posterior crossbite in primary and mixed dentition etiology and management pedo

DEPARTMENT OF PEDIATRIC DENTISTRY

POSTERIOR CROSSBITE IN
PRIMARY AND MIXED DENTITION:
ETIOLOGY AND MANAGEMENT

DEFINITION OF CROSSBITE
According to Graber:
A condition where one or more teeth may be malposed
abnormally-buccally or labially or lingually with refernce
to opposing tooth or teeth.

Other definition:
-A deviation of the normal faciolingual relationship of teeth of
one
arch with those of opposing arch when the two dental arches are
brought into centric occlusion
OR
-Abnormal occlusion in the transverse plane
OR
-Reverse overjet of one or more teeth

INTRODUCTION

Under normal circumstances- maxillary arch overlaps
mandibular arch both labially and buccally.

But when mandibular teeth (single tooth or a segment of
teeth) overlap maxillary teeth labially or buccally depending
upon their location in the arch a crossbite is said to exist

CLASSIFICATION OF CROSSBITES

(1) According to the location in the arch

Anterior Posterior

(2) According to the nature of crossbite

Skeletal Dental Functional
crossbite crossbite crossbite

POSTERIOR CROSSBITE

-This refers to an abnormal transverse relationship between upper
and lower posterior teeth.
- In normal circumstances –mandibular buccal cusps occlude in the
central fossae of maxillary posterior
teeth.
- In posterior crossbite case – mandibular buccal cusp occlude
buccal to maxillary buccal cusp.

PREVELANCE:
In a study (By Kutin and Hawes) involving 515 children, 3-9 years
of age :- the prevelance of posterior crossbite in primary and
and mixed dentition is 1:13 or 7.7%

CLASSIFICATION OF POSTERIOR CROSSBITES

(1) According to the number of teeth involved

single tooth segmental
crossbite tooth crossbite

(2) According to existence on one/both sides of arch

unilateral bilateral

(3) According to etiologic factor

skeletal dental functional

(4) According to extent of crossbite

Simple Buccal Lingual
posterior non occlusion non occlusion
crossbite crossbite crossbite

Buccal cusp of one/more The maxillary posteriors occlude Maxillary posteriors
teeth occlude lingual to entirely on buccal aspect of occlude entirely on
the buccal cusp of mandibular posteriors.Also known as lingual aspect of
mandibular teeth SCISSOR BITE mandibular
posteriors

ETIOLOGY

Based on etiologic factors responsible for crossbite:
CROSSBITE

Dental Skeletal Functional

Dental crossbites

- Generally, single tooth/segmental crossbite.
- No threat to general health of the patient
- Problems arising are – periodontal/ esthetic in nature.
- Usually result from faulty eruption pattern with no irregularity
in the basal bone.
- Once the teeth erupt – the occlusion locks them into position and
drives them even further into a crossbite relationship.

Etiology of dental crossbite are :-

1) Anomalies in tooth number supernumerary teeth
missing teeth
2) Anomalies in tooth size microdontia
macrodontia
3) Anomalies in tooth shape
4) Premature loss of deciduous/ permanent teeth
5) Prolonged retention of deciduous teeth
6) Delayed eruption of permanent teeth
7) Abnormal eruption path
8) Ankylosis

SKELETAL CROSSBITE

- It results from discrepancy in structure of maxilla and mandible
or – malposition of the jaw.
- A basic discrepancy in the width of arches is noted.
- A narrow maxillary arch or a wide mandibular arch often
assosciated with a buccal crossbite.
- They cause appreciable damage to a person’s health and
personality.

Etiology of skeletal crossbites
1) Retarded development of maxilla.
2) Narrow upper arch.
3)Forwardly placed mandible.
4) Unilateral hypo/hyperplastic growth of any jaw.
5) Hereditary (Class III skeletal malocclussion).
6) Congenital ( Cleft lip and palate).
7) Trauma at birth (forcep injury leading to ankylosis of TMJ.)
8) Trauma during growth (ankylosis of TMJ and retardation of
growth in traumatized bone).
9) Trauma after completion of growth (malunion of fracture
segments).
10) Habits such as prolonged thumb sucking and mouth breathing.
Because they cause lowered tongue position ,thus tongue no longer
balances the forces exerted by the buccal group of musculature,
which leads to narrowing of upper arch leading to posterior crossbite.
11) According to RUTRICK – the use of traditional slender type of pacifiers can
cause crossbite.

Functional crossbite

- An acquired muscular reflex pattern during closure of mandible
is involved in functional crossbite.
- Presence of occlusal interferences can result in deviation of
mandible during jaw closure.
- Other causes are : early loss of decidous teeth
decayed teeth
ectopically erupted teeth.
- Thus a functional crossbite results from the mandibular shifting
into an abnormal but often a more comfortable position.

MANAGEMENT

In normally growing mandible, posterior crossbites should be
treated as early as possible to allow the normal growth and
development of the dental arches and the TMJ.

Posterior crossbite management

IN PRIMARY IN MIXED
DENTITION DENTITION

In primary dentition

- Posterior crossbite in primary dentition is usually as a result of
constriction of the maxillary arch which often results from an
active digit or pacifier habit.
- Determine whether there is an associated mandibular shift.
Mandibular shift

present not present
treatment is implemented treatment is delayed until the
to correct the crossbite permanent first molars erupt

If the first permanent If the first permanent
molar erupts into crossbite molar erupts normally

Treatment is initiated Treatment is not indicated until
(if no other malocclusion exists) the permanent premolars erupt

In mixed dentition

- Posterior crossbite correction in mixed dentition can be difficult
and confusing.
- The clinician should rely on a well documented database to
determine whether a skeletal/dental correction is necessary.
- And in areas where mandibular shift is present it should be
managed as soon as possible to prevent soft tissue and
dental compensation.

Posterior dental crossbite

Generalized Localized

Unilateral Bilateral

T h e v a r io u s t r e a t me n t
mo d a l it ie s f o r p o s t e r io r
c r o s s b it e a r e :-
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.

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.

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.

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.

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.

PROCEDURE :
Fit bands to either primary second molars or the permanent first molars.
Take a complete arch impression.
Remove the bands from teeth and seat them in proper position
Seal in place and make a working cast of stone
Use a 0.032 stainless steel wire,
this stainless steel wire contacts all posterior teeth,
anterior aspect of wire is just distal to primary canines,
the contact is close to, but not touching the soft tissue at cervical margin,
the loops or helixes and palatal portion should be 2-3 mm distal to banded teeth
Secure the wire to working cast,solder the wire to molar bands.

- 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.

- The screw is activated a quarter turn twice each day.
- Patient is monitored once a week.
- It brings about 0.2-0.5 mm/day expansion.
- The appliance produces a rapid expansion over 3-4 weeks.
- Crossbite should be over corrected and then retained for atleast
3 months with the same applaince.

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

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

PROCEDURE :
Take upper and lower impressions and pour working models
Casts are occluded in normal intercuspation and sealed
Extend vestibular screen into sulcus–
(where mucosal tissue reflects)
Posteriorly extend the appliance upto distal margin of
the last erupted molar.

Note : The material used is SELF CURE/HEAT CURE acrylic resin.
The patient is made to wear the appliance at night and 2-3 hours
during the day time and maintain lip seal.

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

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.

CONCLUSION

The early and correct diagnosis of posterior crossbite is essential
to prevent the forthcoming occlusal discrepancies in the
permanent
dentition.

Adequate curative measures and treatment modalities should be
advocated to correct the posterior crossbite

REFERENCES

1) S.I. Bhalajhi – Orthodontics-The Art and Science
2) Gurkeerat singh – A Textbook of orthodontics.
3) Mc Donald RE, Avery DR, Dean JA --
Dentistry for the child and adolescence.
4) Angus C Cameron – Handbook of Pediatric Dentistry.
5) Pinkham, Casammassimo, McTigue, Nowak –
Pediatric Dentistry Infancy Through Adolescence.

posterior crossbite in primary and mixed dentition etiology and management pedo

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