Treatment of

cross bite
 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?
CATEGORIES OF EXPANSION
• PASSIVE EXPANSION

• ORTHODONTIC EXPANSION

• ORTHOPEDIC EXPANSION

• SURGICALLY ASSISTED (SARPE)

 1) Occlusal equilibrium.
2) Coffin spring.
3) Cross elastics.
4) Soldered W –arch (Porter appliance).
5) Quad Helix.
6) Removable appliance.
7) Rapid maxillary expansion (RME).
8) Ni-Ti expanders.
9) Oral screening.
10) Fixed orthodontic appliances.
 OCCLUSAL EQUILIBRIUM

- A dental, bilateral, lingual crossbite in primary and mixed

dentition may be simply corrected by removing the occlusal
interferences usually in the cuspid area.

- This may be sometimes needed to be accompanied by some

appliance.
 ORAL SCREEN/VESTIBULAR SCREEN
- Introduced by Newell in 1912.
- It is a myofunctional appliance – that takes form of a curved acrylic
shield placed in labial vestibule.
PRINCIPLE :
It works on the principle of
force application + force limitation.
i.e. to apply the forces of circumoral musculature to certain teeth
OR
to relieve those forces from teeth
therefore allowing them to move due to forces exerted by tongue
It works on principle of “PASSIVE EXPANSION”
INDICATIONS :
To intercept habits – mouth breathing
thumb sucking
tongue thrusting
lip/cheek biting
To treat mild disto-occlusions.
To perform muscle exercise to help correction of hypotonic
lip and cheek muscles.

CONTRAINDICATIONS :
In children with nasal obstruction or
respiratory distress
 MODIFICATIONS :
Hotz modification – made up of additional metal ring.

Patient with tongue thrust – additional screen placement on lingual

aspect

In Mouth breathers – vestibular screen with a number of holes

which are gradually decreased
 COFFIN SPRING

- It was designed by Walter Coffin.

- It is a removable,omega shaped wire appliance
- It produces slow and bilaterally symmetrical expansion.
- It consists of omega shaped wire of 1.25 mm diameter
placed in mid palatal region.
- Free ends of omega are embedded in an acrylic plate that covers
the slopes of the palate.
- It brings about dento alveolar expansion.
- However, it is capable of skeletal changes when used in mixed
dentition with a good retention.
• 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
 SOLDERED W – ARCH
(PORTER APPLIANCE)
- It is an efficient appliance for the correction of posterior
crossbite as well as a reminder appliance in some posterior
crossbites assosciated with thumb sucking.
- Preformed stainless steel bands are adapted to the most distal tooth involved.
- W-arch is constructed of 0.036-0.040 inch steel wire- contoured to the arch.
- Wire is made free of tissue by 1-2 mm.
- Anterior extension of the wire should touch only the teeth that must be moved buccally.
- W-arch is expanded about 4mm wide than its passive width or so that one arm of
“W” is resting over central grooves of teeth when the other arm is in proper position.
- The appliance is cemented during active treatment.
- Activate the appliance by slightly opening the palatal loop with a
corresponding adjustment in the molar loop area.
- The appliance activation:- intra orally
or extra orally.
- Appliance expands the arch approx 1mm/side/month.
- Activated every 3-4 weeks until crossbite is slightly over corrected.
- Retainer used for additional 3 months.
 Modification : UNEQUAL W-ARCH

- Used in case of true unilateral crossbites.

- It has long and short arms.
- Short arm- touches only the teeth to be moved.
- Long arm – touches as many contralateral teeth as possible.
- The idea behind the unequal W-arch is to pit the movement of a
large number of teeth against movement of small number of teeth.
- The side with smaller number of teeth – more movement
side with larger number of teeth - less movement.
 QUAD HELIX

- Introduced by Currier and Austerman, 1993.

- The quad helix is a spring that consists of 4 helices-

2 helices in the anterior palate and
2 helices near solder joint in the posterior palate.
- It is capable of dento alveolar as well as skeletal expansion.
- Activate the appliance prior to cementation.
- Activation is done intra orally - using triple beak plier
extra orally – using hand.
- Activation is done in 2 steps :
Step 1 – Activate the posterior helical loops,
moving the free wires buccally.
Step 2 – Activate the anterior helical loops
moving the molar bands buccally.
- When the wire has been activated the lingual surface of molar
bands will be above the central fossa of the molars.
- The anterior portion of wires will be above the canine cusp tip.
- The appliance produces slow expansion
- Crossbite corrected in 4-6 months.
- Retain the same appliance for further 3 months.
- The quad helix can be used simultaneously with
full bonded appliance therapy.

Modification – UNEQUAL QUAD HELIX

Same as unequal W- arch

Used to correct unilateral crossbites
 REMOVABLE APPLIANCES
- Lateral maxillary expansion is achieved with a parallel expansion screw
housed in upper acrylic plate.
- The appliance should have excellent tissue contact and anchorage with clasps on teeth.
- Provide acrylic relief – palatal to anterior teeth.
- The labial bow should be passive; when expansion occurs-bow becomes activated.
- A full turn is achieved with 4 turns of a key.
- The conventional expansion schedule– ¼ turn every 3-4 days.
- Correction is dental only.
- It causes bilateral expansion.
- Relapse potential is high.
 RAPID MAXILLARY EXPANSION
- Rapid maxillary expansion is indicated for severe cases of bilateral
crossbites where correction requires skeletal expansion.
- It involves the splitting of the mid palatal suture
orthopaedic increase in maxillary width.
- It can easily occur in a growing child (< 9 years).
- The appliance uses a mid–palatal screw (Hyrax) – soldered to bands
on the first permanent molars and primary molars.
RME screw
Banded RME Cemented RME.
 NICKEL TITANIUM EXPANDERS
- They bring about slow expansion (dental changes).
- They require less adjustments than conventional stainless steel
quad helix appliances.
- Molar bands are cemented to maxillary first permanent molars
welding is done.
Ni–Ti wire shapes are attached to lingual sheath
of welded molar band.
- Various sizes are available and need to be selected depending on :
- the amount of expansion desired
- pre treatment width of the palate
- Cooling the expander it gets constricted
it gets inserted into lingual tubes on the
maxillary molars.

As it warms to body temperature it becomes springy

exerts continuous force on teeth
arch expansion
 FIXED ORTHODONTIC APPLAINCES

- Fixed orthodontic appliances can be used for correction

of posterior crossbites.
- The arches can be kept slightly expanded depending upon the
movement required.
- Cross elastics can be used to bring about correction of
individual tooth crossbite in posterior segment.
- Fixed orthodontic appliance are ideal for accurate placement of
teeth in a dental arch as they provide a three dimensional control
over the tooth.
 CROSS ELASTICS

- It is used to treat localized crossbites.

- Select, fit and burnish appropriate band to maxillary and
mandibular teeth.
- Solder hooks or button to the bands- - -
on palatal surface of the maxillary teeth and
on buccal surface of the mandibular teeth.
- After these bands are welded and cemented rubber elastics is
attached on the hooks as shown in fig.

- The rubber elastics used are – heavy rubber elastics,

0.25 i.e. 3/16 inch and
6 ounce elastic
- The elastic should be worn full time except while eating.
- Change it atleast once per day.
- The elastics are worn until the crossbite is slightly over corrected.
- Crossbites are ususally corrected within 3-4 months (with
continuous wearing of elastics).
- Major change will be reflected in position of the maxillary molar
because of the cancellous nature of the maxillary alveolar bone
compared with denser bone around mandibular molar.
- Advantage - Usually no need of retentive appliance
- Disadvantages – Needs patient’s co operation and
is technically more difficult.
 PALATAL EXPANSION
INDICATIONS:

• Skeletal maxillary constriction

• Dentoalveolar compensation (transverse)
• Posterior cross bite (unilateral / bilateral)
• Mild crowding
• Distal molar movement
• Functional appliance treatment
• To aid maxillary protraction
• Surgical cases (arch coordination)
 ORTHOPEDIC EXPANSION
• Changes are primarily skeletal

• Midpalatal suture is opened to widen the palate

• New bone deposited in the area of expansion so

that the integrity of midpalatal suture is
re-established within 3 to 6 months

• Best example: RME

 PALATAL EXPANSION
Palatal expansion:
• Rapid (0.5 mm or more per day)
• Semi-rapid (0.25 mm per day)
• Slow (1mm per week)

Expansion devices classified as :

• Rapid maxillary expansion devices

• Slow expansion devices
 RAPID EXPANSION

• Rapid expansion typically done with 2 turns daily of

the jackscrew (0.5mm)
• Creates 10 – 20 lbs pressure across the suture
• Force transmitted from teeth to suture
• Philosophy: rapid activation to maximize skeletal
response and minimize dental response
• Time taken for bone to fill = skeletal relapse
= teeth retained
Net result: approximately equal skeletal and
dental expansion
• 2 to 3 weeks = 10 mm or more of expansion
 RAPID MAXILLARY EXPANSION
EFFECTS ON MAXILLARY TEETH & ALVEOLAR BONE

• Posterior teeth used as handles to transmit forces

to maxilla
• Posterior teeth tip buccally
• Appearance of midline diastema, which is half of
the distance by which the screw is activated
• Closes spontaneously within 6 months due to trans-
septal fiber traction
RAPID MAXILLARY EXPANSION
MAXILLARY SKELETAL EFFECTS

• Palatal processes separate in a triangular or wedge-

shaped manner
• Maximum opening seen anteriorly
• Maximum opening towards the oral cavity with
progressively less towards the nasal aspect
RAPID MAXILLARY EXPANSION
EFFECTS ON THE MANDIBLE

• Mandible rotates downwards and backwards due to

the downward movement of the maxillary posterior
teeth in a buccal direction
• Palatal cusps of maxillary posterior teeth occlude
with lingual inclines of buccal cusps of mandibular
posterior teeth = open the bite
RAPID MAXILLARY EXPANSION
EFFECTS ON THE NASAL CAVITY

• RME increases the intra-nasal space as outer walls

of nasal cavity move apart
• Improvement in nasal airflow occurs
• In young children may distort nose due to paranasal
swelling and hump
TYPES OF RME APPLIANCES

• REMOVABLE
• FIXED
REMOVABLE RME APPLIANCE
• Appliance consists of a screw in the midline with
retentive clasps on posterior teeth
• Acrylic plate is split in middle
• Activations of the screw force the two halves apart
to result in the desired expansion
• Most effective when used in early mixed dentition
• Efficiency in late mixed dentition and older
patients doubtful due to ossification of suture
• Predominantly dental changes
• Screw activated 1 turn/week
(0.2mm)
 FIXED RME APPLIANCES
• HYRAX EXPANDER:
• Tooth-borne appliance
• Makes use of Hyrax screw (Hygienic rapid expander)
• Has heavy wire extensions, adapted to follow
contour of the palate
• Extensions soldered to metal bands or wire
framework with acrylic splints
Bonded expander
 FIXED RME APPLIANCES
• MINNE EXPANDER

• Tooth-borne appliance
• A spring-loaded screw called MINNE expander (Univ.
of Minnesota)
• Metal framework soldered buccally and palatally
onto 1st premolar and molar bands
• Nut is closed to compress the spring for activation
of expander
FIXED RME APPLIANCES
• HAAS APPLIANCE:
• Tooth and tissue borne appliance
• Transmits forces to teeth as well as palatal shelves
• Rigid wire framework soldered to 1st premolar and
molar bands buccally and palatally
• Palatal extensions of wire incorporated in an acrylic
plate which contains an expansion screw in the
midline
 BONDED ACRYLIC SPINT
EXPANDER
• In mixed dentition
• Incorporates a Hyrax screw into a framework of
wire and acrylic
• Acrylic covering occlusal surfaces of posterior teeth
acts as a bite block and prevents extrusion thus can
be used in patients with steep mandibular plane
angles
• Screw activated ¼ turn (0.2mm) per day until
palatal cusps of upper posterior teeth approximate
the buccal cusps of lower posterior teeth
• Retention for 5 months to allow for reorganization
of midpalatal suture
ACTIVATION OF RME APPLIANCE
• Basic principle involves generation of forces
capable of splitting the midpalatal suture

• Forces generated close to 10 – 20 lbs

• Expansion of 0.2 to 0.5 mm should be achieved per

day
 SLOW EXPANSION

• Rate of 1mm per week

• Pressure: 2 lbs
• Opens suture at rate close to maximum speed of
bone formation
• Tissue damage and hemorrhage minimized
• Both skeletal and dental changes occur at ratio of
1:1 since the beginning
• Large midline diastema does NOT appear
 SLOW EXPANSION APPLIANCES
• SCREW APPLIANCES:
> have a smaller pitch and activated less frequently
as compared to screws used for RME appliances
SLOW EXPANSION APPLIANCES
• COFFIN SPRING:
> can split palate in early mixed dentition
> ideal for unilateral cross bite correction
> differential expansion can be done in premolar
and molar regions
> consists of an omega-shaped wire (1.2mm),
embedded in two acrylic wings also holding the
retentive clasps
> activated by pulling the wings apart
SLOW EXPANSION APPLIANCES
• QUAD-HELIX:
> consists of 4 helices, 2 anterior and 2 posterior,
(0.9mm wire) soldered to molar bands
> capable of producing differential expansion
> anterior bridge = molar expansion
> outer arms = premolar/canine expansion
> skeletal: dental (1:6) effects in pre-adolescence
> force level of 400g by
activating appliance by 8mm
> over-correct and retain
 RAPID OR SLOW??

• Rapid and slow expansion provide approximately

the same result over 10-12 week period

• Major difference : greater expansion across canines

in rapid expansion

• slow expansion = more physiologic response

Rapid Palatal Expansion
• Done in adolescents and adults where strong
interdigitation of suture is present
• This creates 10 to 20 pounds of pressure across
the suture-enough to create microfractures of
interdigitating bone spicules
• rate of 0.5 to I mm/day
• 2 to 3 week
• The expansion device is left in place for 3 to 4
months new bone forms in the space at the
suture, and the skeletal expansion is stable
Slow Palatal Expansion
• Done in preadolescent children esp
with cleft
• 2 pounds of pressure
• 0.5 mm-1mm per week
• damage and hemorrhage at the
suture are minimized
• expansion is completed in 2 to 3
months
SURGICALLY ASSISTED RPE
• Adult patients / severe transverse discrepancy
• Combines technique of palatal widening with a
modification of Lefort I osteotomy
• Can be classified as :
> One piece
> Two piece
> Three piece