crossbite

2. CROSS BITE
By: Aditi Singh
P.G Dept of pediatric dentistry
SDCH

3. DEFINING THE PROBLEM….
• A Condition where one or more teeth may be
malposed abnormally buccally lingually or
labially with reference to opposing tooth or
teeth. - Graber
• Moyers defines a simple anterior tooth
crossbite as a dental malocclusion resulting
from the abnormal axial inclination of one or
more maxillary teeth

4. WHY IS IT AN EMERGENCY..?
• Anterior dental crossbite requires early and
immediate treatment to prevent abnormal
enamel abrasion, anterior teeth mobility and
fracture, periodontal pathosis and
temporomandibular joint disturbance.
• The main goal of treatment is to tip the affected
maxillary tooth or teeth labially to the point
where a stable overbite relationship exists.
• Relapse is usually prevented by the normal
overjet/overbite relationship that is achieved.
Bayrak S,Tunc ES;Treatment of Anterior Dental Crossbite Using Bonded Resin-Composite Slopes:Cas
Reports;EurJournOfDent;2008;2(1)

5. CAUSE…
DENTAL
• ANOMALIES OF NUMBER
• ANOMALIES OF TOOTH SIZE
• ANOMALIES OF TOOTH SHAPE
• PREMATURE LOSS OF DECIDUOUS
&/OR PERMANENT TEETH
• PROLONGED RETENTION OF
DECIDUOUS TEETH
• DELAYED ERUPTION OF
PERMANENT TEETH
• ABNORMAL ERUPTIVE PATH
• TOOTH ANKYLOSIS
SKELETAL
• HEREDITARY
• CONGENITAL
• TRAUMA AT BIRTH
• TRAUMA DURING GROWTH
• TRAUMA AFTER COMPLETION OF
GROWTH
• HABITS

6. CLASSIFICATION…
ANTERIOR
POSTERIOR
SINGLE
SINGLE
SEGMENTAL
SEGMENTAL

7. POSTERIOR CROSSBITE …
SIMPLE
BUCCAL NON
OCCLUSION
LINGUAL
NON
OCCLUSION

8. CLASSIFICATION…
DENTAL
SKELETAL
FUNCTIONAL

9. DIAGNOSIS
• NUMBER OF TEETH INVOLVED
• INCLINATION OF THE INCISORS
• FACIAL PROFILE & MANDIBULAR CLOSURE
PATTERN
• FAMILIAL APPEARANCE
• CEPHALOMETRIC ANALYSIS
• EVALUATION OF BIOMECHANICAL DECISION
FACTORS
McDonald RE, Avery DR, Dean J; Dentistry for the child and adolescent;9Ed;Mosby Elsevier

10. NUMBER OF TEETH
• Single tooth involved --- dentoalveolar
crossbite
• Complete segment involved--- skeletal
crossbite

11. INCLINATION OF INCISORS
• Dentoalveolar & functional crossbite ---lingual inclination of maxillary incisors &
normal to slight labioversion of lower incisors
• Skeletal crossbite ---- lower incisors are
retroclined & maxillary incisors are normal to
proclined

12. FACIAL PROFILE & MANDIBULAR
CLOSURE PATTERN
• DENTOALVEOLAR CROSSBITE --- facial profile
& buccal occlusion should be in neutroclusion
• FUNCTIONAL CROSSBITE --- In full closure the
facial profile becomes prognathic from a
normative profile present at rest. Class III
buccal pattern seen
• SKELETAL CROSSBITE --- smooth closure in
class III molar relation and prognathic facial
profile present at all the time

13. CEPHALOMETRICS
DOWN’S ANALYSIS
• Increased facial angle seen
in skeletal class III
• Decreased angle of
convexity
• Positive A-B Plane angle
• Y-axis less than 53 indicative
skeletal class III
STEINER’S ANALYSIS
• SNA Angle : less than 82
• SNB Angle : more than 80
• ANB Angle : negative & less
than 2
TWEED ANALYSIS
• FMA : more than 25
• IMPA : less than 90

14. BIOMECHANICAL DECISION FACTORS
INCISOR POSTION & SPACING PRESENT : If
spacing present & root of lingual tooth is in
same position as it would occupy in normal
occlusion then simple labial tipping forces on
maxillary incisors can be applied
STAGE OF ERUPTION : Simple leverage forces
can be used if tooth is in active eruption stage

15. CONSIDERATIONS…..
• Presence or absence of an anterior mandibular
displacement
• Possible damage that has or might occur to the
dentition through excessive tooth wear, or to the
supporting periodontal structures
• Prevention of establishment of the developing
malocclusion
• Space availability – this may be rectified by the early
removal of both the upper deciduous canines
• The position of the developing permanent canines in
relation to the roots of the lateral incisors
• The depth of the overbite

16. CONSIDERATIONS…..
• The magnitude of the crossbite —does it
involve a single tooth or an entire segment?
• Is there a displacement associated with the
crossbite?
• How significant is the skeletal component
and will it be possible to compensate for this
discrepancy with tooth movement only?

17. THE SOLUTION..
PRIMARY / MIXED DENTITION
PERMANENT DENTITION

18. PRIMARY/MIXED DENTITION
(PREVENTIVE ORTHODONTICS)
• Elimination of the factors that may lead to the
anterior cross bite
• Removal occlusal prematurities
• Extraction of supernumerary tooth before
they cause displacement of other tooth
• Habit breaking appliance.

19. PRIMARY / MIXED DENTITION
(INTERCEPTIVE ORTHODONTICS)
ANTERIOR CROSSBITE
•
•
•
•
•
TONGUE BLADE/ POPSICLE STICK THERAPY
REVERSED STAINLESS STEEL CROWN
BONDED RESIN COMPOSITE SLOPE
LOWER INCLINED PLANE.
PALATAL SPRING APPLIANCES (REMOVABLE
HAWLEY OR FIXED PALATAL WIRE)
• FIXED TRANSPALATAL WIRE WITH SPRINGS

20. TONGUE BLADE
• INDICATIONS : Used when cross bite is seen at
the time the permanent teeth are making an
appearance in the oral cavity
• Its placed inside the mouth contacting the palatal
aspect of the maxillary teeth.
• Upon slight closure of jaw the opposing side of
the stick come in contact with the labial aspect of
the opposing mandibular tooth acts as a fulcrum.
• This is continued for 1-2 hours for about
2
weeks

21. Drawbacks of using tongue blade
• Only effective till the clinical crown not
completely erupted in the oral cavity
• Used only if sufficient space is available for the
correction
• Patient co-operation is required.

22. CATLAN’S APPLIANCE
• INDICATIONS : Used only in those cases where
the crossbite is due to a palataly placed
maxillary incisors.
(Constructed at 45o angulations on the lower
anterior teeth by acrylic or cast metal.

23. DISADVANTAGES OF CATLAN’S
APPLIANCE
•
•
•
•
Difficulty in speech and chewing
Patient co-operation required
Required frequent recementation
Catalan’s appliance also as an anterior bite
plane.
• Cannot be given if mandibular incisors are
maligned or they are periodontally
compromised.

24. DOUBLE CANTILEVER SPRING /
Z-SPRING
• INDICATION
Used when anterior cross bite
involving 1 or 2 maxillary
anterior teeth
• DISADVANTAGES
Effective only when there is
enough space for aligning the
teeth

25. • POSTERIOR DENTAL CROSS BITE
• CROSS-ARCH ELASTICS followed by retentive
appliance.
• COFFIN SPRING

26. • CROSS BITE ELASTICS:
• INDICATION : Single
tooth cross bite
involving molars can be
treated by elastics
• Elastics are stretched
between the maxillary
palatal surfaces and
mandibular buccal
surfaces.
• .

27. • COFFIN SPRING :
Expansion produced is
slow & bilaterally
symmetrical
• 1.25mm hard SS round
wire omega shaped loop
1mm away from palate
• Activation : upto 2mm at
a time by flattening the
omega loop or pulling the
loop ends gently apart

28. POSTERIOR CROSS BITE
(FUNCTIONAL OR SKELETAL)
• SELECTIVE EQUILIBRATION
• MAXILLARY EXPANSION
McDonald RE, Avery DR, Dean J; Dentistry for the child and adolescent;9Ed;Mosby Elsevier

29. SELECTIVE EQUILIBRATION
• Selective reduction(slanting) of lingual aspect
of upper primary canine & labial reduction of
lower primary canine.
• Maxillary intercanine width is larger than
mandibular intercanine width by a positive 23mm before selective grinding
• When lower intercanine width is more or
equivalent to that of upper intercanine width
upper arch expansion is a must
McDonald RE, Avery DR, Dean J; Dentistry for the child and adolescent;9Ed;Mosby Elsevier

30. FIXED PALATAL WIRE DESIGN
• W – ARCH
• QUAD HELIX

31. W ARCH / PORTER’S APPLIANCE
• 19 gauge wire that
rests 1-1.5mm off
the palate
• Bilateral
constriction in the
primary dentition
Proffit W ,Fields H, Sarver D; CONTEMPORARY ORTHODONTICS 4 ed 2007; Elsevier

32. QUAD HELIX
• The quad helix is a more
flexible version of the Warch.
• The helices in the anterior
palate are bulky, which
can effectively serve as a
reminder to aid in
stopping habit.
• The combination of a
posterior crossbite and a
finger-sucking habit is the
best indication for this
appliance.
Proffit W ,Fields H ,Sarver D; CONTEMPORARY ORTHODONTICS 4 ed 2007; Elsevier

33. APPLIANCES WITH SCREWS
• FIXED : HYRAX
RPE OF HAAS
• REMOVABLE :
• REMOVABLE APPLIANCE WITH MINI SCREWS
• REMOVABLE APPLIANCE WITH MEDIUM
SCREWS
• REMOVABLE APPLIANCE WITH 3D SCREWS

34. SCREWS…
• Active component
providing intermittent
force
• ACTIVATION : quarter
turn 3-7 days which
would produce 0.20.25mm movement per
quarter turn.
• Movement produced is
direct function of the
thread height,more the
opening higher the forces
generated

36. SCREW APPLIANCE
• MICRO SCREW : used on
single tooth
• MINI SCREW : Capable of
moving up to 2 teeth
• MEDIUM SCREW : Used to
correct segmental cross bite
• 3-D screw : capable of
correcting posterior as well
as anterior cross bite

37. ORTHOPEDIC APPLIANCES
• FACE MASK ALONG WITH RME
• FRANKEL III
• CHIN CAP APPLIANCE

38. FACEMASK WITH RME

39. CHIN CAP APPLIANCE

40. THE 2 X 4 APPLIANCE……
• ADVANTAGE….ease with which space
opening can be controlled with a fixed
appliance, and also that the force
magnitude and vector can be controlled
much more precisely than with a
removable appliance.
P. Dowsing,P. J. Sandler ; How to effectively use a 2 X 4 appliance; Journal of Orthodontics;2004;31:248–258

41. A CASE REPORT
• 9 YEAR & 5 MONTH OLD MALE PATIENT
• c/o : MALALIGNED TEETH

42. CLINICAL EXAMINATION
• Mesofacial symmetrical face & a slightly concave
profile.
• Early mixed dentition
• Maxillary 1st molar were mesially tilted & rotated due
to early loss of his primary maxillary second molars.
• End on class II molar with -2.5 mm overjet & 30%
overbite.
• Mandibular dental midline was deviated to the right
about 1mm
• Gingival recession on right mandibular central incisor.

43. RADIOGRAPHIC EXAMINATION
• Skeletal class III (ANB = -2.5mm overjet & 30%
overbite) with hypodivergent growth pattern
i.e (SN-MP: 31.6o)
• Maxillary incisors showed slight retroclination
(U1 to SN :101.5o)
• Mandibular incisors are retroclined (IMPA :
85.4o)

44. Our Goal is to …….
•
•
•
•
•
Correct anterior cross bite
Establish class I molar relation
Improve the localized gingival recession
Improve patient’s smile & esthetics.
Monitor development of permanent dentition
along with mixed dentition space to estimate
the size of unerupted permanent teeth.

45. T/t plan
• Phase I : MMMDA followed by W Arch fixed
expander. (5 months)
• Phase II : routine orthodontic treatment
followed by twist flex wire bonded from lateral
incisor to lateral incisor on maxillary arch &
canine to canine on mandibular arch.
• Phase II Treatment started when patient was
13y 2 month old & completed within 13
months

46. • 0.032” SS wire and run across
the lingual surface of maxillary
anterior teeth to the posterior
anchorage teeth ( primary
maxillary first molar bands or
permanent maxillary first
premolar bands)
• 0.032 SS wire soldered b/w
lateral incisor and canine and
0.024” Co-Cr finger spring
• Additional 0.032” SS wire
soldered to distalize the
molars in the right direction

47. FINALLY…

48. DISCUSSION
• The treatment strategies QH, expansion
plates, and RME are effective in the early
mixed dentition at a high success rate.
However, there is no scientific evidence
available that shows which of the treatment
modalities, grinding, Quad Helix, expansion
plates, or RME, is the most effective.
Petre S,Bondemark L,Soderfeldt B;A Systematic Review Concerning Early Orthodontic Treatment of Unilateral Posterior Crossbite; Angle
Orthodontist;2003;73(5):

49. • Cemented appliances had a tendency to work
within 3weeks and fixed appliances correcting
the crossbite within 6 weeks to 3 months.
Petre S,Bondemark L,Soderfeldt B;A Systematic Review Concerning Early Orthodontic Treatment of Unilateral Posterior Crossbite; Angle
Orthodontist;2003;73(5):

50. ROOT RESORPTION…
• Early treatment might reduce the extent of root
resorption, as long as the treatment is of a short
duration.
• Reitan,when studying apical root
resorption, suggested that there was a protective
mechanism of precementum and predentine
located at young apices and this may be an
influencing factor regarding the prevention of
root resorption

51. FIXED Vs REMOVABLE
Advantages of fixed appliances
• Minimal discomfort
• Reduces need for patient cooperation
• Increase control of tooth
movements
• Movement possible in all three
planes of space
Disadvantages of removable
appliances
• Appliance rarely worn full time
• Appliance damage/lost
appliances
• Difficulty in speech/eating
• Gagging
• Decalcification/caries
• Gingivitis/palatal
hyperplasia/fungal infections
• Incorrect activation produces
unhelpful changes
• Allow only tipping of teeth
P. Dowsing,P. J. Sandler ; How to effectively use a 2 X 4 appliance; Journal of Orthodontics;2004;31:248–258

52. DRAWBACKS….
• Reverse SS Crown
• Tongue blade
• Acrylic bite planes with springs
Bayrak S,Tunc ES;Treatment of Anterior Dental Crossbite Using Bonded ResinComposite Slopes:Case Reports;EurJournOfDent;2008;2(1)