Transverse discrepancy 1

1. Diagnosis And Management
of Transverse
Discrepancy…
Presented By: Dr. Dinesh kumar maddhesia
Department Of Orthodontics & Dentfacial
Orthopedics…

2. Contents…
 Introduction
 Definition
 Classification
 Management of Anterior Crossbite
 Management of Posterior Crossbite
 conclusion

3. Introduction
 Crossbites are term used to describe
abnormal occlusion in transverse plane.
The term is also used to describe
reverse overjet of one or more anterior
teeth.

4. Definition
 Graber
“ Condition where one / more teeth
may be abnormally malposed buccally
/ lingually / labially with reference to
the opposing tooth / teeth “

5.  Moyers
 “ Abnormal Buccolingual (labio-lingual)
relationship of the teeth”

6. Scissors bite
“ Mandibular dentition
completely contained with
in the maxillary dentition “
(buccal non-occlusion)
 Common – PM area (class
II div 1)
 BRODIE SYNDROME –
rare, all lower teeth lingual
to maxi teeth- retrusive
mandi / large maxilla

7. Classification
 Based on location :
I. ACB - Single tooth
Segmental
II. PCB – Unilateral
Bilateral

8.  Based on nature : ( Moyers 1988)
 Dental CB
 Functional / Muscular CB
 Skeletal CB

10. ACB
 Lingual position of
the maxi ant teeth
irt mandi ant teeth
 Single / segmental
 Decidous & Perma
teeth

11. PCB
 Abnormal T/S relation U/L post teeth
 Disharmony in jaw width
 Unilateral / bilateral
 Prevalence – 2-16%,mainly uni CB

12. Functional /muscular CB
 lllr to dental – no clear cut difference,
significant muscular adjustment
 Occlusal interferences – mandi shift
during jaw closure
 Pure muscular CB – young children
Tx – occlusal equilibrium

13. Skeletal CB
 Aberrations in bony growth & /
morphology
 Asymmetric growth of maxi / mandi
 Disharmony in jaw widths
 Hereditary /trauma – development
 Ant / post

14.  Skeletal PCB – common,narrow
maxilla
 Functional shift – mastication
 Pt may have- TMD

15. Etiology
 Prolonged retention of decidous teeth-single
tooth CB
 Crowding – TSALD – CB
 Habits – TS,MB – lowered tongue posture-
narrow maxilla – CB
 Retarded growth of maxilla (sagittal &T/S)
 Collapsed maxilla – CP
 Unilateral hypo / hyperplastic growth of any jaw

17. Factors that can influence Tx of
ACB
 Ant CR-CO shift
 Over bite
 Arch length
 Torque of maxi incisor root
 Alignment of mandi teeth
 Retention

18. Ant CR-CO shift :
 CB with ant functional shift –
 Pseudo class III
edge-to edge U/L incisors in CR
 If No shift – True class III,
no incisal contact
maxi retrusion/ mandi
protrusion

19.  Imp to differentiate skeletal & dental
CB- Tx, prognosis of Tx, stability
 Pseudo class III – short Tx time, good
retention
 True class III – difficult Tx, retention,
long time - surgery

20. Over bite :
 Influence –Tx, retention
 ACB asso deep OB - easy Tx &
retention
 Little / no OB – difficult to Tx &
retention- best Tx fixed appliances

21. Arch length :
 ADEQUATE SPACE – must for Tx
 If no space – appliance (eg:open coil
spring, bite plane)

22. Alignment of mandi teeth :
 DELAYED- until upper incisor
correction
 Premature alignment –complicates Tx

23. Torque of maxi incisor root :
 As roots placed lingualy- after Tx
>labial inclination of tooth
 A labial inclined tooth- slips to CB than
normal tooth
 Torque root labially – up side down
bracket

24. Retention :
 ADEQUATE OB
 NORMAL INCLINATION OF TX
TEETH
 Evaluate – 2-3 wks
 Stable – no retention if no- retention

25. Treatment
Diagnosis:
 Clinical examination
 Photographs
 Study cast
 Radiographs – ceph, occlusal

26. Note :
 CB – dental / functional / skeletal
 Skeletal-deficient maxilla / large mandi
 Single tooth / segmental
 functional shift
 ADEQUATE SPACE – for Tx

27. DENTAL CB :
 Single/multiple
 Crowding /
prolonged retention
of pri teeth

28. Tx :
 ADEQUATE SPACE
 Developing CB – disking / Xn of primary
teeth (for space)

29. TOUNGE BLADE
 Developing single
tooth CB
 ADEQUATE SPACE,
FLAT WOODEN
STICK
 Stick on palatal
surface & incisor
margin of lower tooth –
as fulcrum
 Upwards & forwards -
constant pr
 1-2 hrs for 10-14 days

30. APPLIANCE THERAPY :
 After eruption of incisors in CB
 Removable
 Fixed- effective & in severe CB

31. Removable
appliances :
 ACB –one / two
teeth
 Z-spring & post bite
plane
 A jack screw & a
post bite plane

32.  Bite plate-if deep bite
 Full time wear
 Slightly over corrected & retention –
correct OB achieved
 Disadv :
 Pt compliance,oral hygeine
 Poor design – prolong Tx time

33. Inclined planes
LOWER ANT INCLINED PLANE /
CATALAN’S APPLIANCE :
 Simple & effective
 Maxi teeth- single/segment
 Acrylic / cast metal
 Adequate space & OB
 Catalan’s- cemented inclined plane

34.  Inclined plane - 450
to occlusal plane
 Only CB tooth
should contact
 Tx- not > 6wks
(supraeruption of
post )
 If not-tongue blade
10-14days

35. Acrylic / metal :
 Cementation
 Full time – during meals also
 Check up-every wk, check occlusion
 Not to open bite > 4-5mm - incre VD-
muscle fatigue
 Soft diet

36. MOA :
 Guide the erupting
tooth to erupt in
normal position
(guide plane)
 “ All forces of
occlusion
(swallowing, speech
)transmitted to the
ant teeth ”

37. ADVANTAGES:
 Easy fabrication
 Tx- rapid,functional
& muscle forces
 Lack of soreness /
loose teeth during
Tx
 Rare relapse
DISADVANTAGES:
 Dietary restrictions
 Speech defect
 AOB- if >6wks
 Breakage &
frequent
cementation

38. Types: fig
 Cast incline
 Inclined crown
 Banded incline

39. Cast incline :
 Cast crown – Ag / Au
 450 to OP
 No under cuts
 Ag solder – reinforce crown

40. Inclined crown :
 Long metal crown -1-2mm mre incisaly
 0.006x0.200’’ molar band material welded
/ soldered on lingual side
 Band material – inclined plane 450
 Reinforce crown- Ag solder

41. Banded incline :
 Variant of inclined crown
 Preformed / s.s band
 0.006x0.200’’ weld lingually-labial side
inlined plane

42. OPPENHEIM SPLINT :
 Modification
cementing type
inclined plane
 Covers oclusal
surface of post teeth
 Activ – reducing
occlusal surface of
acrylic-1mm

43. FIXED APPLIANCES :
Effective, for severely displaced
incisors
 Maxillary lingual arch with finger
springs (whip spring)
 2x4 appliance

44. Maxillary lingual arch with finger
springs (whip spring):
 Simple, young/
preadolescent-
compliance problem
 A guide wire also on
incisors
 Activation -
3mm/month-1mm TM
 After Tx-can be
modified as retainer
 Disadv:breakage &
oral hygiene

45.  Fixed appliance post bands & ant
bonded attachments with a flexible
round wire :
 In mixed dentition –crowding,rotations
& more perma teeth in CB

46. 2x4 appliance :
 Gives facial tipping
& lingual root
torque to maxi
incisors
 Arch wire –
asymmetric V-bend

47. Asymmetric V-bend
> moment to incisors & sliding thro molar tube
Facial tipping of incisors
OJ
If arch wire is tied back / cinched to molars –
lingual torque to incisors

48.  Begg light wire : multi loop arch wire
 PEA : brackets are bonded inverted in
order to torque the roots labially
RETENTION :
 For 1-2mos
 Removed if sufficient OB is present

50. Skeletal ACB
Face mask / face mask with RME :
 Due to retrusive maxilla- protraction face
mask
 If narrow maxilla – RME simultaneously

51. Chin cup :
 To redirect the mandible growth-
prevent or correct ACB
Frankel type III appliance:
 Correct developing class III
 Pri / early mixed dentition
 Stimulates ant growth of maxilla &
inhibits mandibular growth

52. Tx of PCB
Factors that can influence Tx of PCB:
 B-L inclination of teeth
 Lateral shift during mandi closure
 Estimate of expansion needed
 Age of patient
 Vertical changes

53. B-L inclination of teeth : most imp
upper molars :
 if abnormally inclined lingualy –
advantage
Tx – tipping teeth buccaly
 If molars inclined buccaly - narrow
maxilla
Tx - RME

54. Lower molars :
 Abnormal buccal inclination –
favorable
Tx – moves lingual position
 Abnormal lingual inclination –
discrepancy in jaw widths

55. Lateral shift during mandi closure:
 Unilateral PCB – mandi shift towards
CB in CO
 Lateral functional shift- CB usually
bilateral- easy Tx

56. Estimate of expansion needed :
Functional shifts- involving perm 1st
molars & post teeth obtained by-
 Diff of width b/w buccal grooves of
mandi 1st molars & MB cusp tips of
maxi 1st M
 Adding to this diff 2/3mm for over
correction of CB

57. If expansion ,
 4 /<4mm upper molars inclined
lingualy-Quad helix,W-
spring,TPA,SWA
 5-12mm-ME with jack screw
 >12mm- combination of jack screw &
surgical ortho Tx

58. Age of patient :
 PCB uni /bilateral with functional shift –
best to treat in children & young
adolescents
 Unilateral PCB with functional shift – Tx
in pri / mixed /perma dentition
 Early –best
 Late- TMDs

59.  Older adolescents & adults – mid palatal
suture ossified,tendency to relapse
- Surgically assisted jack screw expansion
 Adults – bilateral CB with no functional
shift – NO Tx, as compromise
if Tx- by tipping U/L molars- >relapse

60. Vertical changes :
 During Tx – ant OB as teeth in new
occlusion
 Temporary – returns to pre Tx
condition

61. Tx of PCB
Depends on underlying cause,
 Skeletal – narrow maxilla –common
wide mandible – rare
Tx- orthopedic (maxillary expansion)
 Dental CB –
Tx- moving teeth with lighter forces

62. Unilateral PCB :
 Children – common
 Bilateral constriction of maxilla
 Mandi shift / jaw asymmetry
CB due to Mandi shift should be Tx early, to
avoid
 Undesirable soft tissue growth modification

63.  Dental compensation – less space for
teeth in constricted maxilla
 Dental abrasion of pri & perma
teethallows normal development of
occlusion
 Difficult diagnosis –for inter arch
relationship
 Normal path of closure,TMDs
 Early Tx –more stable

65. Tx PCB:
3 main objectives :
 EQUILIBRATION- to eliminate mandi
shift
 EXPANSION- for constricted maxilla
- maxi arch width
 DENTAL CORRECTION- to correct
intra arch asymmetries

66. Tx in pri / early mixed
dentition:
 PCB- mainly occlusal
interference by C’s
 Careful diagnosis-
dental/mandi shift
 Tx –occlusa
equilibration of C’s
 Interceptive – Quad
helix,W-arch

67. In mixed dentition (preadolescents):
 Skeletal / dental , uni / bilateral
 Check for functional shift
 Skeletal- Tx early
 Quad helix, W-arch – common
 True Skeletal CB- surgical +ortho
 Tx Skeletal CB- dental compensation-
unstable,relapse

68. Bilateral PCB :
 Maxi constriction / mandi expansion /
combination
 Children & pre adolescents –full
buccal segment / one or more teeth
 Dental CB- cross elastics / arch wires
( Tipping the teeth in to correct axial
relationship )

69.  Mild skeletal CB- camouflage dental
Tx
 Quad helix, W-arch – common(more
dental & less skeletal changes)
 Skeletal correction- RMEs

71. Perma dentition :
 Age & maxi expansion
 Expansion-before midpalatal suture
fusion (15-16yrs)
 RME- less response after 16yr(fusion of
suture& hard &soft tissue resistance )
 Easy expansion - adolescence
 Adults –surgically assisted RME /
orthognathic-maxi osteotomy

72. Appliances
CROSS BITE ELASTICS:
 Elastics on buccal & lingual attachment
 Reciprocal action
 Full time wear (except meals)-change
daily
 Tx time- 8-15 wks
 Reinforcing anchorage-’ Reinforcing bar ’
 Pt cooperation imp

74.  Molar CB – maxi 2nd
common
 16-20 wks
 Occlusal adjustment
(ML cusp maxi)
 Retention : self
retaining, continue
Elastics for few hrs,
few days –stability
 Adv effect –
EXTRUSION OF
TEETH

75. REMOVABLE
APPLIANCES :
 Acrylic plate with a
wire spring or jack
screw
 Skeletal expansion –
questionable
 Tx- pri / early mixed
dentition- favorable
 Disadv-pt compliance,
less force

76. SCHWARTZ PLATE
:
 Active expansion
plate with a screw
for ACB
Y-PLATE:
 For both Ant & post
expansion

77. W-arch
 Fixed, in bilateral
constriction of
maxilla
 Pri / mixed dentition
 Skeletal & dental
 0.036” s.s, soldered
to molar bands,1-1.5
away from palate

78.  Activation : IO/EO, opening bends
Ant bending- post Xpn
Post bending – ant Xpn
 Xpn- 2mm/mon
 Tx - 2-3mos
 Retention -3mos as passive appliance

79. Quad helix
 Flexible version of
W-arch
 Helices
(2+2),flexibility&
range of action
 0.038”s.s
 Soldered molar
bands, away palate
 pri / early mixed
dentition

80.  Ant bridge – reminder for TS habit
(PCB with TS- best indication)
 Palatal bridge – b/w ant & post helices
 Free ends – outer arms –on palatal
surfaces
 Activation: IO/EO-3 prong plier
 Dental & skeletal Xpn

81. Effect of maxi Xpn using Quad helix during
deciduous & mixed dentition –AJO 1981
 Tx of functional PCB,same effect in both
 in inter canine & inter molar width
 Xpn in 2 wks
 Total tx time 3-6mos

82. AMEX appliance for Tx of true uni
CB: AJO-DO 2002;122:164-73
 Uni CB in 18 pts,14yrs- corrected in
3.3 mos (2.5-4mos)
 in inter canine,PM & inter molar arch
width significantly
 Buccal tipping,effective in Uni CB

83.  Conventional Xpn apliance- expand
arch bilaterally
 AMEX- move selected teeth on
constricted side

84.  0.036” s.s wire-
Quad helix type
apliance
 2 helixes & force
arm on teeth in CB
 ‘Vertical
stopper’(anchor
unit) on non CB
side soldered

85.  Activation : EO
 Expanding force arm by 8mm,keeping
arms parallel
 Reactivation at 4wks till CB corrected
 Adv :effective in uni CB than conventional
 Well tolerable by pts
 Less pt compliance

86. COFFIN SPRING :
 1.25 mm wire
 Omega shaped
wire,free ends in
acrylic
 Dento alveolar &
skeletal in youngs
 Activ-pulling
manually

87. RME :
 Hyrax,hass type
 JACK SCREW-
active element in
plate
 Controlled tooth
movement
 Disadv-heavy
forces,rapid-
damage teeth

88.  Ni Ti expanders:
 Niti wire,diff sizes
 Attached to molars
 Slow Xpn –dental
in adolescents &
adults

89. Functional appliances
Activator:
 Less effective than-Xpn actvive
plates,jack screw
 Acrylic surface should contact teeth
 Jack screw also incuded
 Single tooth / multiple-with springs in
appliance

90. TWIN BLOCK :
 in narrow maxillary
arch-Class II div 1
 Xpn screw

91. Retention
 Self retaining
 Stabilization for 3-4mos (passive
appliance)
 ACB-sufficient OB
 PCB - >chances relapse after Xpn-
elasticity of palatal tissue (palatal
plate/heavy labial wire 0.036)

92.  OVER CORRECTION
 “ Xpn should be stopped when maxi
palatal cusps contacts with the lingual
slopes of the buccal cusps of mandi
teeth “

93. Conclusion
 Its imp to distinguish CB dental /
functional / skeletal (uni / bilateral)
 Dental: segmental ACB –jaw
discrepancy
 Skeletal - ‘ constricted of maxilla ‘
(children )
 Tx- earliest to avoid IIndry effects

94. Thank You…