crossbite.pptx

Presented by: Dr Nandani Jaiswal

• DEFINITION
• CLASSIFICATION OF CROSSBITE
• ANTERIOR CROSSBITE
• Etiology
• Diagnosis
• Tongue blade/popsicle stick therapy
• Lower iinclined plane
• Palatal spring appliances (removable hawley or fixed
palatal wire)
• Fixed transpalatal wires with springs
• Labial edgewise brackets and archwires
• POSTERIOR CROSSBITE
• Dental
• Skeletal
• Functional

Graber 1988 “Condition where one or more teeth may be MALPOSED ABNORMALLY, BUCCALLY OR
LINGUALLY or LABIALLY with reference to the OPPOSING TOOTH OR TEETH”.
Graber TM. Orthodontics: Principles and Practice. 3rd ed.
Philadelphia: W.B. Saunders 1988
Based on
location
Anterior
crossbite
Single tooth Segmental
Posterior
crossbite
Unilateral Bilateral
Based on the
nature of the
cross bite
Skeletal Dental Functional

ANTERIOR CROSSBITE is a condition in which one or more primary or permanent maxillary incisors are
LINGUAL TO THE mandibular incisors.
Over
retained
deciduous
teeth
Crowding,
arch length-
tooth
material
discrepancy
Abnormal
oral habits
Trauma to
primary
incisors
Palatal
eruption of
the maxillary
incisor
Supernumerary
tooth
ETIOLOGY OF ANTERIOR CROSSBITE

Cooperative children can often correct a
localized anterior crossbite using the WEDGING
EFFECT OF A TONGUE BLADE OR POPSICLE
STICK.
Teeth in INITIAL ERUPTION WITH A MINIMAL
DEGREE OF LOCKING can often be repositioned
within 24 to 72 hours.
Jeffrey Dean. Mcdonald and Avery’s Dentistry for Children and
Adolescent south Asian edition. 2nd edition. 2019

Application
• The child is instructed to place the stick
behind the locked tooth and, using the
CHIN AS A FULCRUM, exerts pressure on
the tooth in the LABIAL DIRECTION.
• The procedure is done in 15- to 30-minute
increments at a time for at least SEVERAL
HOURS OF ENGAGEMENT.
• The exercise may be prescribed for
TELEVISION TIME so that it does not
become an BURDENSOME DUTY.
Advantage • “SELF-CORRECTION” avoids the
expense and time
Jeffrey Dean. Mcdonald and Avery’s Dentistry for Children and
Adolescent south Asian edition. 2nd edition. 2019
The proper use of the tongue blade for an
HOUR OR TWICE A DAY FOR 10–14 DAYS is
usually sufficient for proper relationship.

Contraindications:
Lack of
ADEQUATE
SPACE in the
arch
Not effective in
COMPLETELY
ERUPTED
TOOTH
Not effective in
DEEP BITE cases
due to the
INTERFERENCE
FROM THE
OVERBITE
UNCOOPERATIVE
patients.
The treatment
is VERY
UNLIKELY if the
tooth is
erupted into
FULL
CROSSBITE.
Jeffrey Dean. Mcdonald and Avery’s Dentistry for Children and Adolescent south Asian edition. 2nd edition. 2019
Textbook of Orthodontics, Sridhar Premkumar:2015

An acrylic extension from the
LOWER ANTERIOR TEETH
designed to engage the INCISAL
EDGES OF LINGUAL DISPLACED
MAXILLARY TEETH during
closure
Applies PRESSURE ON CLOSURE
that will direct the ENGAGED
TOOTH LABIALLY INTO NORMAL
BITE POSITION

REQUIREMENT :
• Adequate space in the maxillary arch
• A normal or excessive overbite
• Sufficient mandibular teeth for retention of the acrylic
• Class I occlusion
FABRICATION:
• SELF-CURING RESIN on a working model to enclose the lower CANINE-
TO-CANINE ANTERIOR SEGMENT.
• This MAXIMIZES STABILITY while preventing excessive lingual
movement of the lower incisors.
• The acrylic should ENGAGE TOOTH IN CROSSBITE
• 45-DEGREE INCLINE TO THE LONG AXIS of the lower incisors.
• The inclined portion should extend about ¼ INCH POSTERIORLY

Follow up
should be made
at 1 week
Eruption of
posterior teeth
may occur
within 2 weeks
and a TENDENCY
TO AN
ANTERIOR OPEN
BITE may result.
The posterior
“bite opening”
(not more than
2–3 mm) to
AVOID
EXCESSIVE
MUSCLE
FATIGUE.
At placement,
the inclined
plane SHOULD
NOT TOUCH
PALATAL
TISSUE.

Advantages
• Ease of fabrication
• Simplicity of action
• Rapid correction time
• Possible use when there is insufficient eruption to
ENGAGE ACTIVE APPLIANCES.
Disadvantages
• Discomfort associated with forced bite opening,
• Poor aesthetics
• Limitations on diet
• Potential for gingival irritation
• Possibility of creating an open bite
• The risk of traumatic injury if the child hits his/her
chin while the inclined

CASE REPORT:
• A 9-year-old female complained of abnormal
positioning of upper front tooth with corresponding
lower tooth.
• Clinical examination
• Crossbite with 21
• Dental caries in 16, 14, 26, 36, and 46.
Prashanth Prakash et.al Anterior Crossbite Correction in
EarlyMixed Dentition Period Using Catlan’s Appliance: A Case
Report.International Scholarly Research Network ISRN
Dentistry,Volume 2011

• The CROSSBITE was corrected after the
cementation of the Catlan’s appliance within 3
weeks
• Recall examination after 6 months showed
normal incisal relation without any relapse.
Prashanth Prakash et.al Anterior Crossbite Correction in
EarlyMixed Dentition Period Using Catlan’s Appliance: A Case
Report.International Scholarly Research Network ISRN
Dentistry,Volume 2011

• A fixed or removable appliance incorporating palatal springs provides the best option for
dental anterior cross-bites
• Properly oriented springs exert targeted, labially directed pressures against the teeth from the
palatal side and are not affected by the reverse overjet.
Disadvantages
• The finesse needed in engaging the spring to the involved the tooth
• Adjustments, if breakage occurs
• Modification for retention if overbite is not adequate

It can reduce lingual displacement of maxillary incisors, with correction usually achieved in
6–12 weeks
A conventional Hawley retainer incorporating a LABIAL BOW AND ADAMS CLASPS on
the molars PROVIDES THE BASE FOR THE SPRING COMPONENT.
With a helical loop finger spring of 0.020- or 0.022-inch stainless-steel wire, activation
should represent 2–3 MM OF HELICAL LOOP.
When activated, the spring tends EXAGGERATE TIPPING EFFECTS on incisor.

CASE REPORT:
• An 11-year-old female complained of abnormal
positioning of upper front tooth with corresponding
lower tooth.
• CLINICAL EXAMINATION
• 21 was in crossbite with 31
• Proclined 11
• Angle’s class I molar relation bilaterally.
Ankita Sinhaet.al Single Anterior Crossbite Correction in Mixed Dentition Using Z’spring Along with
Posterior Bite Plane: A Case Report Indian Journal of Forensic Medicine & Toxicology, October-
December 2020, Vol. 14, No. 4

The use of Hawley’s appliance was continued to achieve adequate overjet and overbite for
another 2 months.
After 3 months of active treatment, the CROSSBITE was successfully
corrected.
6th week, CROSSBITE was found to be corrected
with 21.
Recalled after every week for the activation of double cantilever spring which was accomplished
by OPENING EACH OF TWO HELICES 2MM.
This appliance is known to DELIVER SLOW-
LIGHTCONTINUOUS FORCE.
“HAWLEY’S APPLIANCE WITH POSTERIOR BITE PLANE to achieve a 2 mm incisal clearance and
DOUBLE CANTILEVER SPRING (23 gauge wire) to push the palatally placed upper incisor labially”.
TREATMENT
Ankita Sinhaet.al Single Anterior Crossbite Correction in Mixed Dentition Using Z’spring Along with Posterior Bite Plane:
A Case Report Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4

A 13 year old female complained of lingually placed front teeth.
Intra-oral examination
• Class III molar and canine relation on left
• Class I molar and canine relation on right side
• 22 was in CROSSBITE with 33
• Midline shift to left by 3mm
• Patient had poor posterior intercuspation with POSTERIOR CROSSBITE tendency due to
narrow maxillary arch
CASE REPORT
Batra P, Agarwal I, Katyal S. Anterior crossbite correction using a removable orthodontic appliance: a case report. MOJ Clin Med Case Rep.

The HAWLEY’S APPLIANCE INCORPORATING Z-
SPRING, POSTERIOR BITEPLATE, AND MIDLINE
EXPANSION SCREW was fabricated.
The active components of the appliance THREE PIN
JACK SCREW was given TO GAIN SPACE FOR
ALIGNMENT OF LATERAL INCISOR
Z-SPRING TO ACTIVELY PUSH THE LATERAL
INCISOR in the arch once the space is gained.
TREATMENT:
Batra P, Agarwal I, Katyal S. Anterior
crossbite correction using a
removable orthodontic appliance: a
case report. MOJ Clin Med Case Rep.

The EXPANSION SCREW
was activated by ONE
QUARTER TURN 2 TIMES A
WEEK.
Continued for 3 months
for MAXILLARY ARCH
EXPANSION.
After gaining space from
expansion
Z-SPRING was then
activated every month till
POSITIVE OVERJET
ACHEIVED.
Treatment process
lasted for around 8
months after which
LATERAL INCISOR GOT
WELL ALIGNED IN THE
ARCH
TREATMENT PROGRESS
Batra P, Agarwal I, Katyal S. Anterior crossbite correction using a removable orthodontic appliance: a case report. MOJ Clin Med Case Rep.

A TRANSPALATAL CONNECTOR WIRE of 0.036- or 0.040-inch SS
soldered to BANDED MOLARS THAT INCORPORATES A HELICAL
LOOP SPRING of 0.020-inch SS wire is used
LINGUAL
COMPOSITE
BUTTON used to
engage the spring
Increased stability
Rigidity of the fixed anchorage system
Enhance directed forces toward the
CENTER OF ROTATION of the engaged
incisors.

ADVANTAGE
LESS TOOTH TIPPING in
offering a MORE BODILY
APPLIED TOOTH
MOVEMENT
PROVIDES CONTINUOUS
FORCE APPLICATION that
is not dependent on the
child’s cooperation.
Average times
ranging from 1 to
3 weeks
Abutment
support
2nd primary
molars or 1st
permanent
molars
Depending on
DEVELOPMENTAL
AND ERUPTIVE
STATUS
CONDITION OF
THE CROWN

Bands are fitted to selected abutments
The anchor wire is approximate the palatal arch
about 5 mm lingual to the anterior teeth in
crossbite.
provides accurate space for active component.
Passively, the helical loop extends from the anchor
wire to rest on the cutoff incisal table, with the free
end at the labial surface.
The original positioning of the palatal anchor wire about
5 mm behind the crossbite teeth.
Careful soldering of the spring to the palatal wire
completes the appliance in preparation for polishing.
FABRICATION

• A 10 year old female complained of one upper
front tooth in abnormal position than the
corresponding teeth.
• Intra oral examination
• Angle′s Class I molar relation bilaterally
• 12 in crossbite
CASE REPORTS
NachiketShah, AshwinRao, Suprabha B.S, Arathi Rao (2014);
Correction of a Single Tooth Anterior Dental Crossbite using a
Fixed Z-Spring: A Series of Three Cases Int. J. of Adv. Res. 2
(Feb). 0] (ISSN 2320-5407)

A “U” shaped 19 gauge wire
is soldered to the palatal
side of the bands.
Z-Spring is fabricated from
23 gauge wire.
During fabrication the active arm of
this Z-SPRING IS KEPT AT THE
BUCCAL SURFACE OF TOOTH.
Spring is soldered onto the
palatal arch and stabilized using
an acrylic button similar to
NANCE BUTTON.
Bite is opened by PLACING BITE BLOCKS on the posterior
molars using Resin Modified Glass Ionomer Cements (GC
Corporation) so as to achieve a 2 MM INCISAL CLEARANCE.
TREATMENT

The appliance is cemented
on the upper permanent
molars using Zinc
Polycarboxylate cement
(Poly F, Dentsply).
Activation was carried out in
both helices simultaneously
by OPENING THE HELICES 2
MM EACH TIME TWICE.
The patient was followed up
for 4 WEEKS
Correction of the crossbite
was achieved.
NachiketShah, AshwinRao, Suprabha B.S, Arathi Rao (2014); Correction of a Single Tooth Anterior
Dental Crossbite using a Fixed Z-Spring: A Series of Three Cases Int. J. of Adv. Res. 2 (Feb). 0] (ISSN
2320-5407)

• EDGEWISE MECHANICS are used
• When multiple incisors are in crossbite,
• Palatal displacement
• Rotations are severe
• Adjacent tooth movements are needed to adjust anterior
spacing.

Finally, it is worth mentioning that an interesting study by Rosa et al.35 showed 84% spontaneous correction of
anterior crossbites in conjunction with rapid palatal expansion treatment in the mixed dentition
DISADVANTAGES
• Increased chair time in placement
• Adjustment, and removal
• Need for special equipment and supplies
• Increased soft tissue irritation
• Decalcification of teeth
• Risk of injury to developing teeth with
excessive biomechanical movements
• The expectations and expenses associated
with “braces.”

• An 8-year-old female complained of improperly aligned
upper front teeth.
• The patient had a history of abscess and early loss of
deciduous maxillary anteriors about 2 years back.
• Intraoral examination
• Crowding in both upper and lower arches.
• 21 was palatally placed and in crossbite relation
CASE REPORTS
Sunil M M, Zareena M A, Ratheesh M S, Anjana G. Early orthodontic interception of anterior crossbite in mixed dentition. J
Int Oral Health 2017;9:88-90

After thorough oral prophylaxis, pre-adjusted
EDGEWISE BRACKET WITH 0.022” slot was
selected and bonded on 11 and 21.
0.014” NICKEL TITANIUM (NITI) wire was
selected and cut symmetrically by 10 mm
from the midline marking.
The wire was placed into the brackets and
stabilized using LIGATURE TIES.
To raise the bite, glass ionomer cement (GIC)
of 2 mm thickness was placed on the occlusal
aspect of 36 and 46
Sunil M M, Zareena M A, Ratheesh M S, Anjana G. Early orthodontic interception of anterior crossbite in
mixed dentition. J Int Oral Health 2017;9:88-90

Patient recall after 1 week
Marked tooth movement was noted in
relation to 21.
After 2 weeks
CROSSBITE was completely corrected.
The GIC placed on 36 and 46 were
removed using an ULTRASONIC SCALER.
The wire was then changed to 0.017 ×
0.022” NiTi
Retained for another 2 weeks followed
by debonding.
Sunil M M, Zareena M A, Ratheesh M S, Anjana G. Early orthodontic interception of anterior crossbite in
mixed dentition. J Int Oral Health 2017;9:88-90

• A 12-year-old female complained of the backwardly
placed upper front tooth since the time of eruption.
• ON EXAMINATION
• CROSSBITE with 21
• CLASS I MOLAR RELATION with mandibular incisor
crowding
• Model analysis revealed both arches had ≤2 mm of
the arch length-tooth material discrepancy.
• Non-extraction correction with fixed appliance was
planned
CASE REPORTS
Remadevi CP, Subramani SM, et al. Anterior Dental Crossbite
Correction: An Esthetic Makeover. J South Asian Assoc Pediatr
Dent 2019;2(1):29–31.

Composite build-up on mandibular molars was removed.
Review after 8 weeks revealed a positive overjet in relation to 21.
The brackets were engaged with 0.016″ OVOID NITI INITIALLY.
This helps counteract the PALATAL TORQUE OF THE ROOTS of 21 and 32.
Brackets on 21 and 32 were ROTATED BY 180°
The occlusal clearance for 21 was done with COMPOSITE BUILD-UP ON THE
MANDIBULAR FIRST MOLARS.
Maxillary and mandibular incisors were bonded with PRE-ADJUSTED
EDGEWISE BRACKETS and the 1st molars were banded.
Treatment plan composed of 2 × 4 APPLIANCE THERAPY
First Phase
Remadevi CP, Subramani SM, et al. Anterior Dental
Crossbite Correction: An Esthetic Makeover. J South
Asian Assoc Pediatr Dent 2019;2(1):29–31.

Second Phase
After debonding the appliance, a FIXED LINGUAL RETAINER was given
to retain the corrected position of 32.
ROTATION CORRECTION of 32 was achieved after 3
months.
2ND ELASTOMERIC CHAIN was extended between the lingual button on
32 and brackets of 31 and 41
1ST ELASTOMERIC CHAIN was extended between the labial bracket of
32 and the lingual button of 34.
2 ELASTOMERIC CHAINS were used to DEROTATE 32.
In this phase, LINGUAL BUTTONS were bonded on the lingual surface
of 34 and 32 .
Remadevi CP, Subramani SM, et al. Anterior Dental Crossbite Correction: An Esthetic Makeover. J South Asian Assoc Pediatr
Dent 2019;2(1):29–31.

Discrepancy is a localized
problem in TOOTH ERUPTION
(DENTAL CROSSBITE)
A gross BASAL DISHARMONY
between the MAXILLA AND
MANDIBLE
(SKELETAL CROSSBITE)
A TRANSVERSE DISCREPANCY in
the upper to lower arch width
that produces a LATERAL SHIFT
OF THE MANDIBLE ON CLOSURE
(FUNCTIONAL CROSSBITE).
Before treatment, the type of posterior CROSSBITES in children must be determined

Most often involving isolated PERMANENT MAXILLARY 1ST MOLARS OR PREMOLARS
Dental crossbites are usually corrected in conjunction with COMPREHENSIVE EDGEWISE ORTHODONTICS.
1st permanent molar cross-bites can be corrected by the use of CROSS-ARCH ELASTICS
A hook or button (either bonded to enamel or welded onto bands) on the lingual and buccal surfaces of the
upper and lower molars, respectively, is used to secure elastics.
Corrected in 4–8 weeks
If either of the opposing molars is in correct alignment before treatment, an anchorage appliance (LOWER
LINGUAL ARCH OR UPPER NANCE/TRANSPALATAL BAR) may help prevent movement of that tooth
DENTAL POSTERIOR CROSSBITES

• Presenting a full bilateral CROSSBITE with severe constriction of the maxilla.
• An acrylic JACKSCREW RAPID PALATAL EXPANDER (HAAS RPE) in the mixed
dentition with bands on the permanent first molars and bonded composite on
the primary canines.
SKELETAL POSTERIOR CROSSBITES
Jeffrey Dean. Mcdonald and Avery’s Dentistry for
Children and Adolescent south Asian edition. 2nd
edition. 2019

(A) and (B)
BILATERAL POSTERIOR
CROSSBITE with
constricted and tapering
maxillary arch form.
(C) and (D)
RAPID PALATAL EXPANSION
appliance appearance at
cementation and after expansion
involving 32 turns once-a-day
schedule.
(E)
The occlusion at
3 months.
(F)
The occlusion 1 year
after appliance
removal.

Functional posterior CROSSBITE corrected with maxillary expansion at a mean age of 8½ years.
As a result of the FUNCTIONAL SHIFT, DENTAL, SKELETAL, AND NEUROMUSCULAR ADJUSTMENTS likely
result in
Further constriction of the
maxillary arch
Maldistribution of erupting
teeth and alveolar bone
Asymmetric growth of the
contralateral sides
Involve LATERAL SHIFT OF THE MANDIBLE during closure in response to transverse occlusal interference
between the Maxillary and mandibular arch widths.
FUNCTIONAL POSTERIOR CROSSBITES

W-ARCH APPLIANCE.
2 years post-treatment
Transverse posterior widths are in proper relationship with no mandibular
shift evident during closure.
The crossbite was corrected in 6 weeks with 2- to 3-mm overexpansion; the
appliance was left in place for 3 months.
Soldered W-lingual arch appliance at
cementation.
In rest to first contact position, the dental midlines are normal with the
posterior segments edge-to-edge bilaterally in transverse width.
Crossbite extends through buccal segment from the LATERAL INCISOR WITH
A 2.5-MM MANDIBULAR MIDLINE shift to the affected side.
Jeffrey Dean. Mcdonald and Avery’s Dentistry for
Children and Adolescent south Asian edition. 2nd
edition. 2019

(E) 2 years after treatment into mid-mixed dentition with proper
transverse relationships and no functional shift of mandible noted.
(D) 6 months post-treatment
Transverse posterior widths remain in proper relationship with no
mandibular shift evident during closure.
(C) Occlusion 2 weeks after appliance removal.
The CROSSBITE was corrected in 4 weeks, and the appliance was left
in place for 2 months.
Note the symmetric and horizontal loop design for optimum
expansion with minimal buccal tipping of molars.
(B) Soldered QUAD-HELIX APPLIANCE at cementation.
(A) CROSSBITE extends through buccal segment with a 1.5-mm
mandibular midline shift to the affected side.
QUAD-HELIX APPLIANCE
Jeffrey Dean. Mcdonald and Avery’s Dentistry for Children
and Adolescent south Asian edition. 2nd edition. 2019

REFERENCES
• Graber TM. Orthodontics: Principles and Practice. 3rd ed. Philadelphia: W.B. Saunders 1988
• Jeffrey Dean. Mcdonald and Avery’s Dentistry for Children and Adolescent south Asian edition.
2nd edition. 2019
• Textbook of Orthodontics, Sridhar Premkumar:2015
• Prashanth Prakash et.al Anterior Crossbite Correction in EarlyMixed Dentition Period Using
Catlan’s Appliance: A Case Report.International Scholarly Research Network ISRN Dentistry,
2011
• Ankita Sinhaet.al Single Anterior Crossbite Correction in Mixed Dentition Using Z’spring Along
with Posterior Bite Plane: A Case Report Indian Journal of Forensic Medicine & Toxicology,
October-December 2020, Vol. 14, No. 4

• Batra P, Agarwal I, Katyal S. Anterior crossbite correction using a removable orthodontic
appliance: a case report. MOJ Clin Med Case Rep.
• NachiketShah, AshwinRao, Suprabha B.S, Arathi Rao (2014); Correction of a Single Tooth
Anterior Dental Crossbite using a Fixed Z-Spring: A Series of Three Cases Int. J. of Adv. Res. 2
(Feb). 0] (ISSN 2320-5407)
• Sunil M M, Zareena M A, Ratheesh M S, Anjana G. Early orthodontic interception of
anterior crossbite in mixed dentition. J Int Oral Health 2017;9:88-90
• Remadevi CP, Subramani SM, et al. Anterior Dental Crossbite Correction: An Esthetic
Makeover. J South Asian Assoc Pediatr Dent 2019;2(1):29–31.

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