Guiding the Child’s Teeth with Class III Dental Malocclusion into Correct Occlusion: A Clinician’s Parenting

Guiding the Child’s Teeth with Class III Dental Malocclusion into
Correct Occlusion: A Clinician’s Parenting

Kapur A*/ Chawla HS**/ Utreja A***/ Goyal A****

Pediatric dentists are often the first ones to be consulted for the presence of an anterior cross bite in the
primary dentition. The condition requires an early interception to avoid progressive dentoalveolar and
skeletal changes. The management, however, poses unique challenges in terms of young age of the child,
correct choice of appliance and unpredictability of the response to treatment due to inability to ascertain
the inherent growth potential. It is very important therefore for the specialist, to be able to recognize the
early signs of a developing class III malocclusion tendency and also know the basic details of successful
management of such cases. The following article describes the appropriateness of appliance choice for
a case of incisor cross bite in primary dentition using different appliances based on their varied clinical
presentations.

Key words: Primary anterior cross bite, management options

INTRODUCTION

R
maxillary and mandibular arches from an unfavorable environment
ight from birth of a child the oral cavity remains a focus is prevented. Unfortunately, sometimes the treatment/ referrals are
of attention for the parents, initially for feeding and later, delayed due to lack of knowledge of the treating dentist. Limited
expectations of cutting the first milk tooth. In majority of experience of pediatric dentists in treating such malocclusions and
the children, the primary teeth erupt in a fairly regular fashion into lack of child management expertise among orthodontists could
good occlusion. In some cases parents observe crooked teeth. With further add to neglect of treatment in such cases.
the growing awareness of malocclusion in the population and the Broadly, primary anterior teeth cross bites can be classified as;
existence of its treatment, they report at an early age, much before Type 1: ‘Functional’, which present with a CR-CO discrepancy due
the eruption of permanent teeth. to occlusal prematurities; and Type 2: ‘True class III tendency’,
Prevalence of malocclusion in primary dentition has been with clinical features of a developing true class III malocclusion
reported to be as high as 46.2%, which includes conditions like deep along with cephalometric support and no CR-CO discrepancy.
overbite (19.7%), posterior cross bite (13.1%), accentuated overjet Type 1 can be further classified into two types; Type 1a: ‘Simple’,
(10.5%), anterior open bite (7.9%) and anterior cross bite (6.7%)1. with no abnormal dentitional or dentoalveolar changes; Type 1b:
The primary anterior dentition cross bite, though not very common ‘Complex’, with abnormal dentoalveolar relation mimicking true
with a reported prevalence of 4-13 %, in different populations 2,3, class III. The varied clinical presentations of cross bite of both types
needs immediate attention, so that further growth disturbance of the coupled with inability to predict mandibular growth accurately and
questionable patient compliance pose different challenges such as,
timing of treatment (due to possibility of self-correction) and most
suitable appliance (out of the various appliances that may have
From the Oral Health Sciences Centre Postgraduate Institute of Medical
been available) for its management. A number of treatment methods
Education and Research, Chandigarh, India. have been reported in the literature for early correction of primary
*Kapur A, Associate Professor of Pediatric Dentistry. dentition incisor cross bites such as, anterior crowns2, 2 x 4 appli-
**Chawla HS,Consultant at Sukhiqbal Dental Centre, Chandigarh, India and ance3, composite or acrylic inclined planes,4 removable mandibular
Former Head of Pediatric Dentistry. retractor5-7, anterior expansion appliance8, and occlusal splints with
***Utreja A, is a Consultant of Orthodontics at CMC, Chandigarh and
Fomer Head.
elastics9; each with successful results. Nearly all the investigators
****Goyal A, Professor of Pediatric Dentistry. in the published case reports have used and advocated a single type
of appliance for management of all types of cross bites. Whether
Send all correspondence to; one type of treatment modality is suitable for all types of cases or
Aditi Kapur one can select a specific treatment method for correction of primary
Phone: 91-9815966348 dentition incisor cross bites having different clinical presentation,
E-mail: [email protected]

72 doi 10.17796/1053-4628-42.1.13 The Journal of Clinical Pediatric Dentistry Volume 42, Number 1/2018
Guiding the Child’s Teeth with Class III Dental Malocclusion into Correct Occlusion: A Clinician’s Parenting

needs to be understood. We at the Oral health Sciences Centre have Fig 1c. 11 erupting in edge-to-edge relation, 21 erupting
been practicing most of the above-mentioned treatment modali- normally
ties for the varied clinical presentation of cross bite depending on
specific need of the case with beneficial treatment results in contrast
to only one appliance for all incisor cross bites in primary dentition.
The present article aims to share a preliminary report on this aspect
to aid the clinician make appropriate decisions depending upon the
specific need of the case. Most of the appliances are simple and can
be managed by the Pediatric Dentist, with occasional guidance of a
willing orthodontist.
Figs 1d-f. Stable normal over jet relation at 24 months follow-up
Posterior Bite Plane (For Type 1a case)

Case 1
A six- year old boy reported with the chief complaint of having
abnormally positioned front teeth. Extraorally the child had a
concave profile with cross bite evident on talking and smiling. On
intra-oral examination a crossbite of primary anterior teeth was
present (fig. 1a). Further examination of the cross bite showed a
CR-CO discrepancy. The child was in early mixed dentition stage
with erupting 31 and 41. There was no family history of such a
malocclusion. Cephalometrically child showed a skeletal class III
pattern which could be due to the forwardly positioned mandible. (
Table 1). Due to presence of a functional shift and normal inclina-
tion of the maxillary incisors (elaborated in the discussion), a simple
disocclusion of the arches was selected as a suitable interceptive
modality for correction of the cross bite. A maxillary appliance Pre and Post facial profile.
with a posterior bite plane was fabricated (fig. 1b). The child was
comfortable with the appliance and it was reported as having been
worn regularly on a follow-up visit. The cross bite was corrected
after two months of regular wear of the appliance. The acrylic bite
planes were trimmed till the occlusion completely settled. At a
follow-up visit timed with eruption of permanent maxillary incisors,
11 was found to be erupting in edge-to-edge relation to the 41 (fig 1
c). The appliance was repeated till 11 erupted fully in a normal over
jet relation. A twenty-four month follow-up of the child showed
stability of the results (fig 1d-f). The cephalometric changes at 24
months, highlighted an improvement in the ANB (Table 1.)

Fig 1a. Cross bite of primary anterior teeth in a six-year-old boy

Fig 1b. Posterior bite plane in acrylic for the maxillary arch

The Journal of Clinical Pediatric Dentistry Volume 42, Number 1/2018 doi 10.17796/1053-4628-42.1.13 73
Guiding the Child’s Teeth with Class III Dental Malocclusion into Correct Occlusion: A Clinician’s Parenting

Table 1 (Cepalometric changes) Fig.2b-c. Maxillary expansion appliance in saggital mode and
corrected cross-bite
PRE POST
Saddle Angle (N-S-Ar) 121.5 118.8
Articular angle (S-Ar-Go) 140.0 140.4
Gonial Angle (A-Go-Me) 128.1 126.4
Bjork’s sum 389.6 397.6
Y-axis 62.7 62.0
FMA 20.7 22.1
SNA 81.4 83.4
SNB 83.1 80.8
ANB -1.7 2.6
Wit’s Appraisal -3.7 mm -2.6 mm
SN Length 63.8 mm 67.2 mm
Maxillary Length 73.4 mm 79.0 mm
Mandibular length 92.8 mm 96.5 mm
SN-MP 29.6 26.8
Upper Incisor to palatal 100.1 116.0 Pre and Post facial profile pics.
plane
IMPA 93.0 94.1
Inter-incisal angle 145.9 124.5

Saggital Expansion Appliance (For Type 1b case)

Case 2
A three and a half-year-old girl reported with an anterior deep
bite and primary maxillary incisors in reverse over jet relation
(Fig. 2a). The maxillary incisors were also lingually tipped and
there was a vertical overbite of nearly 4 millimeters. A functional
shift and a positive family history were absent. Since the child
was very young and there was no obvious signs of a true class III
malocclusion tendency a cephalogram was not taken at that time.
A maxillary appliance with posterior bite planes for disocclusion
and an anterior expansion screw (in sagittal mode) was delivered
Removable Mandibular Retractor (For Type 2 case)
to the patient (Fig.2b). The parents were instructed to follow an
activation schedule of a quarter turn every third day. The cross bite Case 3
was corrected in two and a half months (Fig. 2c). Further activa- A five and a half-year-old boy reported to the Pediatric Dental
tion of the appliance was stopped and patient continued using the OPD with an edge-edge relation of all primary incisors (Fig. 3a).
same appliance, which was periodically trimmed of the posterior There was also proximal caries in relation to 51 and 61. The child
bite acrylic, till the occlusion settled, which happened in less than a had a concave profile with a history of a class III malocclusion in the
month. The appliance was discontinued after settling of occlusion. grandfather. A functional shift of mandible was also absent. Cepha-
The patient, however, was an outstation case and did not report for lometrically the child showed no evident skeletal discrepancy (Table
long-term follow-up after correction. 2) .The proximal caries was restored with composite. A mandibular
retractor was chosen as the treatment modality and was fabricated
Fig.2a Primary anterior cross bite with deep bite in a three and
a half-year-old girl on the dental casts from the prepared alginate impressions of the
arches (Fig. 3b). Compliance with the appliance was excellent and
the cross bite got corrected after about four months of regular wear
of the appliance (Fig. 3c). The appliance was however continued
for another four months and at each follow up visit the labial bow
was activated to lightly rub the labial surface of lower incisors on
closure. At a follow-up visit after two years the primary maxillary
incisors were exfoliating and permanent maxillary central incisors
were found to be erupting in an edge-to-edge relationship, soon
after that. (Fig.3d). The second mandibular retractor appliance was
fabricated on newly prepared dental casts and the patient made to

74 doi 10.17796/1053-4628-42.1.13 The Journal of Clinical Pediatric Dentistry Volume 42, Number 1/2018
Guiding the Child’s Teeth with Class III Dental Malocclusion into Correct Occlusion: A Clinician’s Parenting

Fig 3a. Edge to edge relation of all Fig.3 b A removable mandibular retractor on the maxillary arch
primary incisors in a five and half year old boy

Fig.3.c Corrected cross bite relation Fig 3d. Permanent maxillary incisors Fig. 3 e. Re fabrication of the
erupting in cross bite relation removable mandibular retractor

Fig. 3f Corrected permanent Fig. 3g-i Without relapse at 36-months follow-up

incisor cross bite Fig
Fig. 3g 3h

Fig. 3i Change in facial profile

wear it till complete eruption of the incisors and establishment of a

normal over jet relation (Fig. 3e,f). The desired effect was achieved
in 4 months, following which the appliance was discontinued. The
patient has been followed up for another three years since appliance
discontinuation, with no relapse and a stable occlusion (Fig. 3g-i).
Cephalometric changes after correction of cross bite in the primary
dentition (Post 1) and at three years follow-up (Post 2) are high-
lighted in Table 2.

The Journal of Clinical Pediatric Dentistry Volume 42, Number 1/2018 doi 10.17796/1053-4628-42.1.13 75