lecture about Anterior dental crossbite and class iii malocclusion

2. Dr. Nagi Hussein Al-Awdi
MSc. in clinical Orthodontics
Management of Sagittal Problems
(Anterior Dental Crossbite and Class III Malocclusion)
Early-Age Orthodontic Treatment
of Dentoskeletal Problems

3.  Anterior dental crossbite is a common problem in
the primary or mixed dentition and merits early
intervention to prevent further damage to occlusion.
 Early correction of anterior crossbite not only resolves
esthetic problems but also improves function and
consequently prevents structural damage and
adverse effects on the growth of the dentition and
basal bones.
Introduction

4.  Anterior crossbites can have differing morphology,
etiology, and treatment procedures. Generally there
are three kinds of anterior crossbite:
1. Simple dental crossbite
2. Pseudo-Class III malocclusion (functional crossbite)
3. Skeletal Class III malocclusion
• Precise clinical evaluation in static conditions and
during functional movement and radiographic
examinations (lateral cephalograms in centric
occlusion and centric relation) are required for
differentiation of dental, skeletal, and functional
crossbites.
Introduction

5. • Differential diagnosis of the skeletal and dental
components of anterior crossbite is an important and
essential part of determining the proper treatment
approach and timing of treatment for these anomalies.
• Diagnosis consists of a complete intraoral and
extraoral clinical evaluation, including assessment of
the child’s facial pattern and symmetry, left and right
molar and canine relationships, both in centric relation
and centric occlusion, and dental and facial midlines.
• Any kind of mandibular shift must be carefully
examined to determine the type of abnormality,
treatment options, and prognosis.
Differential diagnosis

6. • Proper treatment planning and good results in the
correction of anterior crossbite require careful
evaluation of the morphology, etiology, and special
characteristics for every single case.
• Two skeletal Class III malocclusions may look alike
but have completely different characteristics that
require different treatment plans.
• Therefore, the first step is differential diagnosis
between different types of anterior crossbites,
• and the second step is the recognition of specific
characteristics for every individual patient.
Differential diagnosis

7.  The following are important points that should be
evaluated in the clinical evaluation:
• Anterior and posterior dental relationships with the
mandible in both centric relation and centric occlusion
• The patient’s soft tissue profile in both centric
relation and centric occlusion
• Any mandibular shift, by holding the mandible to the
most retruded position and checking the incisor
relationships
• Hereditary background, by checking for the possibility
of similar traits in the patient’s parents or siblings
• Cephalometric finding.
Clinical examination

8. Simple Dental Crossbite

9. • Simple anterior dental crossbite is defined as a dental
malocclusion that results from lingual positioning of
the maxillary anterior teeth in relation to the opposing
mandibular anterior teeth.
• The condition is localized and involves the tipping
of only a tooth or teeth and not the basal bone.
• In other words, simple dental crossbite is due
to an abnormal labiolingual relationship between one or
more maxillary and mandibular incisors within the
context of a normal anteroposterior skeletal jaw
relationship.
Simple Dental Crossbite

10. • Single dental crossbite usually results in no
mandibular shift from rest to occlusion, exhibiting a
smooth path of closure to an Angle Class I
relationship.
• When more incisors are involved, some mandibular
anterior shift may occur.
• Simple dental crossbite is the most common kind of
anterior crossbite seen during the primary and early
mixed dentitions.
• Reports show a frequency of 3% to 12%.
Simple Dental Crossbite

11. • As already mentioned, patients with dental crossbite
have a normal ANB angle and profile.
• The maxillary incisors are retroclined, and mandibular
incisors are proclined, but the molars and canines
show Class I relationships in both centric relation
and centric occlusion.
Characteristic signs

12. There are two types of anterior dental crossbite:
1. Crossbite of a single or multiple incisors with lingual
tipping and usually no crowding and mandibular shift.
2. Locked anterior crossbite in which one or two incisors
are tipped lingually and some are labial to the
mandibular incisors.
• Some crowding is present. No shift is present, but
maxillary and mandibular incisors are locked within
each other, and the anterior occlusion is usually more
traumatized.
Characteristic signs

13. • The majority of anterior dental crossbites are caused
by local dental factors. Many etiologic factors have
been reported, such as:
1- Congenital abnormal path of eruption (lingual eruption
of maxillary anterior incisors)
2- Trauma to the primary incisors that has led to
displacement of the permanent tooth buds
3- Direct trauma to the permanent incisors that has
caused luxation and displacement
Etiology

14. 4- Overretained primary teeth in the maxillary incisor
region that have caused palatal eruption of the
permanent incisor or overretained mandibular primary
incisors that have increased the proclination of the
mandibular incisors.
5- Labially positioned supernumerary tooth or odontoma
6- Sclerotic bony or fibrous tissue barrier caused by
premature loss of a primary tooth
Etiology

15. 7- Rarely, a habit of biting the upper lip
8- Overretained necrotic or pulpless primary tooth
9- Crowding in the incisor region
(Bolton discrepancy)
10- Arch length inadequacy
11- Repaired cleft lip or palate
Etiology

17. The following are additional advantages:
• Improvement of dental esthetics
• Prevention of structural damage such as dental
attrition, periodontal disease, and root resorption
• Prevention of dental compensation
and redirection of skeletal growth
modification
• Prevention of growth interferences that cause
maxillary deficiency
• Improvement of the dentoalveolar relationship
• Increase in anterior arch perimeter
Advantages of early treatment

18. Postponing treatment of simple dental crossbite can
have serious repercussions.
• Anterior dental crossbite in the primary dentition is
often transferred to the permanent dentition;
postponing the treatment results in prolonged and
more complex treatment during the permanent
dentition.
• Many reports have indicated that delayed correction of
this anomaly can cause abnormal enamel abrasion;
anterior tooth mobility and fracture; labial alveolar
plate resorption and gingival recession; periodontal
pathosis; reduction of anterior arch circumference,
which can result in canine impaction;
Consequences of delayed treatment

19. Postponing treatment of simple dental crossbite can
have serious repercussions.
• temporomandibular joint disturbances.
• In addition, dentoalveolar and even skeletal Class
III malocclusion can develop due to mandibular
displacement or maxillary underdevelopment.
• Functional shifts cause asymmetric muscle strain
and condylar displacement and consequently
asymmetric mandibular growth.
Consequences of delayed treatment

20. Early treatment strategies

21. Various treatment methods have been proposed to
correct anterior dental crossbite, including
• tongue blades,
• reversed stainless steel crowns,
• fixed acrylic resin inclined planes,
• bonded composite resin slopes,
Early treatment strategies

22. Various treatment methods have been proposed to
correct anterior dental crossbite, including
• removable acrylic resin appliances with finger
springs,
• Anterior cross elastics.
• Expand by Quad helix .
• and 2 × 4 bonding.
Early treatment strategies

23. A 10-year-old girl presented with a single-incisor
crossbite with sufficient space. A few months’ delay
in early intervention caused mandibular trauma and
bone recession.
Case 1: Anterior dental crossbite

24. Treatment:
Because there was no crowding, rotation, or any
displacement of teeth adjacent to the involved incisor
as well as good patient compliance, she was treated
with a removable Hawley appliance with occlusal
coverage and a single finger spring.
Case 1: Anterior dental crossbite

25. A 10-year-old girl in the middle mixed dentition presented with a
Class III molar relationship on the right side because of space
loss, 0- to 1-mm overbite and overjet, and three maxillary incisors
in crossbite.
Case 2: Anterior dental crossbite

26. Treatment:
Because of the severe crowding and displacement of
incisors, the treatment plan incorporated fixed
appliances with maxillary and mandibular 2 × 6 bonding.
Case 2: Anterior dental crossbite

27. A 10-year, 6-month-old boy presented with Class I
malocclusion, anterior locked occlusion, traumatized
occlusion, and three incisors in crossbite. The crossbite
had resulted in crowding of the maxillary and
mandibular incisors as well as displacement and rotation
of the maxillary incisors.
Case 3: Anterior dental crossbite

28. Treatment:
The treatment plan called for maxillary and mandibular 2
× 4 bonding and placement of occlusal composite resin
on the mandibular molars to disocclude the anterior
segment.
Case 11-10: Anterior dental crossbite

29. Pseudo–Class III Malocclusion
(Functional Crossbite)

30. • Functional crossbite is a multitooth anterior
crossbite.
• The interferences prevent posterior occlusion,
resulting in a functional shift of the mandible in an
effort to avoid the anterior interference in centric
relation and to achieve maximal intercuspation.
• Pseudo–Class III malocclusion can involve both the
permanent teeth and the primary dentition.
• Other terms that have been used to describe this
anomaly include pseudoprognathism, postural Class
III, and functional Class III.
Pseudo–Class III Malocclusion (Functional Crossbite)

31. • These anomalies are usually characterized by a
Class I skeletal pattern.
• The patients with a pseudo–Class III malocclusion
exhibit certain morphologic, dental, and skeletal
characteristics, such as retroclined maxillary incisors,
retrusive upper lip, decreased midfacial length,
increased maxillomandibular differences, mandibular
displacement, and normal vertical development.
Pseudo–Class III Malocclusion (Functional Crossbite)

32. • In regard to criteria for distinguishing between
pseudo– Class III and skeletal Class III malocclusion,
cephalometric evaluation may not be the most
reliable tool in differential diagnosis. The most
consistent findings seem to be the dental
characteristics of Angle Class III molars and canines,
retroclined mandibular incisors, and the presence of
an end-to-end or anterior cross-bite occlusion.
• Several other investigators evaluating pseudo–Class
III malocclusion also attributed the retroclined
maxillary incisors and proclined mandibular incisors to
incisor interference.
Pseudo–Class III Malocclusion (Functional Crossbite)

33. Pseudo–Class III Malocclusion (Functional Crossbite)

34. The following are general signs of pseudo–Class III
malocclusion that can be recognized by careful clinical
and Cephalometric evaluation when the mandible in
centric relation :
• Multitooth anterior crossbite
• Normal ANB angle at rest
• Some maxillary incisor retroclination
• Minor maxillary deficiency
• Normal to concave profile (appearing normal at
centric relation and slightly concave at habitual occlusion)
• Class I molar and canine relationships in centric relation
• Habitual shift from rest to occlusion
Characteristic signs

35. • When multiple incisors are involved in a pseudo–Class
III malocclusion and a functional shift is present,
urgent intervention is needed to prevent structural
damage and adverse effects on the maxilla.
• Unlocking the maxilla before the growth spurt
normalizes maxillary growth, improving the profile and
preventing structural damage.
• Early orthodontic intervention for pseudo–Class III
malocclusion is always recommended to prevent
existing problems from worsening and to prepare a
better environment for occlusal development, thereby
minimizing or eliminating the need for comprehensive
orthodontic treatment later.
Advantages of early treatment

37. Treatment strategies

38. • Depending on the severity of the problem and the
patient’s age and compliance, correction may be
achieved with removable, functional, or fixed
appliances.
• When maxillary protraction is needed, extraoral
devices such as a face mask or chin cap might also be
used.
• The methods described for management of simple
anterior dental crossbite (removable Hawley appliance
with occlusal coverage and 2 × 4 bonding) can also be
used for correction of most pseudo–Class III
malocclusions.
Early treatment strategies

39. • In pseudo–Class III malocclusion, multiple incisors
are involved and the crossbite often is accompanied
by crowding and rotation. Application of 2 × 4
bonding is preferable; the result is faster, the
patient’s compliance is not required, and there is the
possibility of incisor alignment after crossbite
correction.
• Patients with some maxillary deficiency resulting
from delayed treatment or hereditary factors may
need extraoral traction.
Early treatment strategies

40. Early treatment strategies

41. incisors in crossbite, which were causing displacement
and rotation of the maxillary incisors and crowding in the
mandibular incisor region.
Case 1: Pseudo–Class III malocclusion

42. Treatment:
Because of financial considerations and in accordance
with the parent’s wishes, treatment was accomplished
with a removable appliance.
Case 11-11: Pseudo–Class III malocclusion

43. An 11-year, 7-month-old boy in the late mixed dentition
presented with a Class I malocclusion, pseudo–
Class III malocclusion, and a severe anterior mandibular
shift.
Case 2: Pseudo–Class III malocclusion

44. Treatment:
The treatment plan in this case was limited to 2 × 6
maxillary bonding and placement of composite resin
on the occlusal surfaces of the molars to disocclude the
anterior segment.
Case 2: Pseudo–Class III malocclusion

45. A 17-year-old girl presented with
a Class I occlusion, anterior crossbite, and
a mandibular shift. Her chief complaints were temporomandibular
dysfunction, pain, and restricted opening. She also had severe
structural damage to the maxillary and mandibular incisors and
periodontium.
• This case clearly demonstrates the consequences of delayed
treatment of anterior crossbite.
Case 3: Pseudo–Class III malocclusion

46. Treatment:
After scaling and periodontal care were provided,
orthodontic treatment was accomplished with 2 × 6
maxillary and mandibular bonding. Occlusal composite
resin buildup was used for anterior disocclusion.
Case 3: Pseudo–Class III malocclusion

47. An 11-year, 7-month-old girl presented with a Class I
anterior pseudo–Class III malocclusion with
mandibular shift, minor damage to the maxillary incisors,
and minor crowding in the maxillary arch.
Case 4: Pseudo–Class III malocclusion

48. Treatment:
Treatment was accomplished with a removable Hawley
appliance that had two Adams clasps. A long
labial bow, separated from the incisors to facilitate their
proclination, was soldered to the Adams clasps
to maintain retention from the posterior segments.
Case 11-14: Pseudo–Class III malocclusion

49. Skeletal Class III Malocclusion

50. • True Class III malocclusion, or mesial occlusion, is an
anteroposterior dentoalveolar or skeletal
malrelationship characterized by a mandibular
dentition that has a more anterior position than the
maxillary dentition.
• This anomaly can be caused by mesial mandibular
basal or dentoalveolar positioning, distal maxillary
basal or dentoalveolar positioning, basal bone size
discrepancy (either shorter maxilla or longer
mandible), or a combination of any of these factors.
Skeletal Class III Malocclusion

51. • Patients with skeletal Class III malocclusion exhibit a
concave facial profile, a retrusive nasomaxillary area,
and a prominent mandibular third of the face. The
lower lip is often protruded relative to the upper lip.
• The maxillary arch is usually narrower than the
mandibular arch, and overjet and overbite can range
from reduced to reverse.
Skeletal Class III Malocclusion

52. Accurate differential diagnosis and careful pretreatment
evaluations are essential for determining the proper
approach to and timing of treatment.
Box 11-3 presents guidelines to consider in treatment
planning in order to achieve efficient correction and long-
term stability.
Guidelines for pretreatment evaluation

53. Box 11-4 shows the differences in characteristics of
dental and skeletal crossbites.
Comparison between skeletal and dental crossbite

54. Comparison between skeletal and dental crossbite

55. • General strategies for early intervention in Class III
maxillary deficiencies or anterior crossbites with the
potential to develop to Class III malocclusion include
the following four major techniques:
1. Unlocking of the occlusion and elimination of
mandibular shift
2. Incisor proclination combined with labial root torque
3. Maxillary protraction and expansion, if needed
4. Enhancement of maxillary growth
Early treatment strategies

56. • Depending on the type of problem and the
dentoskeletal condition of the anomaly, different early
intervention techniques are available, including
- palatal expansion,
- A face mask,
- a standard chin cap,
- a chin cap with spurs,
- and functional appliances.
Early treatment strategies

57. Chin cap with spurs
A chin cap with spurs is an extraoral device that can be
used in Class III orthopedic treatment for simultaneous
control of mandibular growth and protraction of the
maxilla. A rubber band connected from the spurs to the
maxillary arch produces maxillary protraction.
Special appliances

58. Face mask–chin cap combination
This device can be used in early treatment of all kinds of
skeletal Class III malocclusion, whether they result from
maxillary deficiency, mandibular prognathism, or a
combination of both. the FCC can also be applied in
Class III patients with
a horizontal or vertical
growth pattern.
Special appliances

59. • The following case reports present examples of
management of various types of anterior crossbite
with different characteristics and different etiologic
factors; with different treatment options, such as
preventive, interceptive, corrective, or combination
treatment; and in patients at different dental and
skeletal stages of development.
Case Reports

60. • Early intervention at this stage of the dentition usually
consists of interceptive treatment and guidance, and
the main goals are unlocking of the anterior teeth and
slight proclination of the primary incisors, if needed.
• Correction of posterior crossbite is also another goal
to achieve at this stage of treatment.
• Maxillary basal protraction by extraoral devices might
also be necessary in some patients with maxillary
deficiency.
• The fundamental strategy of this type of intervention is
to prepare a normal environment at an early stage of
the dentition to enable coordinated jaw growth and
encourage proper development of the occlusion.
Early treatment during the primary or early mixed
dentition before incisor eruption

61. A 6-year-old girl presented
with both anterior segments
and the posterior left segment
in crossbite. The only permanent teeth that had erupted
were the first molars. She exhibited a mandibular shift
and a concave profile.
Case 1

62. Treatment:
Treatment was accomplished with only a Hawley posterior bite
plate without a labial bow. The appliance included an expansion
screw for posterior crossbite correction and two finger springs for
anterior crossbite correction. Composite resin attachments were
bonded to the buccal surfaces of the maxillary primary molars; the
attachments had long C-clasps hooked over the composite resin
for added retention in place of bands with tubes.
Case 1

63. A 3-year, 5-month-old boy in the primary dentition
presented with a Class III malocclusion that had a
hereditary background. He had a mesial step at the
primary second molars (slight Class III relationships
at centric relation) and a mandibular mesial shift.
Case 2

64. Treatment:
During the primary dentition,
even unlocking the occlusion in the
area of crossbite can eliminate functional shift and guide
development of normal occlusion. This boy showed good
compliance, so the treatment plan included only the use of a
Hawley appliance, banding of the primary second molars with a
buccal tube for better retention, occlusal coverage, and a simple
finger spring behind the maxillary incisors.
Case 2

65. A 5-year, 9-month-old boy presented with a collapsed
maxillary dentition, severe reverse deep bite, and
a mandibular mesial shift. Even in centric relation, the
maxillary and mandibular incisors did not meet in
an end-to-end position. He exhibited a negative ANB
angle and a concave profile. His problems had a
hereditary background.
Case 3

66. Treatment:
The treatment approach was interceptive intervention to correct
the dentoskeletal malrelationships by maxillary expansion,
maxillary protraction by face mask therapy, and some maxillary
incisor proclination. Because the patient’s compliance was
excellent and the parent preferred it, treatment was performed
with a removable appliance and face mask. modified Hawley
appliance, which included two Adams clasps, thick posterior
occlusal coverage to disocclude the anterior segment, a finger
spring for slight incisor proclination, a palatal jackscrew for
expansion, and two horizontal loops on the canines for connecting
elastics to the face mask to achieve maxillary protraction and
provide appliance retention.
Case 3

67. A 6-year, 4-month-old girl presented with skeletal Class
III malocclusion, posterior and anterior crossbites, and a
mandibular shift . Both maxillary permanent lateral
incisors were missing.
Case 4

68. Treatment:
The planned treatment was rapid palatal expansion in
conjunction with maxillary protraction by facemask.
Case 4

69. • As discussed earlier, anterior crossbites with
mandibular shift are not only destructive to the
dentition and supporting structures but also can have
adverse effects on jaw growth and worsen the
anteroposterior basal jaw relationships.
• Therefore, correction of the problem during the mixed
dentition, especially the cases that have some familial
background, are more complicated.
• Patients exhibit a greater sagittal malrelationships (A-
B discrepancy) and usually need a combination of
orthodontic and orthopedic treatment.
Early treatment after eruption of the incisors (middle or
late mixed dentition)

70. A 9-year, 8-month-old girl in the middle mixed dentition
presented with a maxillary deficiency (SNA =
76.5 degrees) and a maxillary arch that was collapsed
within the mandibular arch. There was an A-B discrepancy of
–0.8 degrees as well as severe maxillary incisor crowding,
rotation, and displacement. She had no mandibular shift.
Case 1

71. Treatment:
The treatment plan included rapid maxillary expansion
and maxillary protraction with a type 1 FCC. Treatment
was started with rapid palatal expansion, occlusal
coverage, and a hook to the FCC. The second step was
maxillary incisor bonding and placement of a nickel-
titanium arch for leveling and anterior alignment.
Case 1

72. An 11-year-old boy presented with skeletal Class III
malocclusion, maxillary deficiency, mandibular
prognathism, a steep mandibular plane, and a
mandibular shift.
Case 2

73. Treatment:
Treatment was started with rapid palatal expansion and
a vertical chin cap that had spurs to allow the elastics to
be attached from the spurs to the premolar brackets to
initiate maxillary protraction. After expansion and bite
jumping, treatment was continued with maxillary anterior
bonding. There were also elastics from spurs to the
connected midline arch hook.
Case 2

74. A 10-year-old girl at the beginning of the late mixed
dentition presented with Class III skeletal malocclusion,
maxillary deficiency, anterior and posterior crossbites
(collapsed maxillary arch), and reverse deep bite.
Case 3

75. Treatment:
The treatment plan called for maxillary rapid palatal
expansion and protraction with a type 1 FCC. The
expander had thick occlusal acrylic resin to disocclude
the anterior teeth and facilitate maxillary protraction and
incisor protrusion and thereby correct the reverse
overbite. It also had hooks for connecting elastics to the
face mask.
Case 3

76. • Three cases are presented to show the results of
delayed correction of anterior crossbite.
• Treatment options available during the permanent
dentition are limited to camouflage treatment, either
with or without extraction, and orthognathic surgery,
for patients with severe skeletal discrepancy.
Nonsurgical treatment of Class III permanent dentition

77. 16-year, 5-month-old girl presented with severe anterior
dentoalveolar crossbite, reverse deep bite, two-step
occlusion, maxillary anterior crowding, mandibular
mesial shift, and structural damage to the maxillary
incisors.
Case 1

78. A nonextraction treatment strategy was planned. It
included slight maxillary incisor proclination to eliminate
crossbite and correct the overbite. A posterior bite plate
with acrylic resin occlusal coverage was placed to
disocclude the anterior teeth. Because of the severe
reverse overbite, an occlusal composite resin attachment
could not be used. Complete maxillary and mandibular
bonding was begun with a nickel-titanium archwire to
align the incisors, and then stainless steel archwire with
open loop was used to complete incisor proclination, level
the mandibular arch, and correct the two-step occlusion.
Case 1

79. A 12-year-old boy presented with a severe anterior
dentoalveolar crossbite, severe maxillary anterior
crowding in which the canines were out of the arch,
some maxillary incisor retroclination, a mesial
mandibular shift, and good mandibular dentition.
Case 2

80. Treatment:
After consideration of the maxillary incisor retroclination,
mandibular shift, and good mandibular dentition, the
treatment plan was designed as camouflage with a
nonextraction approach that was limited to maxillary
treatment. The anterior teeth were disoccluded through
the use of a maxillary posterior bite block, and maxillary
complete bonding was used to align and procline the
maxillary incisors to eliminate crossbite.
Case 2

81. A 14-year-old girl presented with a severe dentoalveolar
anterior crossbite, maxillary and mandibular crowding,
minor mandibular incisor proclination, and a mesial
mandibular shift.
Case 3

82. Treatment:
Because she exhibited severe
maxillary and mandibular crowding
and some mandibular incisor proclination, and because
the incisors could not reach end-to-end contact during
centric occlusion or centric relation, the treatment plan
called for both camouflage and extraction of four first
premolars. Because of the age of the patient and the lack of
significant jaw growth, the results of camouflage
treatment were mostly dental, that is, achievement of good
occlusion and dental relationship.
Case 3

83. Any question?