CROSSBITE MANAGEMENT

1. CROSSBITE
Presented by: Dr. Priya Kawana
Department Of Orthodontics &
Dentofacial Orthopedics

2. CONTENTS
◦ Introduction
◦ Definition
◦ Prevalence
◦ Classification
◦ Anterior crossbite
◦ Posterior crossbite
◦ Skeletal crossbite
◦ Functional crossbite
◦ Etiology

3. ◦ Diagnosis
◦ Management of anterior crossbite
◦ Management of posterior crossbite
◦ References

4. INTRODUCTION
◦ Cross bites are term used to describe abnormal
occlusion in the transverse plane.
◦ The term is also used to describe reverse overjet of
one or more anterior teeth.
◦ Crossbite is a form of malocclusion where a tooth
(or teeth) has a more buccal or lingual position
(that is, the tooth is either closer to the cheek or to
the tongue) than its corresponding antagonist tooth
in the upper or lower dental arch.
◦ .

5. ◦ Crossbite occurs when there is an imbalance between upper and lower jaw
members.
◦ Crossbite may be due to localized problems of tooth position or alveolar
growth, or to gross disharmony between maxilla and mandible.
◦ It may include one or more teeth and it may be unilateral or bilateral.
Proffit WR, Fields HW, Larson BE, Sarver DM. Contemporary Orthodontics. Philadelphia, PA:
Elsevier; 2019.

6. ◦ Varies significantly from one ethnic group to another.
◦ Prevalence of posterior crossbite in Asians or Africans < Caucasians.
◦ Anterior crossbite 10% of Japanese population
3% of US population
Prevalence
Proffit WR, Fields HW, Moray LJ. Prevalence of orthodontic treatment need in the United States:
Estimates for the NHANES-III survey. Int J Orthod Orthogn Surg. 1998;13:97-106

7. ◦ A retrospective study was conducted in patients with crossbite. The final sample size was 934
after reviewing 41190 case sheets. The data was collected from the hospital digital database by
reviewing the patients records and analysing them. The data was entered in an excel sheet and
imported to SPSS software version 23 and the results were calculated using Chi square test. It
was observed that the prevalence of crossbite in male population was 60.06% and in the female
population was 39.9%. Crossbite in Class I malocclusion was more common among the male
patients (47.64%) followed by class III malocclusion (8.57%). However, it is not significant
statistically (P value>0.05). Within the limits of the study, it was observed that crossbite was
more prevalent in the male population and crossbite in class I malocclusion was more common
among the patients.
Prevalence and Gender Distribution of Dental Crossbite and its Association
with Malocclusion: An Institution Based Study
Preetha Parthasarathy, Aravind kumar and Sreedevi Dharman

8. DEFINITION
 According to Graber,Cross bite is defined
as a condition where one or more teeth may
be abnormally malposed buccally or
lingually or labially with reference to
opposing tooth or teeth.
 According to Moyers, crossbite is the term
used to indicate an abnormal buccolingual
(labiolingual) relationship of the teeth.
◦

9. CLASSIFICATION
1)Based on their location as:
Anterior : i) single tooth
ii) segmental
Posterior:
a) According to no of teeth involved: i) Single tooth
ii) Segmental

10. b) According to side involved: i) Unilateral
ii) Bilateral
2)Based on the nature of the cross bites
Skeletal
Dental
Functional

11. ANTERIOR CROSSBITE
◦ Simple anterior crossbites are dental malocclusions
resulting from abnormal axial inclinations of maxillary
anterior teeth.
◦ The simple anterior crossbite has many other names (e.g.,
"in-locked" incisors).
◦ The use of the word "simple" implies that some anterior
crossbites are more complicated, and indeed they are,
particularly those which accompany a Class III
malocclusion or are part of a skeletal deep bite.

12. ◦ The dental crossbite involves only tipping of teeth buccally or lingually.
◦ The condition is localized in the alveolar process and does not affect the size or
shape of basal bone.
◦ In this group the upper and lower midlines will coincide when the jaws are
apart, and diverge as teeth come into occlusion.
◦ Some of the teeth in crossbite will not be centered buccolingually in the
alveolar process; therefore, the most important diagnostic point is to localize
asymmetry of the dentoalveolar arch.

13. POSTERIOR CROSSBITE
◦ According to Bjork (1964) Posterior cross bite is
defined as a malocclusion in canine, premolar and
molar regions, characterized by buccal cusps of
maxillary teeth occluding lingual to buccal cusps of
the corresponding mandibular teeth.
◦ This refers to an abnormal transverse relationship
between the upper and lower posterior teeth.
◦ In this condition, instead of mandibular cusps
occluding in the central fossae of maxillary
posterior teeth they occlude buccal to maxillary
cusps.
◦ .

14. It can be :
◦ Unilateral crossbite
◦ Bilateral crossbite
◦ Buccal non occlusion
◦ Lingual non occlusion

15. ◦ BUCCAL NON-OCCLUSION: This is a form of
posterior crossbite where maxillary posteriors
occlude entirely on the buccal aspect of the
mandibular posteriors.
◦ This condition is also called as scissor bite.
◦ LINGUAL NON-OCCLUSION: This is a form of
posterior crossbite where maxillary posteriors
occlude entirely on the lingual aspect of the
mandibular posteriors.

16. SKELETAL CROSSBITE
◦ This involves both a dental and skeletal discrepancy. The dental and skeletal
midlines do not coincide both at rest and in occlusions.
◦ This condition could be due to a basal skeletal deformity.
◦ There may be asymmetrical growth of the maxilla or mandible or a lack of
agreement of their widths.
Robert E Moyers, Handbook Of Orthodontics,4th Edition:418-423.

17. ◦ Skeletal dysplasia might be due to maxillary constriction or mandibular
constriction or may be due to mandibular asymmetry.
◦ It can be due to:
1)Midface deficiency
2)Mandibular prognathism
3)Combination of the two.

18. Anterior crossbite due
to maxillary
retrognathism.
Anterior crossbite due to
mandibular prognathism.
Anterior crossbite due to
maxillary retrognathism and
Mandibular prognathism.

19. ◦ Midface Deficiency: Patients with Class III midface deficiency display a Class
III maxillo-mandibular relationship, a diminished cranial base-maxilla value,
and normal cranial base-mandibular values.
◦ The profile analysis usually shows shortened maxillary skeletal unit and max-
illary dentoalveolar unit distances.
◦ The mandibular skeletal unit distance is near normal, but the mandibular
dentoalveolar unit distance may be slightly above normal.

20. ◦ Mandibular Prognathism: Patients with mandibular prognathism show a Class III
maxillo-mandibular relationship, an excessive cranial base-mandible dimension both
horizontally and vertically, and may show a diminished cranial base angle.
◦ In severe case, the maxillary dentoalveolar unit distance may also be excessive as the
maxillary teeth tip labially to obtain function with mandibular incisors which have
been carried forward by the excessive mandibular length.
◦ Anterior face height is usually excessive when compared with posterior face height,
and lower face height is abnormal anteriorly.

21. ◦ Mandibular prognathism is sometimes seen without excessive anterior face
height (i.e., the mandibular border is not steeply positioned).
◦ Midface Deficiency and Mandibular Prognathism: Patients show a
combination of mild midface deficiency a mandibular prognathism.
◦ The prognosis usually is not as poor as for the serious mandibular prognathism.
◦

22. FUNCTIONAL/MUSCULAR CROSSBITE
◦ Functional/Muscular: This type involves muscular adjustment to tooth
interference.
◦ According to Moyer this muscular type is similar to the dental type of crossbite
except that the teeth are not tipped within the alveolus.
◦ Both dental and skeletal crossbites require occlusal and muscular adjustments to
complete their correction.

23. ◦ Moyer concludes that lack of harmony between maxillary and mandibular widths
usually is due to bilaterally contracted maxilla, in which case the muscles shift the
mandible to one side to acquire sufficient occlusal contact for mastication and
comfort.
◦ If deviation occurs just before the teeth make contact it might be that tooth
interference was the original etiologic factor.
◦ If deviation increases throughout opening, the primary fault is likely to be
asymmetry of bony growth.
Robert E Moyers, Handbook Of Orthodontics,4th Edition:418- 423.

24. ETIOLOGY OF CROSSBITE
Crossbites could be caused due to skeletal disturbances, dental disturbances, or
combination of both.
◦ I) Skeletal growth disturbances
◦ 1. Defects in embryologic Development
◦ 2. Muscle Dysfunctions
◦ 3. Fetal Molding and Birth Injuries
◦ 4. Childhood fractures of the Jaw
Robert E Moyers, Handbook Of Orthodontics,4th Edition:418- 423.

25. ◦ 5. Abnormal pressure Habits
◦ 6. Endocrine imbalance
◦ 7. Functional shifts
◦ 8. Others

26. ◦ II) Dental disturbances
◦ Dental factors include discrepancies of tooth to tooth relationships where the jaws or
bony bases are relatively harmonious in size, shape and symmetry. Significant
disturbances include:
◦ Congenitally Missing Teeth.
◦ Malformed and Supernumerary Teeth.
◦ Interference with Eruption.
◦ Ectopic Eruption.
◦ Early Loss of Primary Teeth.
◦ Traumatic Displacement of Teeth.

27. 1. History
◦ Digit-sucking problem: its frequency
intensity
duration
persistence.
◦ Narrowing of the maxilla may or may not create an apparent dental
crossbite.
DIAGNOSIS
Brook PH, Shaw WC. The development of an index for orthodontic treatment priority. Eur J Orthod.
1989;11:309-332

28. 2. Clinical examination
◦ A functional examination of the mandible’s closing pathway from
maximum opening to first contact and then final, maximum
intercuspation must be performed to determine if a lateral or
anterior-posterior mandible shift occurs following first contact. The
amount and direction of any mandible shifting between first contact
and maximum intercuspation should be noted.
. 2004;26:266-272

29. 3. Diagnostic records
◦ It is necessary to prepare adequate study models and radiographs that depict both the teeth
present in the oral cavity and those developing in the alveolar processes.
◦ For the latter, panoramic radiographs are required.
A posterior-anterior cephalometric radiograph is useful in:
◦ measuring the transverse dimensions of the maxilla and mandible to calculate if a
transverse discrepancy exists.
◦ assessing the position of the dental midlines in relation to their respective skeletal midlines.
Cross D, McDonald JP. Effect of rapid maxillary expansion on skeletal, dental and nasal structure: A postero-
anterior cephalometric study. Eur J Orthod. 2000;22:519-528

30. CBCT
More accurate for:
◦ congenitally missing teeth
◦ formation stages of the permanent teeth’s developing roots and the
resorption of their primary precursors
◦ measuring the transverse dimensions

31. MANAGEMENT OF ANTERIOR
CROSSBITE

32. Management of anterior crossbite
◦ In 4 stages:
◦ 1)In primary dentition
◦ 2) In mixed dentition
◦ 3) In permanent dentition
◦ 4) In post permanent dentition

33. ◦ IN PRIMARY DENTITION :
Elimination of the factors that may lead to anterior crossbite.
Eg:
1) Removal of occlusal prematurities
2) Extraction of supernumerary tooth before they cause displacement of other
tooth.
3) Habit breaking appliance.

34. ◦ Developing anterior cross bites can be treated by
extracting adjacent primary teeth if space is not
available for the erupting permanent teeth.
◦ Extraction should be bilateral to prevent midline
shift.

35. IN MIXED DENTITION :
In pre-adolescent age group
Anterior crossbite should be treated at an early stage
1) If crossbite is present in the deciduous dentition, it may manifest in the mixed
and permanent dentition as well.
2) If simple anterior crossbite is not treated in early stage
it may progress into skeletal malocclusion that later need complicated
orthodontic treatment or surgical treatment.

36. Tongue blade therapy
◦ Indicated when there is sufficient space for
the tooth to erupt.
◦ Flat wooden stick resembling ice cream
stick.
◦ Blade is made to contact the palatal aspect
of the tooth in crossbite which rests on the
mandibular tooth in cross bite which acts as
a fulcrum and patient is asked to rotate the
oral part of the blade upward and forward.
◦ 1-2 hours for 2 weeks

38. ◦ Drawbacks:
1) Only effective till the clinical crown not completely erupted in the oral
cavity.
2) Used only if sufficient space is available for correction.
3) Patient cooperation is required.

39. Catlans Appliance
◦ It is lower anterior inclined plane used to treat
maxillary teeth in crossbite.
◦ It has 45 degree angulation which forces the
maxillary teeth in crossbite in to more labial
position.
◦ Prerequisities for use of inclined plane
1) Enough space in maxillary arch to align the
teeth/tooth.
2) Mandibular incisors should be well aligned
to allow appliance fabrication.

40. ◦ Advantages:
1)Ease of fabrication.
2)Lack of soreness or looseness of teeth during treatment.
3) Rarity of relapse
Disadvantages:
1) Difficulty in speech and chewing.
2) Appliance cannot be given if mandibular incisors are periodontally
compromised.

41. ◦ 3)Prolonged use can lead to anterior open bite.
◦ 4)Possibility of appliance becoming loose and requiring recementation because
of strong occlusal stresses on it.

42. Prakash P, Durgesh BH. Anterior crossbite correction in early mixed dentition period using
Catlan’s appliance: A case report. ISRN Dentistry. 2011;2011:1–5.

44. Reversed stainless steel crowns
◦ Anterior stainless steel crowns cemented backwards on the maxillary
teeth.
◦ Stainless steel crown needs to open the bite 2 to 3 mm and establish at
least a 25 percent overbite for successful treatment.
Robert Staley and Neil Reske. Essentials of orthodonitics- Diagnosis and treatment
planning, Wiley Blackwell publications, 2011

45. ◦ Two disadvantages of using reverse stainless steel crowns are the unsightly silver
appearance of the crown form, and the limitations of working with an inclined
slope that is already formed.
◦ Both problems can be avoided by using a bonded resin-based composite custom
formed inclined slope
Croll TP: Anterior tooth crossbite correction using bonded resin-composite slopes. Quintessence
International 27: 7-10, 1996

46. Composite slopes
◦ The composite slope is designed to elongate the incisor such that some
overbite is created in centric occlusion. The posterior teeth typically do
not contact after slope placement, but normal posterior occlusion is re-
established as soon as the maxillary incisor is displaced labially.
Croll TP: Anterior tooth crossbite correction using bonded resin-composite
slopes.Quintessence International 27: 7-10, 1996

47. ◦ Case report :
An 8-year-old boy visited the pediatric dental clinic for routine control.
Intraoral examination revealed a maxillary left central incisor in crossbite .
A composite slope was bonded to the mandibular left central and lateral incisors and
remained in place for 1 week.
Treatment of Anterior Dental Crossbite Using Bonded Resin-Composite Slopes: Case Reports
European Journal of Dentistry 2(4):303-6

49. Face mask
Facemask is an extraoral traction appliance used to correct skeletal class 3
malocclusion
 In cases of anterior crossbite due to an actual skeletal deficiency of maxilla
it is possible to mesialize the maxilla using a protraction face mask
 If the maxilla is narrow a rapid maxillary expansion screw can be
employed simultaneously.
Force: 300-500 grams per side.
Duration: 12-14 hours per day

51. Chin cup
 A chin cup can be used to redirect the growth of mandible to prevent or correct the anterior
crossbite due to a prominent mandible.
 Chin cup tends to rotate the mandible downward and backward.
Retardation or even sometimes restriction of mandibular growth is supported by some authors
(Proffit 2000, Bishara 2001)
Orthopedic force:300-500 grams per side (Proffit-450 grams per side)
Patients are instructed to wear appliance for 14 hours/day.

53. In adolescent and adults;
Double Cantilever Spring/Z spring
◦ Anterior crossbite involving one or two teeth can be
treated using double cantilever spring provided that
there is adequate space.
◦ It consist of two coils and resembles the shape of
alphabet “Z” when activated hence it is also called
as Z spring.
◦ Consists of double helix between two parallel arms
and the inferior arm extends as retentive component.

54. ◦ Activation: To activate the spring open the coil about 2 to 3 mms.
◦ Open the palatal limb alone and adjust the free end so that it is perpendicular to
the direction of tooth movement.

55. Fixed appliance
◦ Light arch wire combined with maxillary lingual arch with auxillary springs
◦
◦ Indicated for a very young child or preadolescent with whom patient compliance
is a concern
◦ Treats severely displaced incisors
◦ Should be over-corrected by at least 1-2 mm
◦ Distortion and breakage of the appliance and poor oral hygiene
Robert Staley and Neil Reske. Essentials of orthodonitics- Diagnosis and treatment planning, Wiley
Blackwell publications, 2011

56. ◦ Edgewise fixed appliances using nickel titanium arch wires can rapidly correct an
anterior cross- bite in conjunction with either a lower posterior acrylic bite plate or
glass ionomer cement on the occlusal surfaces of the lower molars to open the bite
sufficiently to easily move the upper incisor out of crossbite (Skeggs and Sandler
2002)
Robert Staley and Neil Reske. Essentials of orthodonitics- Diagnosis and treatment planning, Wiley
Blackwell publications, 2011

57. REFERENCES
◦ 1) Proffit WR, Fields HW, Larson BE, Sarver DM. Contemporary Orthodontics. Philadelphia, PA:
Elsevier; 2019.
◦ 2) Robert E Moyers, Handbook Of Orthodontics,4th Edition:418-423.
◦ 3) Graber L, L. V. Orthodontics current principles and Techniques. 7 th ed. Philadelphia: Elsevier -
Health Sciences Division; 2023:313-316.
◦ 4) Björk A, Krebs Aa, Solow B. A method for epidemiological registration of Malocculusion. Acta
Odontologica Scandinavica. 1964;22(1):27–41.
◦ 5) Prakash P, Durgesh BH. Anterior crossbite correction in early mixed dentition period using Catlan’s
appliance: A case report. ISRN Dentistry. 2011;2011:1–5.
◦ 6)Robert Staley and Neil Reske. Essentials of orthodonitics- Diagnosis and treatment planning, Wiley
Blackwell publications, 2011
◦ 7) Croll TP: Anterior tooth crossbite correction using bonded resin-composite slopes.Quintessence
International 27: 7-10, 1996

58. THANK YOU

59. CROSSBITE(PART 2)
Presented by: Dr. Priya Kawana
Department Of Orthodontics &
Dentofacial Orthopedics

60. MANAGEMENT OF POSTERIOR
CROSSBITE

61. ◦ Selective grinding of teeth 􏰀
◦ Elastics
◦ Palatal expansion􏰀
◦ Surgery
Treatment of posterior crossbites
Robert Staley and Neil Reske. Essentials of orthodonitics- Diagnosis and treatment
planning, Wiley Blackwell publications, 2011

62. ◦ Selective grinding for slight maxillary constriction due to primary
canine interferences
◦ Functional shift of the mandible eliminated and the mandible
allowed to assume its natural position
Robert Staley and Neil Reske. Essentials of orthodonitics- Diagnosis and treatment
planning, Wiley Blackwell publications, 2011
Primary dentition

63. ◦ Removable appliances are used. The maxillary arch should be over
expanded and then held passively in this over expanded position
for approximately 3 months before it is removed.
◦ Premature use of fixed rapid palatal expansion appliances has been
known to create an increase in nasal width.
Proffit WR. Contemporary Orthodontics. 3rd ed. St. Louis: Mosby, Inc; 2000
Early mixed dentition period

64. ◦ When only few posterior teeth in crossbite and
crossbite is caused by a mere tipping
◦ 􏰀Use cross elastics if both arches contribute to the
crossbite problem
◦ 􏰀Overcorrect and leave the bands in place right after
active treatment
◦ 􏰀In case of relapse, reinsert the elastics
◦ The major problem - patient cooperation
Elastics

65. Dental crossbite:
• W-ARCH ,Quad Helix & Jack screw appliance are
used
• They deliver less than 2 pounds of force
Management in late mixed dentition
period

66. Skeletal cross bite correction in late mixed dentition
• Corrected by opening the mid palatal suture.
• Growth at this suture continues in most children until late teens &
then ceases.
Robert Staley and Neil Reske. Essentials of orthodonitics- Diagnosis and treatment
planning, Wiley Blackwell publications, 2011

67. CORRECTION OF POSTERIOR CROSSBITE
1.Coffin Spring
This is an omega shaped wire (0.9 mm ) in a
removable appliance used for expansion to correct
the posterior cross bite
The expansion produced is slow and bilaterally
symmetrical
If used in mixed dentition stage the appliance is
capable of producing skeletal changes

68. 2.T Spring
T spring can be used for buccal movement
of premolars
It is made of 0.5 mm hard round stainless
steel wire
Spring consist of t shaped arm whose ends
are embedded in acrylic
Spring is activated by pulling the free end
of T towards the intended direction of
tooth movement

69. 3.Jack screw
A jack screw can used in the removable plate to carry out expansion to
correct the posterior cross bite
The patient should cooperative to maintain the appliance and activate the
screw or atleast get it activated at regular intervals

70. 4.Quad helix
It is a fixed appliance soldered to the molar bands cemented generally on the
first permanent maxillary molars
It can be reactivated using the three pong plier without having to be
removed from the oral cavity
It is a versatile appliance and can be used with usual fixed appliance therapy
It can produce skeletal effects if given in preadolescent

71. 5.Rapid maxillary expansion
 Bilateral skeletal cross bite with a deep palate and narrow maxilla can be
treated by RME where the mid palatal suture is split
It incorporates a screw which is activated 0.5 – 1 mm/day
The force level can build upto 10 to 20 pounds as the screw is turned at this
rate