molar eruption. Lower arch length
decreased less than 1 mm in children with lingual
arches while permanent canines and premolars
erupted an average of 1.5 mm (up to 3.5 mm)
more distally per side than controls. In sum, the
control of molar shifting and sustained arch
length using lingual arches allowed spontaneous
alignment of crowded lower incisors as the den-
tition distalized into the maintained leeway space.
Dugoni et al.11 published similar findings from
25 mixed dentition patients with reductions in
lower incisor crowding greater than 3 mm
demonstrated after placement of passive
lingual arches and selected primary molar
extractions. After an average long-term post-
retention period of 10 years, 19 of the 25 patients
continued to show clinically satisfactory lower
anterior alignment. Compared to 10-year follow-
up of orthodontically aligned patients, these
results show reductions in lower incisor crowding
and long-term stability of the alignment with
lingual arch therapy that was greater than or at
least equal in effectiveness to active orthodontic
treatments.
Rebellato et al.,14 assessing cephalograms,
study models, and tomograms of the mandi-
bular body, reported on arch dimensional chan-
ges in 30 mixed dentition patients presenting
with incisor crowding of 3 mm or more. In 14
patients treated with passive lingual arches, the
arch length did not measurably change over the
course of the eruption of the succedaneous teeth
while an average arch length decrease of
2.5 mm per side was demonstrated in 16
untreated children used as controls. The arch
length changes were related to first molars
moving forward þ1.7 mm in the control group
compared to only þ0.3 mm in the lingual arch
group. Concurrently, incisors tipped forward
slightly in the lingual arch group (þ0.4 mm),
while lingual uprighting of incisors in the con-
trols reduced arch length by 0.65 mm. In sum,
the action of the lingual arch was to reduce
mesial molar migration and incisor lingual move-
ment in controlling the quadrant arch length of
2.49 mm per side compared to non-LHA con-
trols. The additional bilaterally sustained arch
length resulted in concurrent relief of 3–4 mm of
lower incisor crowding in treatment subjects.
Brennan and Gianelly15 quantified the arch
dimensional changes in 107 consecutive mixed
dentition patients treated with passive lingual
arches through eruption of all succedaneous
teeth. Occasional extraction of second primary
molars to facilitate eruption of premolars and
canines was the only other intervention. Arch
length decreased an average of 0.4 mm in the
lingual arch patients while arch width increased
slightly. The patients presented an average
þ4.4 mm of total available lower leeway space,
which resulted in an average decrease in lower
 Space supervision and guidance of eruption
incisor crowding from a pre-treatment level of
4.8 mm to þ0.2 mm of space post-treatment.
The space adjustments were enough to resolve
incisor crowding completely in 65 of the lower
crowding subjects (roughly 60%). An additional
16 subjects (one in six) had a final discrepancy of
less than 1.0 mm and 13 subjects (one in 10) had
a final discrepancy of less than 2 mm. Only 14
patients (13%) had crowding greater than 2 mm
after the full buccal segment eruption was
complete. Of note, the majority of patients with
higher levels of post-treatment crowding pre-
sented with initial ectopic loss of the lower pri-
mary canines. In sum, a passive lingual arch with
selected removal of primary teeth provided
adequate space and eruption guidance to relieve
significant lower incisor crowding in 105 of the
107 subjects.
Villalobos et al.16 reported on 23 patients
treated with lingual arches between 10 and 12
years of age compared to 24 matched untreated
subjects. Molar and incisor movements were
restricted to about a one-half millimeter arch
length decrease for the 18 months of lingual arch
wear while untreated subjects had a decrease of
2 mm in arch length. The lingual arch also
limited first molar extrusion by about 2 mm
compared to non-LHA patients. The study con-
cluded that the lingual arch was effective for
preservation of arch length and control of ver-
tical eruptive movements of banded molars. The
cited consecutive and chronologic LHA studies
consistently confirm that arch length remains
relatively constant or decreases minimally in
patients treated with a passive lingual arch in the
late transitional mixed dentition period. Forward
movement of the lower first molars and lower
incisor lingual movement is reduced notably in
accounting for the relative stability of arch length
which in turn contributed to approximately 4–
5 mm greater arch perimeter than would have
been available after normative arch dimensional
adjustments in the late transitional dentition.
The additional buccal segment space allowed
distal eruptive positioning of the lower canines
and premolars with a positive influence on relief
of incisor crowding in the range of 3–4 mm.
Thus, the timely use of lingual holding arches
and selected extraction of primary molars in the
manner described utilizes the leeway space for
the relief of typical lower crowding amounts that
present in the mixed dentition for about two-
29
thirds to three-fourths of patients. These num-
bers are in line with the percentages predicted by
Gianelly in his original work35 and are confirmed
in the clinical studies reviewed.10–16
Similar to lingual holding arches for the pres-
ervation of lower leeway/E-space, Woods58
reported on the treatment of 182 late-mixed
dentition patients using segmented 2  4 appli-
ances to manage leeway space supervision. All 182
patients were started in treatment while second
primary molars remained and possessed potential
available E-space for relief of crowding. In all
cases, upper and lower 2  4 appliances using
segmental tip-back archwires were applied to
control molar adjustments and incisor alignment.
Buccal segments were bracketed and aligned to
include second molars upon eruption with an
average total treatment time of 28 months. The
actual bilateral E-space measured directly from
models represented a mean of 4.2 mm, with a
range of ⫾1.6 mm. The actual mandibular space
requirements averaged 2.6 ⫾ 3.0 mm. About two-
thirds of patients had 4 mm or less of crowding,
another 25% had 4–8 mm of crowding, and for
about 10%, the crowding was greater than 8 mm.
The 2  4 setup followed by sequential full
appliances controlled arch dimensions such that
the mean change in arch depth was 1.4 mm
after treatment was completed. Molars were held
back and the lower incisors tipped forward less
than 1 mm on average. Canine arch width
increased a mean of 0.9 mm. The greater the
initial crowding was, the greater the dimensional
changes. In most patients with approximately 4–
6 mm of crowding, the control of E-space and the
anterior Edgewise changes accommodated den-
titional alignment. Thus, starting treatment in the
late-mixed dentition using a sequenced 2  4
setup allowed the use of E-space and minimal
anterior expansion needs to provide about 4–
6 mm of space for aligning the mandibular den-
tition. Weinberg and Sadowsky59 reported that
similar amounts of arch dimensional changes
were found in 30 Class I comprehensive
orthodontic patients started in the mixed
dentition for the resolution of mandibular arch
crowding. The phased Edgewise treatment results
represent similar dimensional values as reported
with the use of lower lingual holding arches for
molar and incisor control.
An alternative to lingual holding arches for
E-space preservation is the use of a lip bumper or
30 Bell and Sonis

Figure 11. Case example—Removable lip bumper. Lip bumper placed as lower second primary molars exfoliated
at age 11 years and 6 months. Bumper placement low in vestibule provided holding force on molars while allowing
lip to contour over the bumper to lessen incisor labial movement. After 8 months of bumper wear (age 12 years and
2 months), a significant relief of anterior crowding resulted. Edgewise appliances aligned the dentition into the
established arch form.

lip shield in the late transitional dentition to
enhance the forward positioning of the incisors,
hold the first molar positioning, and allow some
arch development as the buccal segments tran-
sition into the adolescent dentition (Figs. 11 and
12).60–70 Primarily acting through incisor pro-
clination (about þ2 mm on average) as a result
of altered muscle equilibrium between the lip
and tongue, the lip bumper approach also pro-
vides distalization or holding forces against the
banded molars to hold leeway space. The molar
effects are primarily a result of distal crown tip-
ping and not through a true molar bodily dis-
talization. Approximately 1 year of lower lip
bumper wear appears to be necessary to gain 2–
3 mm of arch length beyond the available leeway
space. Additionally, evaluation of lip bumper
wear over the transition time of canine and
premolar eruption indicates that transverse arch
width increases of about 1–3 mm at the canines
 Space supervision and guidance of eruption 31

Figure 12. Case example—Soldered lip bumper placed before second primary molars exfoliated. Bumper
positioned at cervical margins provided holding force on molars, reduced lip contact on incisors to enhance labial
movement. At 6 months (12 years and 5 months), lower crowding reduced through distal movement of canines
and premolars toward E-space, with some arch expansion. Edgewise appliances aligned dentition with retraction of
buccal segments and establishment of a broader arch form.

and 4–5 mm at the molars are possible. Such
increases in arch dimension along with mod-
ifications in muscle function are in turn asso-
ciated with improved anterior alignment and
more laterally developed arches during the active
phase of lip bumper treatment. The application
of lip bumpers in the late-mixed dentition offers
an arch development technique when forward
movement of the incisors can be tolerated, when
distal uprighting and/or anchorage stabilization
of the molars would enhance overall arch length,
and when an increase in arch circumference
might be significant in relieving moderately
crowded incisor levels that are beyond simple
leeway space preservation with lingual holding
arches. Given the reported record of mandibular
expansion approaches with an almost inherent
tendency to return toward pre-treatment levels,
32 Bell and Sonis
the realization of long-term stability without a
structured retention program seems ques-
tionable, though the altered functional envi-
ronment does offer some advantages over more
direct “mechanical” lower expansion approaches
(e.g., Schwarz plates).70
The complications of conventional fixed
appliance therapy rarely manifest themselves in
the limited appliance approaches of mixed denti-
tion guidance of eruption treatment mechanics.
However, preservation of the “E-space” is not a
totally benign intervention. By preventing the
late mesial shift of the lower first permanent
molars, less posterior arch length is available for
the erupting mandibular second permanent
molar with a resulting increase in second molar
eruption problems. A study by Sonis and
Ackerman,71 in examining 200 patients having
undergone E-space preservation with a passive
lingual arch for second molar eruption prob-
lems, reported that 29 patients had at least one
impacted second molar—a four- to five-fold
increase over normative population reports of
impacted lower second molars. A significant
relationship was found between the mandibular
first permanent molar and permanent second
molar angulation patterns and likelihood of
impaction. An intermolar angulation created by
the long axis of the first and second molar of 241
or greater resulted in a positive predictive value
of 1, indicating a high risk of impaction. A similar
study by Rubin et al.72 found that those patients
treated with a fixed lingual arch for E-space
preservation had a 4.7% impaction rate of sec-
ond molars, which was associated with an
increased intermolar angulation and reduced
space distal to the first molar. Consequently, the
prudent clinician observing this relationship will
inform the patient of a likely increased length of
treatment.
Summary of “age-appropriate” and
“staged” guidance of eruption concepts
The control of leeway/“E-space” adjustments in
terms of influencing arch dimensional changes
through various space supervision, and guidance
of eruption techniques offers opportunities to
significantly improve lower tooth size–arch size
discrepancies in the mixed dentition. The relief of
typical levels of lower arch mixed dentition crowd-
ing (i.e., less than 3–4 mm in the mandibular
arch) involves a timely, age-appropriate, sequen-
ced, and staged protocol involving the following:
(1) Preservation of inherent arch dimensions
through a comprehensive preventive, restor-
ative, and space maintenance oversight pro-
gram to optimize the integrity of the primary
and the mixed dentitions throughout the
transitional periods.
(2) After incisor eruption is complete, the aver-
age lower alignment shows crowding of 1.5 ⫾
1.0 mm. No subsequent “growth” changes
will increase lower anterior canine-to-canine
arch dimensions. The preferred approach
during active incisor transition is to allow any
“wedging” effect of eruption to influence
arch dimensions. After lateral incisor erup-
tion is complete at 8 years of age, what you see
is what you get! NOW is the time for Stage 1
decision as to no intervention necessary,
accept as is, disking of the primary canines,
extraction of primary canines, or Phase 1
arch development.
(3) Selected disking of primary canines to
enhance incisor positions when crowding is
in the range of 2–4 mm and the lower
incisors are lingually malpositioned to the
arch form is the first choice of intervention,
especially in deepbite/brachyfacial occlusion
patterns. If intercanine space can be “fine-
tuned” with disking, tongue pressures will
tend to position the lingually displaced
incisors forward into an enhanced arch form
alignment. Intercanine space of 1–2 mm per
side for incisor alignment can be achieved by
disking the mesiolingual corner of the
primary canines to provide “sluiceway” for
incisor alignment once the lateral incisors
are erupted (usually around 7 ½ to 8 ½ years
of age).
(4) Decompensation of severe lower incisor
malpositioning, midline asymmetry associ-
ated with ectopic eruption patterns, and
lower incisor crowding at a level where
removal of lower primary canines is required
to allow proper incisor alignment integrity
(greater than 3–4 mm of liability). Clinicians
must understand and relate to the parent
that the necessity of early primary canine
extraction indicates a significant tooth size–
arch size problems. It is frequently step one
of a serial extraction program, particularly in
 Space supervision and guidance of eruption
vertically sensitive dolichofacial patterns.
The negative effects with lingual collapse
of incisors, arch length loss, deepening of
bite, and increased overjet all are significant
detriments in brachyfacial cases.
Such levels of tooth size–arch size discrep-
ancy may indicate the need for an early
Phase 1 intervention using Edgewise 2  4
mechanics to position incisors and molars
toward favorable Class I relationships, with
incisor integrity, midline coincidence, and
normal overbite and overjet. Crowding and
incisor positioning discrepancies requiring
canine extraction or extensive arch expan-
sion to relieve incisor crowding and offset
negative effects of space loss are candidates
for early 2  4 intervention, and it generally
implies a long-range non-extraction protocol
as compared to a situation where the
extraction of the primary canines is the first
step in a serial extraction plan. The amount
of crowding discrepancy and facial type are
critical factors in the decision-making proc-
ess as to long-term extraction vs. non-extrac-
tion plan. Brachyfacial deepbite patients lead
to a prioritized arch development with arch
expansion to enhance facial balance. Doli-
chofacial openbite patients tend to be
directed toward a serial extraction protocol
that is much more likely to offset vertical
facial imbalance.
(5) Consideration of selective disking of the
mesial surface of the second primary molars
to enhance more distal eruptive position-
ing of the permanent canines and first
premolars.
(6) Timely use of passive lingual holding arches,
lip bumpers, and/or late-staged Edgewise
setups along with selected extraction of
second primary molars to provide space for
relief of typical lower crowding amounts (2–
4 mm). The space control allows canines and
premolars to erupt in more distal positions
than under normal transitional patterns.
This “driftodontics” of the buccal segments
will in turn result in more intercanine
distance for relief of incisor malpositioning
in about two-thirds to three-fourths of
patients. In keeping with the idea of super-
vising space changes in the late transitional
dentition, patients should be evaluated
before the transition of the buccal teeth in
33
each arch. A good clinical guide for timing is
upon the clinical emergence of the lower
canines and first premolars around 10–11
years of age. These teeth erupt about 1 year
ahead of the final buccal segment transition,
leaving adequate time to assess dimensional
needs and plan treatment interventions for
the relief of crowding.
The dimensional parameters presented
through optimal use of available leeway space in
the transitional dentition provide the devel-
opmental potential for a non-extraction protocol
as an achievable priority in the majority of chil-
dren. It is likely that most clinicians would prefer a
non-extraction approach whenever possible
provided other outcome objectives are able to be
met. It is even more likely that patients and
parents would prefer not to have healthy teeth
removed whenever possible. These comments
should not imply that orthodontic extraction of
permanent teeth leads toward a negative result as
a general rule. This is not the case, as a significant
proportion of patients present malocclusion fac-
tors and dentofacial patterns in which an
extraction protocol is consistent with the ach-
ievement of overall esthetic and functional
objectives. As a conceptual model however, a non-
extraction approach for the majority of patients
that possess the developmental potential for a full
complement of teeth provides a sound founda-
tion as a starting point for orthodontic diagnosis
and treatment in the mixed dentition age patient.
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