Crossbite

A VERY GOOD MORNING…

CROSS BITE

By: Aditi SinghP.G Dept of pediatric dentistry

SDCH

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

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:Case Reports;EurJournOfDent;2008;2(1)

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

CLASSIFICATION…

ANTERIOR

SINGLE

SEGMENTAL

POSTERIOR

SINGLE

SEGMENTAL

POSTERIOR CROSSBITE …

SIMPLE BUCCAL NON OCCLUSION

LINGUAL NON

OCCLUSION

CLASSIFICATION…

DENTAL

SKELETAL

FUNCTIONAL

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

NUMBER OF TEETH

• Single tooth involved --- dentoalveolar crossbite

• Complete segment involved--- skeletal crossbite

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

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

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 2TWEED ANALYSIS • FMA : more than 25• IMPA : less than 90

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

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

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?

THE SOLUTION..

PRIMARY / MIXED DENTITION

PERMANENT DENTITION

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.

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

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

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.

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.

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.

DOUBLE CANTILEVER SPRING / Z-SPRING

• INDICATION Used when anterior cross bite involving 1 or 2 maxillary anterior teeth• DISADVANTAGESEffective only when there is enough space for aligning the teeth

• POSTERIOR DENTAL CROSS BITE

• CROSS-ARCH ELASTICS followed by retentive appliance.

• COFFIN SPRING

• 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.

• .

• 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

POSTERIOR CROSS BITE (FUNCTIONAL OR SKELETAL)

• SELECTIVE EQUILIBRATION

• MAXILLARY EXPANSION


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 2-3mm before selective grinding

• When lower intercanine width is more or equivalent to that of upper intercanine width upper arch expansion is a must


FIXED PALATAL WIRE DESIGN

• W – ARCH

• QUAD HELIX

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

QUAD HELIX• The quad helix is a more

flexible version of the W-arch. • 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

APPLIANCES WITH SCREWS• FIXED : HYRAX RPE OF HAAS

• REMOVABLE : • REMOVABLE APPLIANCE WITH MINI SCREWS• REMOVABLE APPLIANCE WITH MEDIUM

SCREWS• REMOVABLE APPLIANCE WITH 3D SCREWS

SCREWS…

• Active component providing intermittent force

• ACTIVATION : quarter turn 3-7 days which would produce 0.2-0.25mm movement per quarter turn.

• Movement produced is direct function of the thread height,more the opening higher the forces generated

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

ORTHOPEDIC APPLIANCES

• FACE MASK ALONG WITH RME

• FRANKEL III

• CHIN CAP APPLIANCE

FACEMASK WITH RME

CHIN CAP APPLIANCE

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

A CASE REPORT

• 9 YEAR & 5 MONTH OLD MALE PATIENT

• c/o : MALALIGNED TEETH

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.

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)

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.

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

• 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

FINALLY…

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):

• 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):

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

FIXED Vs REMOVABLEAdvantages of fixed appliances• Minimal discomfort• Reduces need for patient co-

operation• 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

DRAWBACKS….

• Reverse SS Crown• Tongue blade• Acrylic bite planes with springs

Bayrak S,Tunc ES;Treatment of Anterior Dental Crossbite Using Bonded Resin-Composite Slopes:Case Reports;EurJournOfDent;2008;2(1)

Health & Medicine

Crossbite