Malocclusion in children: what it is and how it is corrected

Dental malocclusion is one of the most common orthodontic problems in childhood: according to an international meta-analysis, it affects on average about 56% of children and adolescents worldwide, with higher figures in European studies (about 72%). The term describes an incorrect alignment between the upper and lower dental arches. It can take many forms and vary in severity, which is why it calls for early, tailored diagnosis.

Understanding malocclusion: more than crooked teeth

Malocclusion is not simply a cosmetic issue. It is a functional problem that involves the whole stomatognathic system, and can affect chewing, speech and breathing. In children, spotting the condition early means preventing future complications that might otherwise require more invasive treatment in adolescence or adulthood.

Malocclusions are traditionally classified into three main classes according to Angle's system, but contemporary research has broadened this classification to include three-dimensional parameters and dynamic functional analysis. This multidimensional approach makes it possible to assess not only the static position of the teeth, but also how the upper and lower jaws interact during functional movements.

Many causes: genetics, environment and habits

The causes of malocclusion in children are complex and multifactorial. Genetic factors play a decisive role, passing on the skeletal features and size of the dental arches. However, environmental and behavioural factors can amplify or soften these inherited tendencies.

The most significant acquired factors include:

Prolonged harmful habits: prolonged dummy use, or sucking a thumb or other objects, can significantly alter how the dental arches develop. A meta-analysis confirms the link between these habits and malocclusion: dummy use was associated mainly with posterior crossbite, thumb or finger sucking mainly with protruding upper teeth, and the risk increases the longer the habit continues.

• Chronic mouth breathing: caused by upper airway obstruction, enlarged adenoids and tonsils or allergies, mouth breathing can affect the growth of the skull and face. A meta-analysis found that children who mainly breathe through their mouth showed a backward and downward rotation of the upper and lower jaws, a more retruded lower jaw, more forward-tilted upper incisors and narrower airways.
• Early loss of baby teeth: losing milk teeth too soon, through injury or decay, can compromise the space needed for the permanent teeth, leading to crowding and misalignment.
• Eruption problems: teeth that fail to erupt, erupt late or come through in the wrong position upset the balance of the bite and the harmonious development of the arches.

Early warning signs: when prevention makes the difference

Being able to recognise the first signs of malocclusion is what separates a reactive approach from a proactive one. Parents should look out for a few specific signs that may already appear before school age.

Visible signs include teeth that overlap excessively, unusual gaps between teeth, difficulty closing the lips fully at rest, an asymmetrical facial profile or a receding chin. On the functional side, chewing difficulties, persistent mouth breathing, snoring at night and recurring headaches can be indirect signs of bite problems.

The first orthodontic check-up should be scheduled at an early age, even when there are no obvious problems. This timing allows skeletal and dental anomalies to be caught early, while the child is still actively growing and there is the greatest opportunity to guide development.

Modern treatment: from interceptive orthodontics to digital technology

The correction of malocclusion in children has been transformed over the last two decades, shifting from a mainly late, corrective approach to increasingly sophisticated early interceptive strategies.

Interceptive orthodontics: acting at the right time

Interceptive orthodontics is an important option for treating some types of malocclusion in the mixed dentition. It harnesses the child's remaining growth potential to guide the development of the jaw bones, creating favourable conditions for the permanent teeth to erupt. Its actual benefits, however, vary depending on the type of malocclusion.

Functional appliances such as the Frankel or the Bionator change the posture of the lower jaw and stimulate or redirect skeletal growth. A rapid palatal expander corrects transverse discrepancies by widening the upper jaw, while devices such as the Delaire face mask treat Class III malocclusions by encouraging the upper jaw to grow forwards.

Technology in the service of precision

Digital technology has radically changed how orthodontic treatment for children is planned and carried out. 3D intraoral scanning replaces traditional impressions, making the experience more comfortable for young patients and providing highly accurate three-dimensional data.

Digital planning software allows tooth movements and arch development to be simulated virtually, giving a preview of the final result and making it easier to explain the treatment to parents and patients. This technology also makes it possible to produce custom appliances using 3D printing, with millimetre precision and greater comfort.

Artificial intelligence is entering orthodontic practice through automated cephalometric analysis algorithms and growth prediction systems. These tools help clinicians identify complex patterns and refine treatment plans.

The growing role of myofunctional therapy

One area of growing interest is orofacial myofunctional therapy, which addresses the muscle dysfunctions behind many malocclusions. This discipline focuses on retraining tongue posture, swallowing patterns and nasal breathing.

Specific daily exercises, carried out under the supervision of a specialist therapist, can correct dysfunctional habits and improve how the muscles work. When combined with traditional orthodontic treatment, myofunctional therapy can be a useful support; whether it is indicated is assessed case by case.

A multidisciplinary approach: when several specialists are needed

Complex malocclusions often require a coordinated, multidisciplinary approach. Collaboration between the orthodontist, paediatrician, ear, nose and throat (ENT) specialist, speech therapist and, where needed, other specialists makes it possible to address every aspect of the problem.

When mouth breathing is caused by an anatomical obstruction, the ENT specialist's input becomes the priority. Removing enlarged adenoids or treating chronic allergies can restore nasal breathing, an essential prerequisite for the correct development of the skull and face.

A speech therapist is involved when there are swallowing problems or speech difficulties related to the malocclusion. Retraining tongue function can support the orthodontic results.

If other related problems are present, the child may also be referred to other specialists, depending on individual needs and the available scientific evidence.

Treatment timing and phases: what to expect

The length of orthodontic treatment in children varies considerably depending on how severe the malocclusion is, the age at which treatment starts and how well the patient cooperates. Early interceptive treatment is usually of limited duration, followed by an observation period during which eruption and growth are monitored.

Some cases require a two-phase approach: a first, interceptive phase in the mixed dentition to correct skeletal problems, followed by a second phase in the permanent dentition to fine-tune tooth alignment. This strategy takes longer overall: for protruding upper front teeth (Class II), a Cochrane review found that early two-phase treatment reduces the risk of injury to the incisors, with no other clear advantages over a single course of treatment in adolescence. The choice should therefore be assessed case by case.

During treatment, regular check-ups every 4-8 weeks make it possible to monitor progress, make adjustments and keep the patient motivated. The child's cooperation and the family's support are key factors for a good outcome: following the treatment instructions has a direct effect on the quality and speed of the results.

Active prevention: building solid foundations from early childhood

Preventing malocclusion starts long before the first orthodontic visit. A number of strategies can be put in place from the first months of life to encourage the harmonious development of the mouth and face.

Breastfeeding, where possible, is associated with a lower risk of malocclusion: according to a meta-analysis, children who were breastfed, particularly exclusively or for longer, are considerably less likely to develop it.

Limiting dummy use to times of real need and not prolonging it helps reduce the risk of acquired malocclusion, which increases the longer the habit continues. It is a good idea to discuss timing and the type of dummy with your paediatrician or dentist.

Encouraging nasal breathing through good daily nasal hygiene and prompt treatment of colds and allergies can help prevent the changes to the skull and face associated with chronic mouth breathing.

Introducing foods that need proper chewing early on can encourage the development of the arches and chewing muscles. Gradually moving from soft textures to firmer foods can support the harmonious growth of the chewing apparatus.

Long-term stability: keeping the results

Achieving an orthodontic correction is only half the job; maintaining it over time takes care and specific strategies. Once active treatment is complete, a retention phase is essential to consolidate the results.

Retainers can be removable or fixed. Clear removable retainers are usually worn at night, while fixed retainers consist of a thin metal wire bonded to the inner surface of the front teeth. The choice depends on the type of malocclusion treated and the risk of relapse.

How long retention lasts varies: in some cases a limited period is enough, while in others long-term or permanent retention may be advisable. Factors such as remaining growth, persistent habits and the type of tooth movement carried out all influence this decision.

Periodic check-ups during the retention phase make it possible to spot any relapse early and correct it with small adjustments before it becomes a significant problem.

On the horizon: the future of paediatric orthodontics

Research in paediatric orthodontics is exploring fascinating new frontiers that promise to transform the field further in the years ahead.

Biological modulation techniques could speed up orthodontic tooth movement through targeted mechanical or biochemical stimulation, with the aim of shortening treatment times. For now, however, a Cochrane review concludes that vibration and photobiomodulation (laser or LED) have not been shown to reduce the overall duration of orthodontic treatment, with low or very low certainty evidence.

Smart, self-adapting materials could lead to appliances that automatically change their configuration in response to biting forces, continuously optimising treatment without the need for frequent adjustments.

Integrating biomedical sensors into orthodontic appliances will allow real-time monitoring of parameters such as applied forces, wear patterns and patient compliance, providing objective data to tailor treatment even further.

Regenerative medicine may offer solutions for complex cases through tissue engineering of the alveolar bone, making possible tooth movements that would otherwise be impossible or extremely slow.

Your partner for a harmonious smile

Treating malocclusion requires specialist expertise, solid clinical experience and a personalised approach that takes into account each child's individual characteristics. Dr Nihad Pljevljak, at Nea Bios Dental Clinic in Rome EUR Laurentina, combines an excellent academic background with more than ten years of experience in treating malocclusion in children.

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His solid training, crowned by a PhD in Dental and Oral Diseases from Sapienza University of Rome, and his registration with the Rome Order of Physicians and Dentists (Ordine dei Medici Chirurghi e Odontoiatri di Roma), ensure professionalism and constant updating on the latest scientific evidence.

The clinic, located at Via Cesare Pavese 135, is a well-established point of reference in the EUR area, where Dr Pljevljak has built his reputation by serving patients from all walks of life with great reliability, including public figures who have chosen to rely on his expertise.

Our reception is available Monday to Friday from 9:00 to 13:00 and 14:00 to 18:00 to give you detailed information, answer your questions and book a first orthodontic visit for your child. Don't wait for a malocclusion to get worse: prevention and timely treatment really do make a difference in helping your child achieve a healthy, functional and harmonious smile.

Sources

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2. Doğramacı EJ, Rossi-Fedele G. Establishing the association between nonnutritive sucking behavior and malocclusions: a systematic review and meta-analysis. J Am Dent Assoc. 2016;147(12):926-934.e6. PubMed
3. Zhao Z, Zheng L, Huang X, et al. Effects of mouth breathing on facial skeletal development in children: a systematic review and meta-analysis. BMC Oral Health. 2021;21(1):108. PubMed
4. Batista KB, Thiruvenkatachari B, Harrison JE, et al. Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children and adolescents. Cochrane Database Syst Rev. 2018;3(3):CD003452. PubMed
5. Peres KG, Cascaes AM, Nascimento GG, et al. Effect of breastfeeding on malocclusions: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):54-61. PubMed
6. El-Angbawi A, McIntyre G, Fleming PS, et al. Non-surgical adjunctive interventions for accelerating tooth movement in patients undergoing orthodontic treatment. Cochrane Database Syst Rev. 2023;6(6):CD010887. PubMed