Best Archwire Sequence for Open Bite Treatment

Anterior open bite (AOB) is a challenging orthodontic malocclusion because successful correction depends on controlling the vertical position and inclination of both anterior and posterior teeth, while addressing the underlying skeletal, dental, and functional factors.

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In patients treated with fixed appliances, archwire selection alone does not determine treatment success. The wire sequence must be integrated with appropriate vertical mechanics, anchorage control, and, when indicated, auxiliary appliances.

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Current evidence supports individualized treatment based on the etiology and severity of the open bite. In particular, posterior intrusion with temporary anchorage devices (TADs) can provide meaningful vertical control, whereas MEAW mechanics and vertical elastics can be useful when dentoalveolar compensation is appropriate.

🔹 What Is the Best Archwire Sequence for Open Bite Treatment?
There is no single archwire sequence supported as superior for every open-bite patient. A practical sequence for patients treated with conventional fixed appliances is:

Treatment Phase	Typical Archwire	Primary Objective
Initial alignment	0.012–0.014 NiTi	Gentle alignment and leveling
Continued alignment	0.016–0.018 NiTi	Progression of alignment while maintaining flexibility
Early working phase	0.016 × 0.022 or 0.017 × 0.025 NiTi	Begin three-dimensional control
Vertical-control phase	0.017 × 0.025 or 0.019 × 0.025 stainless steel/TMA	Rigidity, torque expression, and auxiliary mechanics
Finishing	0.017 × 0.025 or 0.019 × 0.025 stainless steel	Root positioning and occlusal detailing

The exact dimensions should be modified according to bracket prescription, arch form, tooth position, periodontal support, skeletal pattern, and the amount of vertical correction required. The literature does not establish these wire dimensions as a universal evidence-based sequence.

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1. Initial Alignment: Round NiTi
Treatment generally begins with a light round nickel-titanium (NiTi) archwire.
Typical progression may include:
0.012 NiTi → 0.014 NiTi → 0.016 NiTi → 0.018 NiTi
The purpose is primarily alignment and leveling rather than active open-bite closure.
In an open-bite patient, excessive early leveling should be avoided when it produces undesirable posterior extrusion or uncontrolled vertical changes. The clinician should evaluate the vertical position of the molars and incisors before progressing to larger wires.

2. Transition to Rectangular NiTi
Once sufficient alignment has been achieved, a rectangular NiTi archwire can provide improved three-dimensional control.
Examples include:
0.016 × 0.022 NiTi → 0.017 × 0.025 NiTi
or, depending on the bracket system:
0.018 × 0.025 NiTi
This phase allows progressive expression of torque and tip control while maintaining some flexibility.
The rectangular wire should not be considered the principal mechanism for closing the open bite. Its role is to establish adequate tooth control before more rigid vertical mechanics are introduced.

3. Working Archwire: Stainless Steel or TMA
When alignment and leveling are substantially complete, a more rigid rectangular archwire is generally preferable for controlled vertical mechanics.
Common options include:
▪️ 0.017 × 0.025 stainless steel
▪️ 0.019 × 0.025 stainless steel
▪️ 0.017 × 0.025 TMA when greater flexibility is desirable
A rigid working archwire is particularly useful when applying vertical elastics, extrusion mechanics, TAD-supported mechanics, or MEAW-type adjustments.
The choice between 0.017 × 0.025 and 0.019 × 0.025 should not be predetermined. A larger wire may improve control but can also increase force levels and reduce flexibility. Periodontal support and tooth mobility must therefore be considered.

4. Vertical Elastics: An Important Auxiliary
Anterior vertical elastics are frequently used after adequate arch coordination has been established.
They can be attached between:
▪️ maxillary and mandibular incisors,
▪️ canine-to-canine regions, or
▪️ selected anterior segments according to the required force system.
Their principal effect is dentoalveolar extrusion of the anterior teeth, so they are most appropriate when anterior extrusion is compatible with the patient's smile esthetics, incisor display, and skeletal pattern.
Clinical studies have demonstrated successful open-bite correction using vertical elastics combined with posterior vertical control and MEAW mechanics.

5. TADs for Posterior Vertical Control
For patients in whom excessive posterior dentoalveolar height contributes significantly to the open bite, temporary anchorage devices (TADs) may provide a more appropriate biomechanical strategy than relying primarily on anterior extrusion.
TAD-supported posterior intrusion can produce:
▪️ molar intrusion
▪️ counterclockwise mandibular autorotation in appropriate patients
▪️ reduction of anterior facial height in selected cases
▪️ improvement of anterior overbite

A 2025 systematic review and meta-analysis reported a pooled mean molar intrusion of approximately 1.70 mm with TAD-supported treatment, although substantial heterogeneity existed among studies.
Another systematic review reported approximately 2.89 mm of maxillary molar intrusion with skeletal anchorage, with greater effects reported for miniplates than miniscrews.
Therefore, TADs should be considered particularly when the treatment objective is posterior intrusion rather than simply anterior extrusion.

🔹 Additional Appliances Used With Fixed Brackets
Open-bite treatment frequently requires auxiliary appliances in addition to the archwire.

Auxiliary	Main Indication	Principal Biomechanical Role
Vertical elastics	Mild–moderate dentoalveolar AOB	Anterior extrusion and settling
TADs / miniscrews	Skeletal or posterior vertical excess	Posterior intrusion and anchorage
Palatal crib	Persistent tongue-thrusting or habit-related AOB	Habit modification and tongue control
Bonded lingual spurs	Selected patients with abnormal tongue posture or habits	Restriction of anterior tongue pressure
MEAW	More complex dentoalveolar or skeletal open bite	Posterior uprighting, occlusal-plane control, and anterior extrusion
Posterior bite blocks	Selected growing patients	Vertical control and posterior eruption modification
High-pull headgear / chin cup	Selected growing patients	Additional orthopedic and vertical control

Evidence for habit-breaking appliances is strongest in growing patients with a functional component. Systematic reviews have found that palatal cribs, bonded spurs, and related appliances can improve overbite, although the certainty of evidence varies.

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🔹 MEAW Mechanics: When Should They Be Considered?
The Multiloop Edgewise Archwire (MEAW) technique remains an option for selected open-bite patients, particularly when detailed control of posterior tooth inclination and the occlusal plane is required.
A typical MEAW approach uses a rectangular stainless-steel wire with multiple loops and is frequently combined with vertical elastics.
Clinical studies have reported approximately 4 mm of overbite improvement following MEAW therapy, with favorable stability reported in selected patients. However, much of the literature consists of observational studies and treatment reports rather than high-level comparative trials.
Consequently, MEAW should be regarded as a specific biomechanical technique, not as a universally superior archwire sequence.

🔹 Archwire Sequence According to Treatment Objective
The most appropriate sequence depends more on the vertical problem being treated than on wire size alone.

Clinical Situation	Preferred Strategy
Mild dental open bite	Alignment → rectangular working wire → vertical elastics
Open bite associated with tongue habit	Fixed appliances + habit control/crib or spurs + vertical mechanics
Increased posterior dentoalveolar height	Rigid rectangular wire + TAD-supported molar intrusion
Significant skeletal open bite in a nonsurgical patient	Rigid rectangular mechanics ± MEAW + TADs/elastics
Severe skeletal discrepancy	Orthodontic camouflage or orthognathic surgery, depending on diagnosis
Finishing after bite closure	Rigid rectangular stainless steel + controlled settling

💬 Discussion
The principal limitation of describing a single “best archwire sequence” is that open bite is not a uniform biomechanical problem. A patient with predominantly anterior dentoalveolar deficiency requires a different force system from a patient with excessive posterior dentoalveolar height or a pronounced skeletal vertical pattern.
The current evidence increasingly favors vertical control rather than indiscriminate anterior extrusion when posterior vertical excess is present. TAD-supported molar intrusion has demonstrated clinically relevant improvements in overbite, although treatment outcomes vary substantially between studies.
MEAW mechanics can also produce substantial open-bite correction, but the evidence base is less robust and should not be interpreted as proof that MEAW is superior to conventional rectangular archwires combined with appropriate auxiliaries.
Long-term stability remains an important consideration. A systematic review of TAD-supported molar intrusion found approximately 1.23 mm of standardized overbite relapse, with reported molar relapse of approximately 12% for maxillary molars and 27.2% for mandibular molars. The certainty of evidence was low to very low.
Therefore, etiologic diagnosis, vertical anchorage, controlled tooth movement, and retention are more important than selecting a particular wire sequence in isolation.

🎯 Clinical Recommendations
1. Do not use a fixed archwire sequence for every open-bite patient. Adapt wire progression to the vertical diagnosis and periodontal condition.
2. Use round NiTi primarily for alignment, progressing to rectangular NiTi once adequate alignment permits three-dimensional control.
3. Introduce rigid rectangular mechanics before demanding vertical movements with elastics, TADs, or MEAW.
4. When posterior vertical excess is a major component, prioritize posterior intrusion rather than relying exclusively on anterior extrusion.
5. Use TADs when reliable posterior anchorage and intrusion are required, particularly in nongrowing patients with skeletal or dentoalveolar vertical excess.
6. Reserve MEAW mechanics for cases in which its specific control of posterior inclination and the occlusal plane provides a biomechanical advantage.
7. Plan retention from the beginning. Open-bite correction has a recognized relapse tendency, particularly when the original functional or skeletal factors remain unresolved.

✍️ Conclusion
The best archwire sequence for open bite treatment is not a single standardized progression of wire sizes. A practical approach is to begin with light round NiTi for alignment, transition to rectangular NiTi for three-dimensional control, and use a rigid rectangular stainless-steel or TMA working wire for vertical mechanics and finishing.
However, the decisive factor is the force system applied to the malocclusion. Vertical elastics may be sufficient in mild dentoalveolar cases, whereas TAD-supported posterior intrusion or MEAW mechanics may be more appropriate when greater vertical control is required. The final treatment strategy should therefore be based on the patient's skeletal pattern, posterior vertical dimension, incisor display, functional factors, growth status, and periodontal support rather than on archwire size alone.

📚 References

✔ Alsafadi, A. S., Alabdullah, M. M., Saltaji, H., Abdo, A., & Youssef, M. (2016). Effect of molar intrusion with temporary anchorage devices in patients with anterior open bite: A systematic review. Progress in Orthodontics, 17, 9. https://doi.org/10.1186/s40510-016-0122-4
✔ Burgos-Lancero, P., Ibor-Miguel, M., Marqués-Martínez, L., Boo-Gordillo, P., García-Miralles, E., & Guinot-Barona, C. (2025). Correction of anterior open bite using temporary anchorage devices: A systematic review and meta-analysis. Journal of Clinical Medicine, 14(14), 4958. https://doi.org/10.3390/jcm14144958
✔ Kim, Y. H., Han, U. K., Lim, D. D., & Serraon, M. L. (2000). Stability of anterior openbite correction with multiloop edgewise archwire therapy: A cephalometric follow-up study. American Journal of Orthodontics and Dentofacial Orthopedics, 118(1), 43–54. https://doi.org/10.1067/mod.2000.104830
✔ Omidkhoda, M., Bardideh, E., Jahanbin, A., & Zarei, M. (2023). Effects of posterior intrusion using skeletal anchorage on treating anterior open bite: A systematic review and meta-analysis. Journal of Dental Research, Dental Clinics, Dental Prospects, 17, 196–210. https://doi.org/10.34172/joddd.2023.40754
✔ Papageorgiou, S. N., Konstantinidis, I., Papadopoulou, K., Jäger, A., & Bourauel, C. (2014). A systematic review and meta-analysis of experimental clinical evidence on initial aligning archwires and archwire sequences. Orthodontics & Craniofacial Research, 17(4), 197–215. https://doi.org/10.1111/ocr.12048
✔ Peterkin, C., Abu Arqub, S., Murphy, N., Karanth, D., & Dolce, C. (2024). A retrospective comparative cephalometric evaluation of non-extraction multiloop edgewise archwire and bicuspid extraction therapies in anterior open bite treatment. Clinical Oral Investigations, 28, 569. https://doi.org/10.1007/s00784-024-05966-y

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Pediatric Endodontics: Current Concepts and Techniques

Pediatric endodontics focuses on preserving primary and immature permanent teeth affected by dental caries, trauma, developmental abnormalities, or pulpal and periapical disease.

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Contemporary management has shifted from a predominantly tissue-removal approach toward biologically based pulp therapy, emphasizing preservation of healthy pulp tissue whenever possible.

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Current recommendations distinguish treatment according to pulpal diagnosis, tooth restorability, root development, and the expected lifespan of the tooth.
For primary teeth, evidence increasingly supports indirect pulp treatment and calcium-silicate cement pulpotomy for appropriately selected vital teeth. In immature permanent teeth, maintaining pulp vitality is particularly important because it permits continued root maturation and apexogenesis.

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✅ Pulpal Diagnosis in Children
Accurate diagnosis is the foundation of pediatric endodontic treatment. Clinical history, symptoms, clinical examination, radiographic findings, and, when appropriate, pulp sensibility testing should be interpreted collectively.
In primary teeth, symptoms may be less predictable than in permanent teeth; therefore, clinical and radiographic findings should not be interpreted in isolation. Important findings include spontaneous or lingering pain, abnormal mobility, swelling, sinus tract formation, furcation radiolucency, pathological root resorption, and changes in the supporting tissues.

The principal diagnostic categories include:
▪️ Normal pulp
▪️ Reversible pulpitis
▪️ Symptomatic or asymptomatic irreversible pulpitis
▪️ Pulp necrosis
▪️ Previously treated or previously initiated therapy, when applicable
The treatment objective is not simply to eliminate pain but to control infection and preserve the tooth and surrounding tissues for as long as clinically appropriate.

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✅ Vital Pulp Therapy in Primary Teeth
For primary teeth with normal pulp or reversible pulpitis, contemporary management favors conservative approaches that preserve radicular pulp vitality.

Indirect Pulp Treatment
Indirect pulp treatment (IPT) is particularly useful for deep carious lesions when the pulp is considered vital and there are no clinical or radiographic findings indicating irreversible disease.
Selective caries removal reduces the probability of pulp exposure while allowing the remaining dentin and pulp-dentin complex to maintain biological activity. The 2024 AAPD guideline provides strong evidence supporting IPT for deeply carious primary teeth.

Pulpotomy
A pulpotomy removes the coronal pulp while preserving the radicular pulp. It remains an important treatment for vital primary teeth when caries removal results in exposure and the remaining radicular pulp is considered capable of healing.
Current evidence favors calcium-silicate materials, particularly mineral trioxide aggregate (MTA) and Biodentine, over several traditional pulpotomy medicaments. The AAPD 2024 guideline found higher 24-month success with IPT or calcium-silicate cement pulpotomy compared with several alternative approaches.
Consequently, calcium-silicate cement pulpotomy has become a major contemporary approach in primary-tooth vital pulp therapy.

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✅ Non-Vital Pulp Therapy in Primary Teeth
When a primary tooth presents with irreversible pulpitis or pulp necrosis, treatment generally requires removal of infected or necrotic tissue.

Pulpectomy
Pulpectomy involves removal of the pulp from the entire root canal system, followed by canal debridement, disinfection, and filling with a resorbable material.
Hand and rotary instrumentation can both be used. Evidence reviewed by the AAPD indicates that rotary instrumentation can substantially reduce instrumentation time without demonstrating a significant difference in filling quality or overall treatment success compared with manual instrumentation.
Irrigation is an essential component of canal disinfection. Sodium hypochlorite may be used at appropriate concentrations, but because of its tissue toxicity, extrusion beyond the root apex must be avoided. The final obturation material should be compatible with the physiologic resorption of primary roots.

Lesion Sterilization and Tissue Repair
Lesion sterilization and tissue repair (LSTR) is a non-instrumentation or minimally instrumented approach involving antimicrobial agents. It may have a role in selected primary teeth, particularly when conventional pulpectomy is unfavorable.
However, the evidence indicates that its application should be selective. LSTR may be advantageous in teeth with preoperative root resorption, whereas conventional pulpectomy performs better when roots remain intact. Close clinical and radiographic follow-up is therefore essential.

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✅ Vital Pulp Therapy in Immature Permanent Teeth
The management of immature permanent teeth differs fundamentally from that of primary teeth because preservation of vital pulp tissue can allow continued physiologic root development.

For permanent teeth with normal pulp or reversible pulpitis, contemporary options include:
▪️ Indirect pulp treatment
▪️ Direct pulp capping
▪️ Partial pulpotomy
▪️ Complete pulpotomy
The 2025 AAPD guideline indicates that selective caries removal is strongly recommended for deep caries in permanent teeth with normal pulp or reversible pulpitis. When pulp exposure occurs, calcium-silicate materials may be used for direct pulp capping, partial pulpotomy, or complete pulpotomy.

Partial Pulpotomy
Partial pulpotomy removes a limited portion of inflamed coronal pulp while preserving deeper healthy tissue. It is particularly relevant for traumatic exposures and selected carious exposures.
For traumatic exposures, the Cvek technique removes approximately 1–3 mm of superficial inflamed pulp, or more when necessary to reach healthy tissue. Hemostasis and a biologically compatible pulp-capping material are then required.

Complete Pulpotomy
Contemporary evidence has expanded the potential indications for complete pulpotomy in permanent teeth. In selected teeth with symptoms traditionally associated with irreversible pulpitis, complete pulpotomy may be considered when the pulp remains vital and adequate hemostasis can be achieved.
The 2025 AAPD guideline recommends calcium-silicate materials for vital pulp therapy and emphasizes appropriate hemostasis, with sodium hypochlorite recommended for pulp-hemostasis procedures.

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✅ Apexogenesis, Apexification, and Regenerative Endodontics
The primary biological objective in an immature permanent tooth with vital pulp is apexogenesis, allowing continued root development and thickening of the dentinal walls.
When the pulp is necrotic, conventional treatment may compromise further physiologic root development. Depending on the clinical situation, regenerative endodontic procedures or apexification may therefore be considered.
Regenerative approaches aim to promote continued root maturation and development of the apical region. Treatment selection should consider the stage of root development, infection control, restorability, and the long-term prognosis of the tooth. The current AAPD framework includes apexification and regenerative endodontics among the principal options for non-vital immature permanent teeth.

✅ Contemporary Materials and Techniques

Clinical Situation	Preferred Contemporary Approach	Key Consideration
Deep caries, vital primary tooth	Indirect pulp treatment	Selective caries removal and an effective coronal seal
Pulp exposure in a vital primary tooth	Calcium-silicate pulpotomy	MTA or another appropriate calcium-silicate cement
Necrotic primary tooth	Pulpectomy	Effective disinfection and resorbable obturation
Immature permanent tooth, vital pulp	Vital pulp therapy	Preserve vitality and promote apexogenesis
Traumatic pulp exposure	Partial pulpotomy	Remove inflamed superficial pulp and obtain hemostasis
Necrotic immature permanent tooth	Regenerative endodontics or apexification	Root maturity, infection control, and long-term prognosis

Table based on current AAPD recommendations and contemporary evidence.

✅ Technical Principles for Pediatric Endodontic Procedures
Successful pediatric endodontics depends not only on treatment selection but also on infection control, isolation, tissue preservation, and coronal sealing.

Isolation
Rubber dam isolation should be considered fundamental whenever endodontic treatment is performed. It improves moisture control, reduces microbial contamination, and protects the child from aspiration or ingestion of instruments and materials.

Magnification
Magnification can improve visualization of pulp tissue and facilitate assessment during vital pulp procedures. Its value is particularly relevant when determining the quality of the remaining pulp and controlling hemorrhage.

Hemostasis
In vital pulp therapy, controlled hemorrhage is an important clinical indicator. Persistent bleeding may indicate more extensive inflammation and influence the decision to remove additional pulp tissue or change the treatment approach.

Coronal Seal
A durable coronal restoration is essential because bacterial leakage can compromise otherwise successful pulp therapy. The definitive restoration should provide an effective seal and sufficient structural protection for the expected life of the tooth.

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💬 Discussion
The contemporary concept of pediatric endodontics is increasingly centered on biological preservation rather than routine removal of the entire pulp. This is particularly evident in the growing evidence supporting IPT and calcium-silicate pulpotomy in primary teeth and vital pulp therapy in immature permanent teeth.
The 2024 AAPD guideline found high-certainty evidence favoring IPT and calcium-silicate cement pulpotomy for deeply carious vital primary teeth. It also moved clinical practice further away from several traditional medicaments, including calcium hydroxide as a primary pulpotomy medicament and toward calcium-silicate materials.
At the same time, the 2025 AAPD guideline for permanent teeth reflects an important conceptual change: irreversible pulpitis does not automatically require complete pulpectomy or conventional root canal treatment when the pulp remains clinically viable and the tooth can be appropriately managed. Selected cases may benefit from partial or complete pulpotomy using calcium-silicate materials.
Nevertheless, evidence quality is not uniform across all pediatric endodontic interventions. Treatment decisions should therefore integrate the best available evidence with clinical diagnosis, tooth restorability, root development, infection status, patient cooperation, and long-term prognosis.

🎯 Clinical Recommendations
1. Prioritize biological diagnosis over symptoms alone. Combine history, clinical examination, radiographic findings, and pulp testing when appropriate.
2. Preserve vital pulp tissue whenever predictable healing is possible, particularly in immature permanent teeth where vitality supports continued root development.
3. Consider IPT as a first-line approach for appropriately selected deeply carious vital primary teeth, avoiding unnecessary pulp exposure.
4. When pulpotomy is indicated in a primary tooth, calcium-silicate cements such as MTA or Biodentine should be strongly considered based on current evidence.
5. For necrotic primary teeth, select pulpectomy or carefully indicated LSTR according to root resorption, infection, restorability, and prognosis.
6. In immature permanent teeth, consider partial or complete pulpotomy before conventional root canal treatment when the pulp remains potentially reparable and adequate hemostasis can be achieved.
7. Do not compromise apical development unnecessarily. Preservation of pulp vitality in immature permanent teeth should remain a major treatment objective.
8. Establish an effective coronal seal and schedule clinical and radiographic follow-up, because treatment success depends on both biological management and restoration quality.

✍️ Conclusion
Pediatric endodontics has evolved toward conservative, biologically oriented treatment. Current evidence supports indirect pulp treatment and calcium-silicate pulpotomy as important approaches for selected primary teeth, while vital pulp therapy has an increasingly important role in immature permanent teeth.
The fundamental principle is to match the intervention to the biological condition of the pulp rather than relying exclusively on historical treatment protocols. Accurate diagnosis, strict isolation, effective disinfection, appropriate biomaterials, durable coronal sealing, and systematic follow-up remain essential to achieving predictable outcomes.

📚 References

✔ American Academy of Pediatric Dentistry. (2026). Pulp therapy for primary and immature permanent teeth. In The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry.
✔ Coll, J. A., Dhar, V., Chen, C.-Y., Crystal, Y. O., Guelmann, M., Marghalani, A. A., AlShamali, S., Xu, Z., Glickman, G. N., & Wedeward, R. (2024). Use of vital pulp therapies in primary teeth 2024. Pediatric Dentistry, 46(1), 13–26.
✔ Coll, J. A., Dhar, V., Chen, C.-Y., et al. (2023). Primary tooth vital pulp treatment interventions: Systematic review and meta-analyses. Pediatric Dentistry, 45(6), 474–546.
✔ Coll, J. A., Vargas, K., Marghalani, A. A., et al. (2020). Use of non-vital pulp therapies in primary teeth. Pediatric Dentistry, 42(5), 337–349.
✔ Coll, J. A., Dhar, V., Guelmann, M., Crystal, Y. O., Chen, C.-Y., Marghalani, A. A., Alshamali, S., Xu, Z., Ather, A., Sabeti, M., & Wedeward, R. (2025). Guideline for use of vital pulp therapy in permanent teeth. Pediatric Dentistry, 47(5), 299–311.
✔ Duggal, M., Gizani, S., Albadri, S., Krämer, N., Stratigaki, E., Tong, H. J., Seremidi, K., Kloukos, D., BaniHani, A., Santamaría, R. M., Hu, S., Maden, M., Amend, S., Boutsiouki, C., Bekes, K., Lygidakis, N., Frankenberger, R., Monteiro, J., Anttonen, V., ... Parekh, S. (2022). Best clinical practice guidance for treating deep carious lesions in primary teeth: An EAPD policy document. European Archives of Paediatric Dentistry, 23(5), 659–666. https://doi.org/10.1007/s40368-022-00718-6
✔ Da Silva, E. J. N. L., et al. (2024). Success of primary teeth pulpotomy using calcium silicate cements: A systematic review and meta-analysis of randomized clinical trials. Pediatric Dentistry, 46(6), 373–395.

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Bruxism Splints in Children: Are They Recommended?

Bruxism in children is a common masticatory muscle activity characterized by repetitive tooth grinding or clenching during sleep or wakefulness.

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One of the most debated questions in pediatric dentistry is whether myorelaxant splints (occlusal splints) should be prescribed to manage bruxism in growing children.
Current scientific evidence indicates that splints should not be considered a routine treatment for pediatric bruxism because their effectiveness remains uncertain, while craniofacial growth and tooth eruption require careful clinical consideration. Instead, management should focus on identifying associated factors, evaluating symptoms, and individualizing treatment according to each child's clinical presentation.

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✅ What Is Bruxism in Children?
According to contemporary international consensus, sleep bruxism is a rhythmic or non-rhythmic masticatory muscle activity that may involve tooth grinding, clenching, bracing, or mandibular thrusting during sleep. In children, diagnosis is usually based on parental reports combined with clinical findings such as tooth wear, grinding sounds, muscle discomfort, or functional symptoms rather than instrumental confirmation alone.
Importantly, physiological tooth wear may occur during normal development, especially in the primary dentition. Therefore, tooth wear by itself should not be interpreted as definitive evidence that treatment is necessary. Clinical relevance depends on symptoms, progression, functional impairment, and associated risk factors.

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✅ Are Myorelaxant Splints Recommended for Children?
The short answer is not routinely.
Occlusal splints are widely used in adult dentistry for several indications, particularly temporomandibular disorders and tooth protection. However, evidence supporting their effectiveness for treating bruxism in children remains limited and inconclusive.
Recent systematic reviews evaluating pediatric sleep bruxism found that occlusal splints did not demonstrate consistent superiority over observation or other conservative approaches. Some small clinical studies reported reductions in parental reports of grinding, whereas others using objective muscle activity measurements found no significant reduction in sleep bruxism activity after splint therapy. Consequently, current evidence does not justify prescribing splints as the standard treatment for every child with bruxism.
The International Association of Paediatric Dentistry (IAPD) recognizes that occlusal splints may be included among individualized management options, but emphasizes that treatment should be based on comprehensive diagnosis rather than the presence of tooth grinding alone. Similarly, contemporary pediatric literature stresses that growth and continuous dental eruption require close monitoring whenever an intraoral appliance is used.

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✅ Evidence-Based Indications and Limitations
The following table summarizes the current clinical position regarding occlusal splints in pediatric patients.

Clinical Situation	Current Evidence-Based Interpretation
Asymptomatic sleep bruxism	Routine splint therapy is not recommended; periodic observation is generally preferred.
Progressive tooth wear with functional concern	A splint may be considered individually for tooth protection after comprehensive assessment.
Muscle pain or temporomandibular symptoms	Management should prioritize diagnosis of the underlying condition; splints are only one possible reversible therapy.
Mixed dentition and active eruption	Appliances require frequent monitoring and adjustment because dentition and occlusion are continuously changing.
Grinding without clinical damage	Education, monitoring, and evaluation of associated factors usually provide greater clinical value than immediate appliance therapy.

✅ When Could a Splint Be Considered?
Although splints are not routinely indicated, there are selected situations where an occlusal appliance may be considered by a pediatric dentist after careful evaluation.

Potential indications include:
▪️ Severe and progressive tooth wear with risk of structural damage.
▪️ Documented functional symptoms associated with excessive parafunctional activity.
▪️ Children presenting with painful masticatory muscle overload when a reversible appliance is considered appropriate within a broader management plan.
▪️ Situations where the primary objective is tooth protection rather than elimination of bruxism.
These indications should never be interpreted as automatic criteria. The decision depends on growth stage, dentition, eruption pattern, occlusal development, symptoms, and the presence of contributing medical or sleep-related conditions.

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✅ Why Are Splints More Complex in Growing Children?
Unlike adults, children experience continuous craniofacial growth and dental eruption. This biological characteristic represents the principal limitation of prolonged occlusal appliance therapy.
A splint fabricated during one developmental stage may gradually lose adaptation as teeth erupt or exfoliate. Poor adaptation may alter occlusal contacts or reduce appliance effectiveness, making regular clinical follow-up essential whenever a splint is prescribed. For this reason, pediatric occlusal splints should be regarded as carefully monitored reversible appliances rather than long-term universal therapy.

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💬 Discussion
The current literature demonstrates an important distinction between protecting the dentition and treating the bruxism itself. Occlusal splints may theoretically reduce mechanical consequences of grinding by distributing occlusal forces and protecting tooth surfaces; however, this does not necessarily mean they reduce the underlying masticatory muscle activity responsible for sleep bruxism.
Systematic reviews consistently conclude that the quality of available pediatric evidence is low and that treatment protocols remain insufficiently supported by robust randomized clinical trials. The most recent umbrella and systematic reviews emphasize that associated factors—including sleep disturbances, respiratory conditions, psychosocial influences, and individual clinical characteristics—should receive greater attention than routine appliance therapy. Therefore, contemporary pediatric dentistry favors an individualized, conservative, and evidence-based approach rather than universal splint prescription.

✍️ Conclusion
Myorelaxant splints are not routinely recommended for treating bruxism in children. Current scientific evidence does not demonstrate sufficient consistency to support their universal use as first-line therapy.
When clinically indicated, an occlusal splint should be prescribed primarily as a reversible protective intervention, not as a guaranteed treatment capable of eliminating pediatric bruxism. Comprehensive diagnosis, identification of associated factors, and periodic monitoring remain the foundation of evidence-based management in growing patients.

🎯 Clinical Recommendations
▪️ Do not prescribe an occlusal splint solely because parents report nocturnal tooth grinding.
▪️ Assess tooth wear progression, muscle symptoms, TMJ function, sleep history, and respiratory factors before deciding on treatment.
▪️ Consider splints only when there is a clear clinical objective, particularly protection of dental structures or management of specific reversible symptoms.
▪️ Schedule regular follow-up visits to monitor appliance fit during primary and mixed dentition, adapting the appliance as eruption and growth occur.
▪️ Refer for pediatric or sleep evaluation when clinical findings suggest obstructive sleep disorders or relevant systemic contributing factors.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). *Management of the developing dentition and occlusion in pediatric dentistry*. The Reference Manual of Pediatric Dentistry.
✔ American Academy of Pediatric Dentistry. (2024). *Temporomandibular disorders in children and adolescents, including those with special health care needs*. The Reference Manual of Pediatric Dentistry.
✔ Hardy, R. S., & Bonsor, S. J. (2021). The efficacy of occlusal splints in the treatment of bruxism: A systematic review. *Journal of Dentistry, 108*, 103621. https://doi.org/10.1016/j.jdent.2021.103621
✔ Huynh, N., Lavigne, G. J., et al. (2024). Sleep bruxism in children and adolescents: A scoping review. *Journal of Oral Rehabilitation, 51*(1). https://doi.org/10.1111/joor.13603
✔ International Association of Paediatric Dentistry. (2022). *Management of bruxism in children: Consensus recommendations*. IAPD Foundational Articles and Recommendations.
✔ Minervini, G., Franco, R., Marrapodi, M. M., et al. (2024). Sleep bruxism in children main methods of treatment: A systematic review with meta-analysis. *Journal of Clinical Pediatric Dentistry, 48*(5), 41–50. https://doi.org/10.22514/jocpd.2024.102
✔ Restrepo-Serna, C., & Winocur, E. (2023). Sleep bruxism in children, from evidence to the clinic: A systematic review. *Frontiers in Oral Health, 4*, 1166091. https://doi.org/10.3389/froh.2023.1166091
✔ Silva, F. S., et al. (2022). Management of idiopathic sleep bruxism in children and adolescents: A systematic review of the literature. *Journal of Oral Rehabilitation, 49*(2), 210–219.
✔ Soares, J. P., et al. (2024). Childhood and adolescents sleep bruxism treatment: A systematic review. *Sleep Science*.

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Space Maintainer Classification: Types & Clinical Uses

Space maintainers are orthodontic appliances designed to preserve the position of adjacent teeth and maintain available arch space following the premature loss of primary teeth.

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Their primary objective is to prevent unwanted tooth migration that may compromise the eruption path of the permanent successor.

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The American Academy of Pediatric Dentistry (AAPD) currently classifies space maintainers primarily according to their method of retention and distribution within the dental arch.
Contemporary clinical decision-making also considers the tooth lost, dental age, eruption status of the permanent successor, occlusion, existing crowding, oral hygiene, and patient cooperation.

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🔹 Classification of Space Maintainers
Space maintainers can be broadly classified as fixed or removable. Fixed appliances can be further categorized as unilateral or bilateral according to their extension and anchorage.

Classification	Examples	Typical Clinical Use
Fixed unilateral	Band and loop, crown and loop, distal shoe	Premature loss of a single primary tooth or localized space
Fixed bilateral	Lower lingual holding arch, Nance appliance, transpalatal arch	Bilateral space management and preservation of arch length
Removable	Removable partial denture, Hawley-type appliance	Selected cases requiring appliance removal or replacement of multiple teeth

The AAPD specifically describes fixed unilateral appliances as including band-and-loop, crown-and-loop, and distal-shoe designs, while fixed bilateral appliances include the lower lingual holding arch, Nance appliance, and transpalatal arch. Removable options include partial dentures and Hawley-type appliances.

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1. Fixed Unilateral Space Maintainers
These appliances generally preserve space on one side of the arch.
Band and loop is one of the most commonly used designs following premature loss of a primary molar. It is particularly useful when a single primary first molar has been lost and the adjacent teeth provide suitable anchorage.
Crown and loop follows the same basic principle but uses a stainless-steel crown as the abutment. It can be advantageous when the abutment tooth has extensive structural loss and requires full-coverage restoration.
Distal shoe is a specialized appliance used primarily when a second primary molar is lost prematurely before eruption of the permanent first molar. Its intra-alveolar extension guides the eruption of the permanent molar and helps prevent mesial migration. Recent evidence suggests favorable eruption outcomes, although case selection and technical execution remain important.

2. Fixed Bilateral Space Maintainers
These appliances provide bilateral anchorage and are particularly useful when space must be controlled across a larger portion of the dental arch.
Common examples include:
▪️ Lower lingual holding arch (LLHA): commonly used in the mandibular arch during the mixed dentition.
▪️ Nance appliance: primarily used in the maxillary arch, with acrylic support against the anterior palatal tissues.
▪️ Transpalatal arch (TPA): connects the maxillary molars and provides transverse and anteroposterior control.
These appliances are especially relevant when bilateral primary molar loss or preservation of leeway space requires greater arch-wide control.

3. Removable Space Maintainers
Removable space maintainers are typically acrylic-based appliances that can be removed by the patient or clinician. Examples include removable partial dentures and Hawley-type appliances.
Their principal advantages include easier cleaning and the possibility of replacing multiple missing primary teeth. However, their effectiveness depends substantially on patient compliance, making them less predictable in children who do not consistently wear the appliance. Recent clinical evidence has reported higher failure rates for removable appliances than fixed appliances in some clinical populations, particularly because of appliance loss.

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🔹 Classification by Clinical Location
Space maintainers may also be described according to the location and extent of the space being preserved:

▪️ Unilateral: maintains space in one quadrant.
▪️ Bilateral: provides space control on both sides of the arch.
▪️ Maxillary: designed for space management in the upper arch.
▪️ Mandibular: designed for the lower arch.
This anatomical classification should complement, rather than replace, the fixed-versus-removable classification, because appliance selection ultimately depends on the clinical circumstances.

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🔹 How to Select a Space Maintainer
The choice of appliance should not be based solely on the identity of the missing primary tooth. The AAPD recommends considering several variables, including the tooth lost, time since extraction, occlusion and space analysis, dental age, development of the permanent successor, alveolar bone coverage, oral habits, oral hygiene, and patient cooperation.
Recent systematic reviews demonstrate that premature primary molar loss can produce measurable space changes, although the magnitude varies according to the tooth involved, arch, eruption status, and occlusal characteristics. Therefore, individualized assessment is preferable to routine appliance placement after every premature extraction.

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💬 Discussion
The traditional classification of space maintainers remains clinically useful because it provides a practical framework for selecting an appliance according to retention, extension, and location. However, classification alone does not determine treatment necessity.
Current evidence indicates that space loss following premature primary tooth extraction is variable and that the effectiveness of space maintainers is not equally established for every clinical situation. A 2023 systematic review of premature second primary molar loss found that space maintainers may preserve arch length, but also identified limited evidence regarding their broader clinical effects and potential periodontal complications.
Similarly, a 2024 systematic review found that fixed space maintainers had significantly lower failure rates than removable appliances in the evaluated clinical population, although both categories required continued maintenance, repair, or replacement.
Consequently, the modern approach is not simply to classify an appliance and place it automatically. Risk assessment, space analysis, eruption monitoring, and periodic clinical evaluation should guide treatment.

🎯 Clinical Recommendations
1. Perform a space analysis before selecting a space maintainer, particularly when the permanent successor is developing normally.
2. Consider fixed appliances when predictable retention and minimal dependence on patient compliance are priorities.
3. Consider a distal shoe when a second primary molar is lost before eruption of the permanent first molar and preservation of its eruption path is indicated.
4. Reassess cementation, appliance integrity, plaque accumulation, abutment teeth, and eruption of the permanent successor at regular intervals.
5. Do not assume that every premature primary tooth extraction requires space maintenance; base the decision on individual space-loss risk and occlusal development.

✍️ Conclusion
Space maintainer classification is primarily based on whether the appliance is fixed or removable, with fixed appliances further divided into unilateral and bilateral designs. Band-and-loop, crown-and-loop, distal shoe, lingual holding arch, Nance, and transpalatal appliances represent the principal fixed categories, while removable partial dentures and Hawley-type appliances represent the removable group.
Although classification facilitates appliance selection, contemporary pediatric dentistry emphasizes individualized diagnosis and risk assessment. The decision to maintain space should integrate the location and timing of tooth loss, dental development, occlusion, space analysis, eruption status, oral hygiene, and patient cooperation.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Management of the developing dentition and occlusion in pediatric dentistry. In The Reference Manual of Pediatric Dentistry (pp. 497–515). American Academy of Pediatric Dentistry.
✔ Abdin, M., Ahmed, E., Hamad, R., Splieth, C., & Schmoeckel, J. (2024). Success rates and failures of fixed and removable space maintainers after the premature loss of primary molars. Quintessence International, 55(4), 304–312. https://doi.org/10.3290/j.qi.b4984249
✔ Durward, C. S. (2000). Space maintenance in the primary and mixed dentition. Annals of the Royal Australasian College of Dental Surgeons, 15, 203–205.
✔ Tabatabai, T., & Kjellberg, H. (2023). Effect of treatment with dental space maintainers after the early extraction of the second primary molar: A systematic review. European Journal of Orthodontics, 45(4), 462–467. https://doi.org/10.1093/ejo/cjad006
✔ Zhao, J., Jin, H., Li, X., & Qin, X. (2023). Dental arch spatial changes after premature loss of first primary molars: A systematic review and meta-analysis of split-mouth studies. BMC Oral Health, 23, 430. https://doi.org/10.1186/s12903-023-03111-x

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Archwire Sequence for Periodontally Compromised Patients

Orthodontic treatment in periodontally compromised patients requires a different biomechanical approach from conventional orthodontic treatment.

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Reduced alveolar bone support alters the center of resistance, increases the susceptibility to unwanted tooth movement, and reduces the periodontal reserve available to tolerate excessive orthodontic forces.

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Current evidence supports orthodontic treatment in patients with a stable, treated periodontium, provided that forces are light and controlled and periodontal health is continuously monitored. However, there is no evidence-based universal archwire sequence specifically validated for periodontally compromised patients.
The sequence should therefore be individualized according to periodontal support, tooth mobility, movement objectives, anchorage requirements, and the characteristics of the orthodontic appliance.

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🔹 Why the Archwire Sequence Must Be Modified
In a reduced periodontium, the periodontal ligament may remain healthy despite substantial loss of alveolar bone. Nevertheless, the center of resistance moves apically, changing the moment-to-force relationship during tooth movement.

Consequently, conventional archwire progression may generate unnecessarily high forces or uncontrolled tipping. The principal objectives should be:
▪️ Low and controlled force delivery
▪️ Progressive alignment without excessive activation
▪️ Maintenance of periodontal stability
▪️ Adequate control of the center of resistance
▪️ Minimization of unwanted tipping and extrusion
▪️ Controlled anchorage management
A systematic review found that orthodontic treatment can be performed successfully in periodontally compromised patients when minimal, controlled forces are applied under non-inflammatory conditions, although the available evidence remains limited and heterogeneous.

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🔹 Recommended Archwire Sequence
Rather than prescribing a rigid sequence, the following progression provides a practical framework for a 0.022-inch fixed appliance. Wire dimensions should be adapted to the bracket slot, treatment objectives, and periodontal support.

Stage	Suggested Archwire	Primary Objective	Periodontal Consideration
1. Initial alignment	0.012–0.014 in NiTi	Gentle alignment	Use low-deflection, low-force mechanics; avoid forcing severely displaced teeth into the arch.
2. Early leveling	0.014–0.016 in NiTi	Continue alignment and leveling	Progress only when periodontal parameters and tooth mobility remain acceptable.
3. Working/control phase	0.016 × 0.022 or 0.017 × 0.025 in NiTi/TMA	Three-dimensional control	Use only when sufficient alignment has been achieved and rectangular engagement is biomechanically justified.
4. Space closure / major tooth movement	Rectangular stainless steel, when required	Torque and root-position control	Use controlled mechanics and carefully monitor force systems, anchorage, and mobility.
5. Finishing	Rectangular SS or TMA, case dependent	Final root and occlusal control	Avoid unnecessary torque or excessive compensatory bends in teeth with limited periodontal support.

This sequence is a clinical framework rather than a standardized evidence-based protocol. Published clinical cases in severely reduced periodontium have used gradual NiTi progression followed by rectangular wires, but the available literature does not establish one archwire sequence as superior to another.

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🔹 The Most Important Biomechanical Principle: Force, Not Wire Size
The critical variable is not simply whether a clinician progresses from 0.014 to 0.016 to a rectangular wire. It is how much force and moment the wire delivers to a tooth with reduced periodontal support.
A larger or stiffer archwire can increase control but may also increase the force system when significant deflection or activation is present. Therefore, advancing to a larger rectangular wire should be based on the patient's biological response rather than on a predetermined calendar.
Light continuous forces, small activations, and adequate intervals for tissue response are preferable to aggressive wire progression. Published clinical reports of severely reduced periodontal support have successfully used gradual archwire progression with careful force verification.

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🔹 When to Slow or Modify the Sequence
The standard progression should be reconsidered when there is:

▪️ Increasing tooth mobility
▪️ Recurrent periodontal inflammation
▪️ Persistent bleeding on probing
▪️ Deep residual periodontal pockets
▪️ Progressive gingival recession
▪️ Radiographic evidence of unfavorable periodontal changes
▪️ Excessive tipping during alignment
▪️ Poor plaque control
In stage IV periodontitis, the EFP guideline recommends initiating orthodontic treatment after periodontal treatment endpoints have been achieved. During orthodontic therapy, periodontal evaluation should ideally occur at orthodontic appointments, and active tooth movement should be interrupted if periodontitis recurs.

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🔹 Periodontal and Orthodontic Treatment Must Be Integrated
The archwire sequence cannot compensate for uncontrolled periodontal disease. Active periodontal inflammation should be controlled before orthodontic tooth movement begins.
For patients with severe periodontitis and pathological tooth migration, periodontal–orthodontic treatment has been associated with improvements in clinical attachment level, probing depth, and marginal bone level. However, the certainty of evidence remains limited, and outcomes depend heavily on patient selection and interdisciplinary management.
For patients with stage IV periodontitis, the EFP specifically recommends orthodontic treatment as part of a multidisciplinary approach after periodontal therapy has achieved stability. Lifelong supportive periodontal care and individualized orthodontic retention are recommended after active treatment.

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💬 Discussion
The concept of a “best archwire sequence” in periodontally compromised patients should therefore be interpreted differently from conventional orthodontics. Current evidence does not support a single standardized sequence based exclusively on wire dimensions.
A practical approach is to begin with small, flexible NiTi wires, progress gradually to rectangular NiTi or TMA when three-dimensional control becomes necessary, and reserve rectangular stainless steel for situations requiring greater rigidity and control. The exact transition point should be determined by the periodontal phenotype, residual bone support, tooth mobility, desired movement, and anchorage requirements.
Importantly, some patients may benefit from sectional mechanics, splinting, skeletal anchorage, or shortened active mechanics rather than complete engagement of progressively larger continuous archwires. This is particularly relevant when individual teeth have markedly reduced periodontal support.
The evidence indicates that orthodontics itself does not necessarily worsen periodontal status when performed in a stable, non-inflammatory periodontium with controlled forces, but the quality of evidence remains insufficient to justify a universal biomechanical protocol.

🎯 Clinical Recommendations
1. Do not use a rigid archwire sequence solely because it is standard for conventional patients.
2. Start with the lightest wire capable of producing the intended movement.
3. Progress from round NiTi toward rectangular wires only when additional control is clinically required.
4. Measure and control force systems, particularly during space closure, intrusion, torque expression, and bodily movement.
5. Consider sectional mechanics or skeletal anchorage when full-arch mechanics would overload teeth with reduced support.
6. Reassess periodontal stability throughout treatment and stop active movement if periodontal inflammation recurs.
7. Plan retention and lifelong supportive periodontal care as integral components of treatment rather than as post-treatment additions.

✍️ Conclusion
The optimal archwire sequence for periodontally compromised patients is individualized rather than standardized. A gradual progression from light NiTi alignment wires to controlled rectangular mechanics is generally consistent with the biomechanical principles described in the literature, but wire size alone should never determine treatment progression.
The decisive factors are periodontal stability, controlled force magnitude, appropriate moment-to-force relationships, anchorage management, and continuous periodontal monitoring. In patients with substantial attachment loss, modifying the mechanics may be more important than following a conventional archwire sequence.

📚 References

✔ Erbe, C., Heger, S., Kasaj, A., Berres, M., & Wehrbein, H. (2023). Orthodontic treatment in periodontally compromised patients: A systematic review. Clinical Oral Investigations, 27(1), 79–89. https://doi.org/10.1007/s00784-022-04822-1
✔ Han, S.-H., et al. (2024). Precautions and possibilities in orthodontic treatment of periodontally compromised patients: Current recommendations. Journal of Esthetic and Restorative Dentistry, 36(4), 566–577. https://doi.org/10.1111/jerd.13166
✔ Herrera, D., Sanz, M., Kebschull, M., Jepsen, S., Sculean, A., Berglundh, T., Papapanou, P. N., Chapple, I., Tonetti, M. S., & EFP Workshop Participants and Methodological Consultant. (2022). Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology, 49(Suppl. 24), 4–71. https://doi.org/10.1111/jcpe.13639
✔ Papageorgiou, S. N., Antonoglou, G. N., Michelogiannakis, D., et al. (2022). Effect of periodontal–orthodontic treatment of teeth with pathological tooth flaring, drifting, and elongation in patients with severe periodontitis: A systematic review with meta-analysis. Journal of Clinical Periodontology, 49(Suppl. 24), 102–120. https://doi.org/10.1111/jcpe.13529

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