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crossbite orthodontics final yearl bds.pptx

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RagenduRNair1

The document discusses the classification, etiology, and treatment options for crossbite, a condition characterized by abnormal occlusion in the transverse plane of the dental arches. It categorizes crossbite into anterior and posterior types, further subdivided into skeletal, dental, and functional forms, and outlines various factors influencing treatment such as overbite, space, and tooth movement type. Treatment modalities include removable and fixed appliances, with specific strategies detailed for anterior and posterior crossbites based on individual patient needs.

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MANAGEMENT OF CROSS BITE RAGENDU R NAIR FINAL YEAR PART 1 BDS PSMDC
CONTENTS • Classification of crossbite • Anterior crossbite • Posterior crossbite • Skeletal crossbite • Dental crossbite • Functional crossbite • Etiology of crossbite
• Factors that influence treatment of anterior crossbite • Treatment of anterior crossbite using removable appliances • Fixed appliances for treatment of anterior crossbite • Factors that influence treatment of posterior crossbite • Treatment of posterior crossbite using removable appliances • Treatment of posterior crossbite using fixed appliances
CROSSBITE • Crossbite is a 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. • GRABER has defined crossbite as a condition where one or more teeth may be abnormally malposed bucally or lingually or labially with reference to the opposing tooth or teeth • Definition of American Association of Orthodontists Glossary: “An abnormal relationship of a tooth or teeth to the opposing teeth, in which normal buccolingual or labiolingual relationships are reversed.”
CLASSIFICATION OF CROSSBITE 1. BASED ON LOCATION A. Anterior crossbite • Single tooth • Segmental B. Posterior crossbite • Unilateral • Bilateral
2.BASED ON THE NATURE OF CROSS BITE A. Skeletal crossbite B. Dental crossbite C. Functional crossbite
ANTERIOR CROSSBITE • Anterior crossbite is defined as a malocclusion resulting from the lingual position of the maxillary anterior teeth in relationship with the mandibular anterior teeth. • An anterior crossbite can involve a single tooth or an entire segment of the arch. • The underlying etiology could be either skeletal or dental,or a combination of these two factors
Anterior functional crossbites • An anterior functional shift on closure from centric relation (CR) to centric occlusion due to the habitual forward positioning of the mandible (pseudo-Class III) may lead to anterior crossbite • Some anterior crossbites are associated with an anterior functional shift on closure from centric relation (CR) to centricocclusion (CO), • If the patient touches his or her upper and lower incisors together edge-to-edge in CR, the occlusion is seemed to an Sunday bite or psuedo-Class III. Thus the habitual forward positioning of the mandible (pseudo-Class II) may lead to anterior crossbite. • Pseudo-Class III also results from an early occlusal interference that forces the mandible to move forward to obtain maximum intercuspation • Pseudo-Class III is also seen in premature loss of posterior teeth and the patient brings his mandible forward have a comfortable bite in the anterior region where teeth are present
crossbite orthodontics final yearl bds.pptx
POSTERIOR CROSSBITE • This refers to an abnormal transverse relarelationship between the upper and lower posterior teeth. • In this condition ,instead of the mandibular buccal cusp occluding in the central fossa of the maxillary posterior teeth,they occlude buccal to the maxillary buccal cusps. • Thus posterior crossbite occur as a result of lack of cordination in the lateral dimension between the upper and lower arches. • Posterior crossbite can occur as a result of :- 1.Upper arch being too narrow. 2.The lower arch being too wide. 3.One or more maxillary buccal teeth displaced towards the palate. 4.One or more of the mandibular buccal teeth displaced buccally. 5.Functional lateral shift of the mandible during closure of the mandible.
Telescopic bite or scissors bite or Buccal non-occlusion 1. This is a form of posterior crossbite where the one or more of the adjacent maxillary posteriors occlude entirely on the buccal aspect of the mandibular posteriors in CO. The palatal cusps of maxillary teeth overlap the mandibular buccal cusps. This is found most frequently in the premolar region of Class II Division I Lingual Non-occlusion • This is a form of posterior cross bite where the maxillary posteriors occlude entirely on the lingual aspect of the mandibular posteriors
Complete Maxillary Buccal Crossbite • A rare buccal crossbite in which all of the lower teeth (both anterior and posterior) are positioned lingual to the upper teeth occurs in patients having a retrusive and small mandible along with relatively large maxilla. This is referred as the BRODIE SYNDROME. It can be seen as if whole mandibular dentition is contained within the maxillary arch and mandibular dentition is hardly visible
Complete maxillary palatal crossbite • It is present when all the maxillary teeth are palatal to the mandibular arch due to narrow maxillary arch
crossbite orthodontics final yearl bds.pptx
crossbite orthodontics final yearl bds.pptx
SKELETAL CROSSBITE • It is associated with a discrepancy in the size of maxilla and mandible. • It is usually inherited or may a result from defective embryological development • They may present either in anterior or posterior region. • Skeletal anterior crossbite are usually as a result of retarded maxillary growth or excessive mandibular growth . • Skeletal posterior crossbite are usually characterized by a narrow upper arch.
crossbite orthodontics final yearl bds.pptx
DENTAL CROSSBITE • Dental crossbite are usually localized conditions where one or more teeth are abnormally related to that of opposing arch. • A variety of factors have been reported to cause a dental anterior crossbite including 1. lingual eruption path of maxillary anteriors 2. trauma to the deciduous dentition in which there is displacement of the tooth buds 3. delayed eruption of the deciduous dentition and supernumerary teeth. • Tooth material arch length discrepancies can result in crowding and lingual positioning of upper teeth leading to a dental crossbite
DIFFERENCE BETWEEN SKELETAL AND DENTAL ANTERIOR CROSSBITE Skeletal anterior crossbite Dental anterior crossbite Etiology Mostly genetic and hereditary Lack of space ,crowding ,over retained deciduous teeth Molar & Canine relationship Class III Class I Maxillary incisor inclination Proclined Upright or retroclined Transverse discrepancy May be associated with posterior crossbite in some cases Usually none Sagittal discrepancy Significant Anteroposterior discrepancy between maxilla and mandible No significant discrepancy between maxilla and mandible Mandibular growth pattern Often vertical Normal Position of teeth Normally positioned Deflected tooth position Number of teeth in crossbite Segment crossbite Single mostly
FUNCTIONAL CROSSBITE • Presence of occlusal interferences can result in the deviation of mandible during jaw closure • This can present as a unilateral posterior crossbite. • Habitual forward positioning of mandible (pseudoclass III) may lead to an anterior crossbite • Pseudo class III results from an early dental interference that forces the mandible to move forward to obtain maximum intercuspation. • An acquired muscular reflex pattern during closure of mandible is involved in functional crossbites.
ETIOLOGY OF CROSSBITE • Crossbite of anterior and posterior region can occur as a result of a number of causes 1. Persistance of deciduous tooth often results in palatal deflection of its erupting successor causing single tooth anterior crossbite. 2. Crowding and abnormal displacement of one or more teeth as a result of arch length tooth material discrepancy may cause dental crossbite 3. Upper airway obstruction in the form of hypertrophied adenoids or tonsils and allergic rhinitis can result in mouth breathing and are correlated with the development of posterior crossbite
4. Presence of habits such as thumb sucking or mouth breathing can cause lowered tongue position.Thus the tongue no longer balances the forces exerted on the teeth by the buccal group of musculature.This disharmony between the internal and external muscle forces can lead to the narrowing of upper arch leading to posterior crossbite. 5.Lip biting habit may lead to an abnormal axial inclination of upper incisors, which is another cause of dental anterior crossbite. 6.Retarded development of maxilla in sagittal as well as transverse direction can cause crossbites in the anterior or posterior region. 7.Narrow upper arch resulting from decreased growth stimulation in the mid palatal suture. 8. Collapse of maxillary arch as seen in congenital defects such as clefts of palate. Syndromes such as Crouzon syndrome,Apert syndrome are associated with a degree of midface deficiency that , in many instances, results in an anterior crossbite due to the maxillary skeletal deficiency.
9. Sagittal discrepancies of the jaws such as a forwardly positioned mandible results in the wider part of the mandibular arch occluding with the narrower part of the maxillary arch. 10. Unilateral hypo or hyperplastic growth of any of the jaws can cause crossbite. 11. Congenital maxillary deficiency can occur due to prenatal pressure against the developing fetal face .
FACTORS THAT INFLUENCE TREATMENT OF ANTERIOR CROSSBITE 1. Overbite • Overbite considerations are important in the treatment and retention of crossbites. • Whenever the anterior crossbite is accompanied by deep overbite it may be necessary to have a posterior bite plane or block incorporated in the appliance to help in buccal movement of the maxillary anteriors without the interference of the mandibular anteriors. • Presence of a good overbite after treatment of anterior cross- bite prevents relapse tendency and therefore aids in retention. • If the patient exhibits little overbite or an open bite at the end of the treatment there is an increased chance of relapse of the crossbite. • In such patients it may be advisable to have the upper or the lower anteriors extruded to achieve adequate overbite after the crossbite is treated.
2. Space • There should be adequate space in the dental arch to move the maxillary teeth labially out of crossbite. • If there is insufficient space to move the tooth or teeth labially, then adequate space must be gained prior to attempting the treatment of crossbite. • Minor space can be obtained by reproximation. • Finger springs used along with removable appliances help in opening up the space for the labial movement of the tooth in crossbite. • Space gaining can be done using open coil spring along with fixed orthodontic appliance. However presence of moderate to severe crowding may need extraction of teeth to gain space.
3. Type of tooth movement • Consideration should be given to the type of tooth movement required. • If tipping movements will suffice, a removable appliance can be considered, however, if bodily movement is required then fixed appliances are indicated. 4. Maxillary incisor torque • The maxillary tooth that is in crossbite is often found to have their roots far lingually. • Thus when they are moved labially, the roots may need torqueing to move them labially. This is best done using fixed appliance. • Maxillary anteriors that are inclined lingually rather than bodily displaced are often easier to treat.
5. Functional shift on closure of mandible • Patients with anterior crossbite are examined to determine if there is a shift of the mandible anteriorly during the closure of the mandible. • Ask the patient to move the mandible back and try to bring the up- per and lower anteriors edge to edge. • If the patient is able to do this it is often a positive indication of a good prognosis. • This forward functional shift of the mandible from centric relation to centric occlusion is an indication that there would be a posterior dis- placement of the mandible after the correction of the crossbite. 6.Number of teeth in crossbite • The more the number of teeth in crossbite the harder it gets to correct it and would require fixed orthodontic appliance to correct it
TREATMENT OF ANTERIOR CROSSBITE USING REMOVABLE APPLIANCES It is indicated when the amount of tooth movement is minimal and there is absence of major crowding and rotations 1. Use of tongue blade • Developing single tooth anterior cross bites can be successfully treated using a tongue blade. • It can be used in case there is sufficient space for the tooth to be brought out. • The tongue blade is a flat wooden stick resembling an ice cream stick. It is placed inside the mouth contacting the palatal aspect of the tooth in crossbite . • The blade is made to rest on the mandibular tooth in crossbite that acts as a fulcrum and the patient is asked to rotate the oral part of the blade upwards and forwards. • This is continued for 1_2 hrs for about 2 weeks.Most developing crossbites that are recognised by the dentist at an early stage can be successfully corrected by this way.
crossbite orthodontics final yearl bds.pptx
2. Catlan’s appliance or Lower anterior inclined plane • Inclined planes constructed on the lower anterior teeth can be used to treat maxillary teeth in crossbite . • The inclined plane can be made of acrylic or cast metal and can be designed to treat a single tooth in crossbite or a segment of the upper arch in crossbite • The inclined plane is designed to have a 45° angulation, which forces the maxillary teeth in crossbite to a more labial position. • It is indicated when adequate space exists in the arch for the alignment of the maxillary teeth in crossbite. They are to be used only in those cases where the crossbite is due to a palatally displaced maxillary incisor. • The lower anterior inclined plane has a number of disadvantages, which include: 1. The patient encounters problems in speech during the therapy 2. The patient has to put up with dietary restriction 3. The appliance may need frequent recementation 4. If the appliance is used for more than 6 weeks it can result in anterior openbite due to supra eruption of posteriors
crossbite orthodontics final yearl bds.pptx
crossbite orthodontics final yearl bds.pptx
3. Use of double cantilever spring or Z spring • Anterior cross bites involving one or two maxillary teeth can be treated using a double cantilever spring • In case of a deep over- bite the spring should be given along with a posterior bite plane to help in jumping the bite . • The use of Z spring is indicated only when there is adequate space for labialization of the teeth in crossbite. • A flapper spring can also be used to correct single tooth crossbite
crossbite orthodontics final yearl bds.pptx
crossbite orthodontics final yearl bds.pptx
4.Treatment of skeletal anterior crossbite during growth period Skeletal anterior crossbite that occurs as a result of a retro-positioned maxilla should be treated before termination of growth by using a protraction facemask (reverse head gear). These facemasks help in protraction of the maxilla thereby normalizing the skeletal crossbite. • Excessive mandibular growth leading to skeletal anterior crossbites should be intercepted by use of chin cap. • In permanent dentition, Surgical procedures such as Le Fort I and advancement for correction of maxillary retrognathism are indicated. In case of mandibular excess, set back procedures with recontouring the chin by genioplasty can be carried out Ramus osteotomy, mandibular inferior border osteotomy or vertical sigmoid osteotomy is indicated.
TREATMENT OF ANTERIOR CROSSBITE USING FIXED APPLIANCES Dental anterior crossbite involving one or more teeth can be treated with fixed appliances. Fixed appliances are preferred as they offer excellent control of the tooth movement. Crossbites where more tooth movement is required along with correction of lower anteriors to get adequate overbite at the end of the treatment. This again is best treated using fixed appliance. The major problem in treating anterior crossbites is the lower anteriors that prevent the forward movement of the upper anteriors . Therefore something should be done that enables the opening of the bite temporarily enabling the free anterior movement of the upper anteriors. This is often done using a lower posterior bite plane that opens the bite sufficiently to jump the bite . Another method adopted by many orthodontists is the use of glass ionomer cement which is applied over the occlusal surface of the mandibular first molars or the second deciduous molars for a short period of time This enables the bite to remain open in the anterior region and therefore enables the forward movement of the maxillary anteriors. • Multilooped archwires or nickel titanium archwires are used efficiently to move the upper anteriors forward to jump the bite. Rarely compressed coil springs may be needed to procline the anteriors.
crossbite orthodontics final yearl bds.pptx
crossbite orthodontics final yearl bds.pptx
FACTORS THAT INFLUENCE TREATMENT OF POSTERIOR CROSSBITE 1. Buccolingual tooth inclination • If the upper posteriors that are in crossbite are inclined palatally, it is considered favourable as the correction of the crossbite usually improves their inclination as the posteriors are tipped bucally . • On the other hand if the maxillary posteriors are inclined bucally it indicates a narrow maxillary arch and the need for widening the maxillary arch. • Upper arch expansion is more likely to be stable if the teeth to be moved were tilted palatally initially.
2. Etiology • It is important to consider the etiology of the posterior crossbite prior to its treatment. • If the crossbite due is to displacement of one tooth away from the arch, it may be possible to align this tooth to bring about favourable results. Sometimes reciprocal movement of two or more opposing teeth may be required such as by use of crossbite elastics. If the crossbite is skeletal in nature we need to consider if it is possible to compensate for this by tooth movement. • Most unilateral posterior crossbites occur as a result of lateral functional shift of the mandible due to premature contact or discrepancy between upper and lower arch widths. • These cases in reality are bilateral crossbites that respond well to reciprocal expansion of both sides. It is therefore important to look for lateral shift of the mandible during jaw closure. A simple diagnostic test would be look at the dental midlines. If the upper and lower midlines are co-incident on opening but are deviated on occluding the teeth, it is an indicator that there is a functional shift. • True unilateral crossbites that are not accompanied by lateral shift of the mandible on closure may not be treated by reciprocal expansion of both sides. These cases may require use of unilateral mechanics such as the use of crossbite elastics or even surgically assisted rapid expansion.
3. Vertical changes • Many a times expansion of the upper buccal segment teeth will result in some tipping down of their palatal cusps. • This results in the mandible rotating downwards leading to an increase in lower face height. • This may be undesirable in patients who already have an increased lower facial height and/or reduced overbite. • If expansion is indicated in these patients, fixed appliances are required to apply buccal root torque to the buccal segment teeth in order to try and resist this tendency. • In addition high-pull headgear may also be indicated.
TREATMENT OF POSTERIOR CROSSBITE USING REMOVABLE APPLIANCES 1.Crossbite elastics • Single tooth crossbite involving the molars can be treated using elastics that are stretched between the maxillary palatal surface and mandibular buccal surface . • These elastics extend through the bite and are indicated if sufficient space exists for moving the tooth into the arch. • These elastics are to be worn day and night. • The treatment should not be continued for more than six weeks as the elastics can extrude the teeth.
2. Coffin spring • The Coffin spring was designed by Walter Coffin. • Is a removable appliance that consists of an omega shaped wire of 1.25mm diameter placed in the mid – palatal region. • The free ends of the omega are embedded in an acrylic plate that covers the slopes of the palate. • The spring brings about dento-alveolar expansion. However, it is capable of skeletal changes when used in young patients.
3. Quad helix • The quad helix is a spring that consists of four helices . • The incorporation of four helices increases the wire length and therefore the flexibility and range of action. • The quad helix is capable of dento alveolar expansion of the molar as well as premolar region. • Quad helix can be used in conjunction with fixed orthodontic appliance. • Appliance is constructed using 0.038 inch wire and is soldered to bands on the first molars. The quad helix may be laboratory constructed or are available in various prefabricated sizes.
4. RAPID MAXILLARY EXPANSION • Bilateral skeletal crossbite characterized by a deep palate, nasal obstruction and narrow maxilla can be treated by rapid maxillary expansion where in the mid palatal suture is split. • This is done by using appliances that incorporate screws that are to be activated at regular intervals.
5. Removable plates Bilateral posterior crossbite can be treated using removable appliances incorporating a midline jack screw. Unilateral crossbites can be treated using removable appliances incorporating jackscrews. The appliance consists of a split acrylic plate, a jackscrew and Adam’s clasps on the posterior teeth to retain the plate. A labial bow can also be incorporated into the appliance for minor space closure and retraction. • The desired effect is achieved by sectioning the plate in such a way that a small segment and larger segment are formed. The two segments are connected by one or more jackscrews. The smaller segment of the plate adjoins the area in crossbite whereas the larger segment is used for anchorage.
TREATMENT OF POSTERIOR CROSSBITE USING FIXED APPLIANCES • Fixed appliances can be used in the treatment of posterior crossbite. • The treatment can be achieved by incorporation of quad helix or other expanders in conjunction with fixed appliance therapy. • Expansion can also be achieved by expanded archwires and by use of crossbite elastics that pass through the bite. • Asymmetrically expanded archwires can bring about correction of unilateral crossbite.
THANK YOU 😊

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crossbite orthodontics final yearl bds.pptx

  • 1. MANAGEMENT OF CROSS BITE RAGENDU R NAIR FINAL YEAR PART 1 BDS PSMDC
  • 2. CONTENTS • Classification of crossbite • Anterior crossbite • Posterior crossbite • Skeletal crossbite • Dental crossbite • Functional crossbite • Etiology of crossbite
  • 3. • Factors that influence treatment of anterior crossbite • Treatment of anterior crossbite using removable appliances • Fixed appliances for treatment of anterior crossbite • Factors that influence treatment of posterior crossbite • Treatment of posterior crossbite using removable appliances • Treatment of posterior crossbite using fixed appliances
  • 4. CROSSBITE • Crossbite is a 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. • GRABER has defined crossbite as a condition where one or more teeth may be abnormally malposed bucally or lingually or labially with reference to the opposing tooth or teeth • Definition of American Association of Orthodontists Glossary: “An abnormal relationship of a tooth or teeth to the opposing teeth, in which normal buccolingual or labiolingual relationships are reversed.”
  • 5. CLASSIFICATION OF CROSSBITE 1. BASED ON LOCATION A. Anterior crossbite • Single tooth • Segmental B. Posterior crossbite • Unilateral • Bilateral
  • 6. 2.BASED ON THE NATURE OF CROSS BITE A. Skeletal crossbite B. Dental crossbite C. Functional crossbite
  • 7. ANTERIOR CROSSBITE • Anterior crossbite is defined as a malocclusion resulting from the lingual position of the maxillary anterior teeth in relationship with the mandibular anterior teeth. • An anterior crossbite can involve a single tooth or an entire segment of the arch. • The underlying etiology could be either skeletal or dental,or a combination of these two factors
  • 8. Anterior functional crossbites • An anterior functional shift on closure from centric relation (CR) to centric occlusion due to the habitual forward positioning of the mandible (pseudo-Class III) may lead to anterior crossbite • Some anterior crossbites are associated with an anterior functional shift on closure from centric relation (CR) to centricocclusion (CO), • If the patient touches his or her upper and lower incisors together edge-to-edge in CR, the occlusion is seemed to an Sunday bite or psuedo-Class III. Thus the habitual forward positioning of the mandible (pseudo-Class II) may lead to anterior crossbite. • Pseudo-Class III also results from an early occlusal interference that forces the mandible to move forward to obtain maximum intercuspation • Pseudo-Class III is also seen in premature loss of posterior teeth and the patient brings his mandible forward have a comfortable bite in the anterior region where teeth are present
  • 10. POSTERIOR CROSSBITE • This refers to an abnormal transverse relarelationship between the upper and lower posterior teeth. • In this condition ,instead of the mandibular buccal cusp occluding in the central fossa of the maxillary posterior teeth,they occlude buccal to the maxillary buccal cusps. • Thus posterior crossbite occur as a result of lack of cordination in the lateral dimension between the upper and lower arches. • Posterior crossbite can occur as a result of :- 1.Upper arch being too narrow. 2.The lower arch being too wide. 3.One or more maxillary buccal teeth displaced towards the palate. 4.One or more of the mandibular buccal teeth displaced buccally. 5.Functional lateral shift of the mandible during closure of the mandible.
  • 11. Telescopic bite or scissors bite or Buccal non-occlusion 1. This is a form of posterior crossbite where the one or more of the adjacent maxillary posteriors occlude entirely on the buccal aspect of the mandibular posteriors in CO. The palatal cusps of maxillary teeth overlap the mandibular buccal cusps. This is found most frequently in the premolar region of Class II Division I Lingual Non-occlusion • This is a form of posterior cross bite where the maxillary posteriors occlude entirely on the lingual aspect of the mandibular posteriors
  • 12. Complete Maxillary Buccal Crossbite • A rare buccal crossbite in which all of the lower teeth (both anterior and posterior) are positioned lingual to the upper teeth occurs in patients having a retrusive and small mandible along with relatively large maxilla. This is referred as the BRODIE SYNDROME. It can be seen as if whole mandibular dentition is contained within the maxillary arch and mandibular dentition is hardly visible
  • 13. Complete maxillary palatal crossbite • It is present when all the maxillary teeth are palatal to the mandibular arch due to narrow maxillary arch
  • 16. SKELETAL CROSSBITE • It is associated with a discrepancy in the size of maxilla and mandible. • It is usually inherited or may a result from defective embryological development • They may present either in anterior or posterior region. • Skeletal anterior crossbite are usually as a result of retarded maxillary growth or excessive mandibular growth . • Skeletal posterior crossbite are usually characterized by a narrow upper arch.
  • 18. DENTAL CROSSBITE • Dental crossbite are usually localized conditions where one or more teeth are abnormally related to that of opposing arch. • A variety of factors have been reported to cause a dental anterior crossbite including 1. lingual eruption path of maxillary anteriors 2. trauma to the deciduous dentition in which there is displacement of the tooth buds 3. delayed eruption of the deciduous dentition and supernumerary teeth. • Tooth material arch length discrepancies can result in crowding and lingual positioning of upper teeth leading to a dental crossbite
  • 19. DIFFERENCE BETWEEN SKELETAL AND DENTAL ANTERIOR CROSSBITE Skeletal anterior crossbite Dental anterior crossbite Etiology Mostly genetic and hereditary Lack of space ,crowding ,over retained deciduous teeth Molar & Canine relationship Class III Class I Maxillary incisor inclination Proclined Upright or retroclined Transverse discrepancy May be associated with posterior crossbite in some cases Usually none Sagittal discrepancy Significant Anteroposterior discrepancy between maxilla and mandible No significant discrepancy between maxilla and mandible Mandibular growth pattern Often vertical Normal Position of teeth Normally positioned Deflected tooth position Number of teeth in crossbite Segment crossbite Single mostly
  • 20. FUNCTIONAL CROSSBITE • Presence of occlusal interferences can result in the deviation of mandible during jaw closure • This can present as a unilateral posterior crossbite. • Habitual forward positioning of mandible (pseudoclass III) may lead to an anterior crossbite • Pseudo class III results from an early dental interference that forces the mandible to move forward to obtain maximum intercuspation. • An acquired muscular reflex pattern during closure of mandible is involved in functional crossbites.
  • 21. ETIOLOGY OF CROSSBITE • Crossbite of anterior and posterior region can occur as a result of a number of causes 1. Persistance of deciduous tooth often results in palatal deflection of its erupting successor causing single tooth anterior crossbite. 2. Crowding and abnormal displacement of one or more teeth as a result of arch length tooth material discrepancy may cause dental crossbite 3. Upper airway obstruction in the form of hypertrophied adenoids or tonsils and allergic rhinitis can result in mouth breathing and are correlated with the development of posterior crossbite
  • 22. 4. Presence of habits such as thumb sucking or mouth breathing can cause lowered tongue position.Thus the tongue no longer balances the forces exerted on the teeth by the buccal group of musculature.This disharmony between the internal and external muscle forces can lead to the narrowing of upper arch leading to posterior crossbite. 5.Lip biting habit may lead to an abnormal axial inclination of upper incisors, which is another cause of dental anterior crossbite. 6.Retarded development of maxilla in sagittal as well as transverse direction can cause crossbites in the anterior or posterior region. 7.Narrow upper arch resulting from decreased growth stimulation in the mid palatal suture. 8. Collapse of maxillary arch as seen in congenital defects such as clefts of palate. Syndromes such as Crouzon syndrome,Apert syndrome are associated with a degree of midface deficiency that , in many instances, results in an anterior crossbite due to the maxillary skeletal deficiency.
  • 23. 9. Sagittal discrepancies of the jaws such as a forwardly positioned mandible results in the wider part of the mandibular arch occluding with the narrower part of the maxillary arch. 10. Unilateral hypo or hyperplastic growth of any of the jaws can cause crossbite. 11. Congenital maxillary deficiency can occur due to prenatal pressure against the developing fetal face .
  • 24. FACTORS THAT INFLUENCE TREATMENT OF ANTERIOR CROSSBITE 1. Overbite • Overbite considerations are important in the treatment and retention of crossbites. • Whenever the anterior crossbite is accompanied by deep overbite it may be necessary to have a posterior bite plane or block incorporated in the appliance to help in buccal movement of the maxillary anteriors without the interference of the mandibular anteriors. • Presence of a good overbite after treatment of anterior cross- bite prevents relapse tendency and therefore aids in retention. • If the patient exhibits little overbite or an open bite at the end of the treatment there is an increased chance of relapse of the crossbite. • In such patients it may be advisable to have the upper or the lower anteriors extruded to achieve adequate overbite after the crossbite is treated.
  • 25. 2. Space • There should be adequate space in the dental arch to move the maxillary teeth labially out of crossbite. • If there is insufficient space to move the tooth or teeth labially, then adequate space must be gained prior to attempting the treatment of crossbite. • Minor space can be obtained by reproximation. • Finger springs used along with removable appliances help in opening up the space for the labial movement of the tooth in crossbite. • Space gaining can be done using open coil spring along with fixed orthodontic appliance. However presence of moderate to severe crowding may need extraction of teeth to gain space.
  • 26. 3. Type of tooth movement • Consideration should be given to the type of tooth movement required. • If tipping movements will suffice, a removable appliance can be considered, however, if bodily movement is required then fixed appliances are indicated. 4. Maxillary incisor torque • The maxillary tooth that is in crossbite is often found to have their roots far lingually. • Thus when they are moved labially, the roots may need torqueing to move them labially. This is best done using fixed appliance. • Maxillary anteriors that are inclined lingually rather than bodily displaced are often easier to treat.
  • 27. 5. Functional shift on closure of mandible • Patients with anterior crossbite are examined to determine if there is a shift of the mandible anteriorly during the closure of the mandible. • Ask the patient to move the mandible back and try to bring the up- per and lower anteriors edge to edge. • If the patient is able to do this it is often a positive indication of a good prognosis. • This forward functional shift of the mandible from centric relation to centric occlusion is an indication that there would be a posterior dis- placement of the mandible after the correction of the crossbite. 6.Number of teeth in crossbite • The more the number of teeth in crossbite the harder it gets to correct it and would require fixed orthodontic appliance to correct it
  • 28. TREATMENT OF ANTERIOR CROSSBITE USING REMOVABLE APPLIANCES It is indicated when the amount of tooth movement is minimal and there is absence of major crowding and rotations 1. Use of tongue blade • Developing single tooth anterior cross bites can be successfully treated using a tongue blade. • It can be used in case there is sufficient space for the tooth to be brought out. • The tongue blade is a flat wooden stick resembling an ice cream stick. It is placed inside the mouth contacting the palatal aspect of the tooth in crossbite . • The blade is made to rest on the mandibular tooth in crossbite that acts as a fulcrum and the patient is asked to rotate the oral part of the blade upwards and forwards. • This is continued for 1_2 hrs for about 2 weeks.Most developing crossbites that are recognised by the dentist at an early stage can be successfully corrected by this way.
  • 30. 2. Catlan’s appliance or Lower anterior inclined plane • Inclined planes constructed on the lower anterior teeth can be used to treat maxillary teeth in crossbite . • The inclined plane can be made of acrylic or cast metal and can be designed to treat a single tooth in crossbite or a segment of the upper arch in crossbite • The inclined plane is designed to have a 45° angulation, which forces the maxillary teeth in crossbite to a more labial position. • It is indicated when adequate space exists in the arch for the alignment of the maxillary teeth in crossbite. They are to be used only in those cases where the crossbite is due to a palatally displaced maxillary incisor. • The lower anterior inclined plane has a number of disadvantages, which include: 1. The patient encounters problems in speech during the therapy 2. The patient has to put up with dietary restriction 3. The appliance may need frequent recementation 4. If the appliance is used for more than 6 weeks it can result in anterior openbite due to supra eruption of posteriors
  • 33. 3. Use of double cantilever spring or Z spring • Anterior cross bites involving one or two maxillary teeth can be treated using a double cantilever spring • In case of a deep over- bite the spring should be given along with a posterior bite plane to help in jumping the bite . • The use of Z spring is indicated only when there is adequate space for labialization of the teeth in crossbite. • A flapper spring can also be used to correct single tooth crossbite
  • 36. 4.Treatment of skeletal anterior crossbite during growth period Skeletal anterior crossbite that occurs as a result of a retro-positioned maxilla should be treated before termination of growth by using a protraction facemask (reverse head gear). These facemasks help in protraction of the maxilla thereby normalizing the skeletal crossbite. • Excessive mandibular growth leading to skeletal anterior crossbites should be intercepted by use of chin cap. • In permanent dentition, Surgical procedures such as Le Fort I and advancement for correction of maxillary retrognathism are indicated. In case of mandibular excess, set back procedures with recontouring the chin by genioplasty can be carried out Ramus osteotomy, mandibular inferior border osteotomy or vertical sigmoid osteotomy is indicated.
  • 37. TREATMENT OF ANTERIOR CROSSBITE USING FIXED APPLIANCES Dental anterior crossbite involving one or more teeth can be treated with fixed appliances. Fixed appliances are preferred as they offer excellent control of the tooth movement. Crossbites where more tooth movement is required along with correction of lower anteriors to get adequate overbite at the end of the treatment. This again is best treated using fixed appliance. The major problem in treating anterior crossbites is the lower anteriors that prevent the forward movement of the upper anteriors . Therefore something should be done that enables the opening of the bite temporarily enabling the free anterior movement of the upper anteriors. This is often done using a lower posterior bite plane that opens the bite sufficiently to jump the bite . Another method adopted by many orthodontists is the use of glass ionomer cement which is applied over the occlusal surface of the mandibular first molars or the second deciduous molars for a short period of time This enables the bite to remain open in the anterior region and therefore enables the forward movement of the maxillary anteriors. • Multilooped archwires or nickel titanium archwires are used efficiently to move the upper anteriors forward to jump the bite. Rarely compressed coil springs may be needed to procline the anteriors.
  • 40. FACTORS THAT INFLUENCE TREATMENT OF POSTERIOR CROSSBITE 1. Buccolingual tooth inclination • If the upper posteriors that are in crossbite are inclined palatally, it is considered favourable as the correction of the crossbite usually improves their inclination as the posteriors are tipped bucally . • On the other hand if the maxillary posteriors are inclined bucally it indicates a narrow maxillary arch and the need for widening the maxillary arch. • Upper arch expansion is more likely to be stable if the teeth to be moved were tilted palatally initially.
  • 41. 2. Etiology • It is important to consider the etiology of the posterior crossbite prior to its treatment. • If the crossbite due is to displacement of one tooth away from the arch, it may be possible to align this tooth to bring about favourable results. Sometimes reciprocal movement of two or more opposing teeth may be required such as by use of crossbite elastics. If the crossbite is skeletal in nature we need to consider if it is possible to compensate for this by tooth movement. • Most unilateral posterior crossbites occur as a result of lateral functional shift of the mandible due to premature contact or discrepancy between upper and lower arch widths. • These cases in reality are bilateral crossbites that respond well to reciprocal expansion of both sides. It is therefore important to look for lateral shift of the mandible during jaw closure. A simple diagnostic test would be look at the dental midlines. If the upper and lower midlines are co-incident on opening but are deviated on occluding the teeth, it is an indicator that there is a functional shift. • True unilateral crossbites that are not accompanied by lateral shift of the mandible on closure may not be treated by reciprocal expansion of both sides. These cases may require use of unilateral mechanics such as the use of crossbite elastics or even surgically assisted rapid expansion.
  • 42. 3. Vertical changes • Many a times expansion of the upper buccal segment teeth will result in some tipping down of their palatal cusps. • This results in the mandible rotating downwards leading to an increase in lower face height. • This may be undesirable in patients who already have an increased lower facial height and/or reduced overbite. • If expansion is indicated in these patients, fixed appliances are required to apply buccal root torque to the buccal segment teeth in order to try and resist this tendency. • In addition high-pull headgear may also be indicated.
  • 43. TREATMENT OF POSTERIOR CROSSBITE USING REMOVABLE APPLIANCES 1.Crossbite elastics • Single tooth crossbite involving the molars can be treated using elastics that are stretched between the maxillary palatal surface and mandibular buccal surface . • These elastics extend through the bite and are indicated if sufficient space exists for moving the tooth into the arch. • These elastics are to be worn day and night. • The treatment should not be continued for more than six weeks as the elastics can extrude the teeth.
  • 44. 2. Coffin spring • The Coffin spring was designed by Walter Coffin. • Is a removable appliance that consists of an omega shaped wire of 1.25mm diameter placed in the mid – palatal region. • The free ends of the omega are embedded in an acrylic plate that covers the slopes of the palate. • The spring brings about dento-alveolar expansion. However, it is capable of skeletal changes when used in young patients.
  • 45. 3. Quad helix • The quad helix is a spring that consists of four helices . • The incorporation of four helices increases the wire length and therefore the flexibility and range of action. • The quad helix is capable of dento alveolar expansion of the molar as well as premolar region. • Quad helix can be used in conjunction with fixed orthodontic appliance. • Appliance is constructed using 0.038 inch wire and is soldered to bands on the first molars. The quad helix may be laboratory constructed or are available in various prefabricated sizes.
  • 46. 4. RAPID MAXILLARY EXPANSION • Bilateral skeletal crossbite characterized by a deep palate, nasal obstruction and narrow maxilla can be treated by rapid maxillary expansion where in the mid palatal suture is split. • This is done by using appliances that incorporate screws that are to be activated at regular intervals.
  • 47. 5. Removable plates Bilateral posterior crossbite can be treated using removable appliances incorporating a midline jack screw. Unilateral crossbites can be treated using removable appliances incorporating jackscrews. The appliance consists of a split acrylic plate, a jackscrew and Adam’s clasps on the posterior teeth to retain the plate. A labial bow can also be incorporated into the appliance for minor space closure and retraction. • The desired effect is achieved by sectioning the plate in such a way that a small segment and larger segment are formed. The two segments are connected by one or more jackscrews. The smaller segment of the plate adjoins the area in crossbite whereas the larger segment is used for anchorage.
  • 48. TREATMENT OF POSTERIOR CROSSBITE USING FIXED APPLIANCES • Fixed appliances can be used in the treatment of posterior crossbite. • The treatment can be achieved by incorporation of quad helix or other expanders in conjunction with fixed appliance therapy. • Expansion can also be achieved by expanded archwires and by use of crossbite elastics that pass through the bite. • Asymmetrically expanded archwires can bring about correction of unilateral crossbite.