Before initiating ortho-restorative procedures, many cases necessitate preliminary space management, as a significant proportion of patients present with malocclusion.
Selecting the least invasive yet most effective treatment modality poses a clinical challenge. The benefits and risks of each intervention vary considerably depending on individual anatomical and functional factors.
Contemporary patients increasingly expect enhanced function alongside aesthetic improvements, delivered with minimal chair time, cost, and invasiveness. These expectations heighten the complexity of choosing the optimal approach to address crowding.
Aetiology of crowding
Malocclusion may arise from several common factors, including genetic predisposition (for example, disproportionate jaw-tooth size relationships), premature loss of deciduous teeth,[i] delayed eruption of permanent dentition, jawbone pathology, trauma, obsessive thumb sucking in infants or periodontal disease.[ii]
Some studies suggest that malocclusion may be influenced by genetic traits caused by an evolutionary trend towards smaller facial volume without the subsequent reduction in the overall size of dentition.[iii]
Health and well-being
Oral hygiene is significantly more challenging for patients suffering with malocclusion. Crowded teeth create tight spaces that are difficult to reach with a toothbrush or floss, allowing plaque and food debris to accumulate. This increases the risk of cavities, periodontal disease, and halitosis.[iv]
Beyond hygiene, malocclusion can also affect a person’s self-esteem due to its impact on facial appearance and smile aesthetics.[v] Crooked, protruding, or gapped teeth may cause individuals to feel self-conscious, leading them to avoid smiling or speaking freely in social situations. This can influence personal relationships and professional confidence, making orthodontic treatment to correct malocclusion not just a medical necessity but also a psychological and emotional benefit.
In addition, untreated malocclusion compromises the long-term success of restorative procedures by affecting occlusal stability, periodontal health, and functional outcomes.[vi]
Pre-restorative correction
Addressing underlying malocclusion and dental alignment issues is essential to restore functional parameters such as mastication, deglutition, phonetics, and periodontal integrity.vi The goal is to achieve functional occlusion with minimal loss of tooth structure, thereby facilitating subsequent restorative interventions.
Several space-gaining techniques are available, each with distinct indications and limitations.
Optimising the IPR approach
Despite its simplicity and lack of invasiveness, IPR carries potential risks. Rough enamel surfaces may predispose to plaque accumulation which can result in periodontal compromise if not properly finished and maintained.[vii]
Advanced tools are helping clinicians to navigate the technical challenges associated with IPR including excessive enamel removal which can weaken tooth structure, increasing susceptibility to caries.vii New generation IPR burs and strips offer greater control and precision during the procedure.
Artificial intelligence is also being used to predict optimal IPR sites and volumes based on 3D scans and patient-specific data. This reduces human error and improves safety margins.[viii]
When executed judiciously, IPR remains a safe and effective option for managing mild to moderate crowding and tooth size discrepancies.
Different techniques
Palatal expansion, while effective for addressing transverse maxillary deficiencies and severe crowding, carries several clinical risks that must be carefully considered. Arapid palatal expander (RPE), in particular, can induce discomfort, transient speech disturbances, and pressure-related pain during the initial phases.[ix]
In younger patients, the improper appliance design of a rapid palate expander or the overexpansion of the palate may lead to asymmetrical growth or skeletal discrepancies due to excessive dental tipping instead of skeletal expansion.[x] Additionally, poor appliance hygiene can result in mucosal irritation, inflammation or in rare cases, infection.
Alternatives for adolescents and adults
For adults and adolescents with fully matured palatal structures, miniscrew-assisted rapid palatal expansion (MARPE) may be a necessary alternative. This is because the fully mature mid-palatal suture has fused, making the palate rigid and less pliable.[xi]
As a result, removable expanders often fail to effectively widen a mature palate, necessitating the need for more robust treatment options such as surgery.xi
While MARPE is generally effective in achieving its goal of skeletal expansion, some studies indicate that complications may arise in up to one-third of cases.[xii] Common issues include screw loosening, peri-implant mucositis, incomplete expansion, and on rare occasions, complete treatment failure.xii
The long-term stability of any palatal expansion method depends on proper retention protocols, early identification of complications, and careful case selection to minimise future risks.[xiii]
Scale-up your knowledge
For clinicians seeking to refine their approach in minimally invasive aesthetic dentistry, the IAS Academy’s Align, Bleach & Bond course offers a comprehensive framework. It equips practitioners with the diagnostic and technical skills to integrate alignment strategies with whitening and bonding techniques delivering predictable, aesthetically pleasing and patient-centred results.
This course exemplifies the synergy between orthodontic planning and restorative excellence, reinforcing the importance of foundational space management in modern dental practice.
Effective space management is foundational to successful ortho-restorative treatment. The choice between interproximal reduction, palatal expansion or alternative options such as tooth extraction or fixed braces must be guided by a thorough clinical assessment of the severity of the crowding and the age of the patient, weighed against invasiveness, long-term stability and aesthetic outcomes.
For more information or to book the course, visit https://courses.iasortho.com/courses or call 01932 336470 (Press 1)
Author: Dr Tif Qureshi
[i] Ahamed S S S, Reddy V N, Krishnakumar R, Mohan M, Sugumaran D K, Rao A P. (2012). Prevalence of early loss of primary teeth in 5 – 10 year old school children in Chidambaram town. National Centre for Biotechnology Information. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC3341755/#:~:text=loss%2C%20malocclusion%2C%20prevalence-,Introduction,%2Dyear%2Dold%20school%20children.
[ii] Ghodasra R, Brizuella M. (2023). Orthodontics, Malocclusion. National Center for Biotechnology Information. Avaialble at: https://www.ncbi.nlm.nih.gov/books/NBK592395/
[iii] Yan-Vergnes W, Vergnes J N, Dumoncel J, Baron P, Marchal-Sixou C, Braga J. (2013). Asynchronus dentofacial development and dental crowding: a cross-sectional study in a contemporary sample of children in France. National Center for Biotechnology Information. Available at: https://www.bos.org.uk/wp-content/uploads/2022/03/British-Orthodontic-Society-InterproximalReductionMarch2019.pdf https://pmc.ncbi.nlm.nih.gov/articles/PMC11624512/ https://pmc.ncbi.nlm.nih.gov/articles/PMC3843590/
[iv] Hassan A, Hobani N, Almokri S, Almokri N, Alotibi F, Alshoubi E. (2018). Effect of anterior crowding or spacing on oral health-related quality of life: A cross-sectional study. National Library of Medicine. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC5877494/
[v] Zorlu M, Camci H. (2023). The relationship between different levels of facial attractiveness and malocclusion perception: an eye tracking and survey study. National Library of Medicine. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10440334/
[vi] Aldowish A F, Alsubaie M N, Alabdulrazzaq S S, Alsaykhan D B, Alamri A K, Alhatem L M, Algoufi J F, Alayed S S, Aljadani S S Alashjai A M, Almari A S. (2024). Occlusion and its role in the long-term success of dental restorations: a literary review. National Center for Biotechnology Information. Available at:
[vii] Barcoma E, Shroff B, Best A M, Shoff M, Lindauer S. (2014). Interproximal reduction of teeth: Differences in perspective between orthodontists and dentists. The Angle Orthodontist. Available at: https://angle-orthodontist.kglmeridian.com/view/journals/angl/85/5/article-p820.xml
[viii] Dua B, Gupta R, Bhargava A, Bhardwaj A, Jain M. (2025). Redefining oral healthcare through artificial intelligence: a review of current applications and a roadmap for the future of dentistry. BMC. Available at: https://bmcartificialintel.biomedcentral.com/articles/10.1186/s44398-025-00013-6
[ix] Khan M K, Sharma D S, Jindal M K. (2023). Unusual systemic and nondental effects of maxillary expansion therapy: A comprehensive and updated review of literature. Journal of Orthodontic Science. Available at: https://journals.lww.com/joos/fulltext/2023/09040/unusual_systemic_and_nondental_effects_of.38.aspx
[x] Lopponi G, Maino B G, Dalessandri D. (2021). Rapid palatal expansion should not be trivialized: Two case reports of unexpected complications. European Journal of Dentistry. Available at: https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0041-1728840
[xi] Angelieri F, Franchi L, Cevidanes L H S, Beuno-Sila B, McNamara, J A. (2016). Prediction of rapid maxillary expansion by assessing the maturation of the midpalatal suture on cone beam CT. National Center for Biotechnology Information. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC5278941/#:~:text=ABSTRACT,occurred%20either%20partially%20or%20totally.
[xii] Rajalakshmi S J , Ahmed N, Eduru N, Deeksha Y N, Ravi K, Singaraju G S. (2025). Hidden risks of miniscrew-assisted rapid palatal expansion (MARPE): A retrospective analysis of treated cases with preventive strategies. National Center for Biotechnology Information. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC12467438/
[xiii] Park J H. (2022). Addressing miniscrew-assisted rapid palatal expander complications. American Journal of Orthodontics & Dentofacial Orthopaedics. Available at: https://www.ajodo-clinicalcompanion.com/article/S2666-4305(22)00093-0/abstract
