Dr.

Assem Abbass
B.D.S. M.Sc. Ph.D. Ortho.
 DEFINITION OF CROSSBITE
According to Graber:
A condition where one or more teeth may be
malposed abnormally-buccally , labially or lingually with
reference to opposing tooth or teeth.

OR
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.
 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.
Lingual crossbite: the buccal cusps of the
lower teeth occlude lingual to the lingual
cusps of the upper teeth. This is also
known as a scissors bite.
• When a case is identified as having an
anterior or posterior crossbite, it must be
determined whether a functional shift exists
between centric relation (CR) and centric
occlusion (CO).
• As a patient closes the mandible in
centric relation, tooth interferences cause the
mandible to shift either laterally or
anteriorly to allow the patient to bring the
teeth together in a more comfortable
position.
• The anteroposterior or lateral difference
between centric relation and centric occlusion
is known as a functional shift. The goal of
treatment is to make centric occlusion equal to
centric relation and thus eliminate the
functional shift.
• The presence of a shift might indicate that
the malocclusion is dental in nature and may
be considered for limited treatment, whereas
the lack of a shift may indicate an
underlying skeletal problem.
• A true unilateral crossbite occurs when the patient
exhibits no lateral functional shift of the mandible during
closure from CR into CO.
• Most patients with a unilateral posterior crossbite do
exhibit some CR-CO lateral functional shift upon closure
of the mandible and thus actually have a bilateral
posterior crossbite associated with a lateral functional
shift. In unilateral posterior crossbite, the lower dental
midline is usually deviated away from the upper dental
midline toward the side of the crossbite.
• The patient should be asked to open his mouth. If the
lower dental midline is coincident with the upper dental
midline when the mouth is open, a lateral shift is occurring
as the teeth are brought into occlusion.
CLASSIFICATION OF CROSSBITES

(1) According to the location in the arch

Anterior Posterior

(2) According to the nature & causes of crossbite

Skeletal Dental Functional Soft tissue

crossbite crossbite crossbite causes
 Anterior cross bite

Single tooth anterior Segmental anterior

cross bite cross bite
• The Simple Anterior Crossbite.

• The Functional Anterior Crossbite

(pseudo Class III).

• The Skeletal Anterior Crossbite.

• Simple anterior crossbites are generally the
result of an abnormal eruption of the permanent
incisors.

• The term simple is used because these

crossbites can easily be corrected using
removable appliances by practitioners with
limited experience in orthodontics.
 Trauma to the primary incisors with displacement
of the permanent tooth bud;

 Delayed exfoliation of a primary incisor with

palatal deflection of the erupting permanent
incisor;

 Supernumerary anterior teeth; odontomas;

 Congenitally abnormal eruption patterns ,

 An arch perimeter deficiency.

1. The crossbite usually involves only one or two
teeth.
2. The facial profile is usually normal in centric
relation and centric occlusion.
3. Many of these patients exhibit Class I skeletal
patterns.
4. There is usually no shift from rest to
intercuspation, as the teeth involved in the
crossbite have moved to accommodate the
interference.
• These cross bites are usually caused due to the
presence of occlusal interferences during the act
of bringing the jaws into occlusion result in
deviation of mandible into an abnormal but
often a more comfortable position.
• These can be caused by the early loss of
deciduous teeth, decayed teeth or ectopically
erupting teeth.
• If not corrected early, these can ultimately lead
to skeletal cross bites! Is that true?
• It is essential to check for a displacement of the
mandible on closure from a premature contact into
maximal interdigitation. In Class Ill malocclusions
this can be ascertained by asking the patient to try
to achieve an edge-to-edge incisor position. If such
a displacement is present, the prognosis for
correction of the incisor relationship is more
favorable.
• In the past it was thought that such a
displacement led to overclosure and greater
prominence of the mandible, with the condylar
head displaced forward.
• In fact cephalometric studies suggest that in
most cases, although there is a forward
displacement of the mandible to disengage the
premature contact of the incisors as closure into
occlusion occurs, the mandible moves backwards
until the condyles regain their normal position
within the glenoid fossa.
The Skeletal Anterior Crossbite:
1.Anterior cross bite due to
maxillary retrognathism:

.
• 2.Anterior cross bite due to mandibular
prognathism:
• 3.Anterior cross bite due to maxillary
retrognathism and mandibular prognathism:
a. In centric occlusion their facial profile will be
straight or concave.
b. There will be a Class III molar relationship and an
anterior crossbite.
c. The arc of mandibular closure remains smooth
without any occlusal interferences.
d. In an attempt to compensate for the skeletal
discrepancy during growth, the maxillary incisors
usually become proclined and the mandibular
incisors become retroclined.
Anterior crossbite may lead to:

 Tooth attrition,
 Gum recession and periodontal pockets,
 Mandibular displacement, mostly the
forward postural type which may mask the
increase in overjet in the central incisor
area.
 May lead to temporomandibular disorder.
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:
a. unilateral b. bilateral

With Displacement Without Displacement.

 When the whole of the buccal segment is involved,
the underlying aetiology is usually that the maxillary
arch is of a similar width to the mandibular arch (i.e.
it is too narrow) with the result that on closure from
the rest position the buccal segment teeth meet cusp
to cusp. In order to achieve a more comfortable and
efficient intercuspation, the patient displaces their
mandible to the left or right.
 It is often difficult to detect this displacement on
closure as the patient soon learns to close straight
into the position of maximal interdigitation. This
type of crossbite may be associated with a
centerline shift in the lower arch in the direction of
the mandibular displacement.
 This category of cross bite is less common.
It can arise as a result of deflection of two (or
more) opposing teeth during eruption, but the
greater the number of teeth in a segment that
are involved, the greater is the likelihood that
there is an underlying skeletal asymmetry.
Bilateral buccal cross bite:
• Bilateral cross bites are more likely to be
associated with a skeletal discrepancy either in the
anteroposterior or transverse dimension, or in both.
Unilateral lingual cross bite:
• This type of cross bite is most commonly due to
displacement of an individual tooth as a result of
crowding or retention of the deciduous
predecessor.
Bilateral lingual cross bite (scissors bite):

This cross bite is typically associated with

an underlying skeletal discrepancy. often a
Class II malocclusion with the upper arch
further forward relative to the lower so that
the lower buccal teeth occlude with a wider
segment of the upper arch.
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
associated with a buccal cross bite.
- They cause appreciable damage to a person’s health and
personality.
 For this reason buccal crossbites of an entire
buccal segment are most commonly associated
with Class III malocclusions, and lingual crossbites
are associated with Class II malocclusions. Anterior
crossbites are associated with Class III skeletal or
dental patterns.
 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 malocclusion).
6) Congenital ( Cleft lip and palate).
7) Trauma at birth (forceps injury leading to ankyloses of TMJ.)
8) Trauma during growth (ankyloses of TMJ and retardation of
growth in traumatized bone).
9) Trauma after completion of growth (mal-union of fracture
segments).
.
 In cleft lip and palate, growth in the width
of the upper arch is restrained by the scar
tissue of the cleft repair.
Trauma to, or pathology of, the
temporomandibular joints can lead to
restriction of growth of the mandible on one
side, leading to asymmetry.
 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.
 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) Ankyloses.
• The following factors should be considered:
• What type of movement is required? If tipping movements
will suffice, a removable appliance can be considered,
however, if bodily or apical movement is required then
fixed appliances are indicated.
• How much overbite is expected at the end of treatment?
For treatment to be successful there must be some
overbite present to retain the corrected incisor position.
However, when planning treatment it should be
remembered that proclination of an upper incisor will
result in a reduction of overbite compared with the
pretreatment position.
• Is there a space available within the arch to
accommodate the tooth/teeth to be moved? If
not, are extractions required and if so which
teeth?
• Is movement of the opposing tooth/teeth
required? If reciprocal movement is required, a
fixed appliance is indicated.
The removable appliance should incorporate the
following features:
• Good anterior retention to counteract the displacing
effect of the active element (where two or more teeth are
to be proclined, a screw appliance may circumvent this
problem).
• Buccal capping just thick enough to free the occlusion with
the opposing arch (if the overbite is significantly increased
a flat anterior bite-plane may be utilized instead);
• An active element, for example a Z-spring.
• The apex of the incisor in crossbite is palatally
positioned.
• If there will be insufficient overbite to retain the
corrected incisor(s), consideration should be given
to using fixed appliances to move the lower
incisor(s) lingually at the same time as the upper
incisor(s) is moved labially in order to try and
increase overbite.
• Other features of a malocclusion necessitate the
use of fixed appliances.
• Eliminate the factors that may lead to the anterior
cross bite, E.g.
 Removal of occlusal prematurity.
 Extraction of supernumerary tooth, before they cause
displacement of other tooth.
 Habit breaking appliance.
(1) Use of tongue blade:
Used when a cross bite is seen
at the time the permanent
teeth are making an appearance
in the oral cavity.
It is 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.
Disadvantages of using tongue
blade:
 Only effective when the clinical
crown is not completely erupted in
the oral cavity.
 Used only if sufficient space is
available for the correction.
 Patients cooperation is required.
(2) Double cantilever spring / z-spring:

Indication:
Used when anterior
cross bite involving 1
or 2 max. anterior
teeth.
Disadvantage:
Effective only when
there is enough
space for aligning the
teeth.
(3) Screw appliance:
Micro screw:
• Used on individual
teeth.
• Multiple micro screw
can be used to
correct individual
tooth in segmental
cross bite.
Mini screw:
• Capable of moving up
to 2 teeth.
3-D screw
(3dimensional screw):
Capable of correcting
posterior as well as
anterior cross bite
 Generally, one full turn of the screw
brings about 0.4 or 0.8 mm expansion
(Skeleton-Fischer type) that is one fourth turn
would bring about 0.1 - 0.25 mm expansion.

With this slow expansion, approximately

2 - 3 months are needed to obtain the
expansion, and the appliance can be removed
in another 3 months (retention period).
(4) Face mask (or face mask along with
maxillary expansion):
Used to correct skeletal anterior cross bite
(Anterior cross bite) due to actual skeletal
deficiency of the maxilla (Protraction face mask
or Reverse head gear)
(5) Chin cap appliance:

Used to correct or prevent the anterior cross

bite due to a prominent mandible.
Chin cap appliance rotate mandible backward
and downward.
(6) Frankel III appliance:

Used to correct skeletal class III

Malocclusion.
 MANAGEMENT of posterior crossbite

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 (single tooth)

Unilateral Bilateral
The various treatment modalities for posterior
crossbite are :-
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 (Hyrax) (RME).
8) Ni-Ti expanders.
9) Oral screening.
10) Fixed orthodontic appliances.
Unilateral buccal crossbite:
• For crossbite correction of a premolar or molar, consider
the use of a T -spring or screw section, respectively, on an
URA.
• If reciprocal movement of opposing teeth is required, use
fixed attachments and cross elastics. Consider also the
relief of crowding if a tooth is mildly displaced, or
extraction of a tooth in crossbite if there is more marked
displacement.
• For correction of unilateral buccal segment crossbite
associated with a mandibular displacement, use an URA
with a midline expansion screw and buccal capping or
quad helix, provided teeth are not tilted buccally.

• Even when fixed appliances are used. expansion of the upper

buccal segment teeth will result in some tipping down of the
palatal cusps. This has the effect of hinging the mandible
downwards leading to an increase in lower face height. which 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, perhaps with high-pull headgear as well.
 If there is unilateral buccal segment
cross bite with no mandibular displacement,
as there is no functional problem, correction is
not usually indicated unless it is part of a
more comprehensive treatment in cases of
cleft palate or condylar hyperplasia.
 Unless the upper buccal segment teeth are tilted
palatally to a significant degree. bilateral buccal crossbites
are often accepted.

Rapid maxillary expansion can be used to try and

expand the maxillary basal bone. but even with this
technique a degree of relapse in the buccopalatal tooth
position occurs following treatment, with the risk of
development of a unilateral cross bite with displacement.

Surgically assisted RME can also be considered.

 The rapid maxillary expansion (RME)
involves a hyrax screw type of appliance which
produces high forces capable of splitting the mid-
palatine suture and bringing about skeletal changes
within a matter of days (0.5-1mm/ day).
The RME screw can be incorporated in two type
of appliances:
-The banded RME, and
-The cemented RME.
 In the banded RME the expansion screw
is soldered to bands which are cemented on to
the first premolar and the first permanent molar
in the maxillary arch.
RAPID MAXILLARY EXPANSION

Hyrax Appliance Haas Expander

 Activation of the RME appliance
• The basic principle of the appliance involves the generation
of forces that are capable of splitting the mid palatal
suture. Hence, the forces should be more than the usually
used ortho. Forces. The forces generated are closed to 10-
20 pounds.
• An expansion of 0.2-0.5 mm should be achieved per day.
The screw is activated at between 0.5-1mm/day and
about 1 cm of expansion can be expected in 2-3 weeks.
The activation schedules tend to vary depending upon the
age of the patient and the form of appliance.
• Timmis has suggested an activation of 90˚ morning and
evening for patients up to 15 years of age. In patients
above this age he suggests an activation of 45˚ four times
a day.
• Zimmering and isaacson recommended 2 turns/day for
initial 4-5 days followed by 1 turn/day in growing
individuals. For adults they recommended 2 turns/day for
the first 2 days followed by 1 turn/day for the next 5-7
days and then only 1 turn every alternative day till the
desired expansion is achieved.
• Slow expansion
• It involves the use of relatively lesser forces (2-4 pounds)
over longer periods (2-6 months) to achieve the desired
results.

• Indications of slow expansion:

• 1. Correction of unilateral cross bites.
• 2. Correction of V shaped arches as in thumb sucking cases.
• 3. Preparation for bone grafts in cleft cases.
• 4. Minimal crowding in the upper arch (1-2 mm).
• 5. Elimination of displacement.
• NOTE
• Each 1 mm increase in the inter-molar width
will:
• 1. Reduce overjet by 0.3 mm.
• 2. Create space of 0.3 mm/side.
• Bilateral buccal cross bites are common in patients with a
repaired cleft of the palate. Expansion of the upper
arch by stretching of the scar tissue is often indicated in
these cases and is readily achieved using a quad helix
appliance.
COFFIN SPRING
SOLDERED W – ARCH
CROSS ELASTICS REMOVABLE APPLIANCES
Quad-Helix Appliance
NICKEL TITANIUM EXPANDERS