TRANSVERSE DISCREPANCY

MANAGEMENT

Presented by, Guided by,

Dr Vineeth V Dr Laxmikanth S M
3rd year MDS HEAD OF
Department of Orthodontics
DEPARTMENT
Orthodontics and
and dentofacial orthopaedics
dentofacial
orthopaedics
CONTENTS
• Rapid maxillary expansion
• Introduction
• Slow maxillary expansion
• Transverse Growth
• MARPE
• Etiology
• SARPE
• Diagnosis of transverse problems
• Mandibular expansion
• Clinical examination
• Case disscusion
• Radiographic analysis
• Conclusion
• Rickket’s Analysis
• References
• Literature review
 INTRODUCTION

 The management of transverse discrepancies has been

universally recognized as one of the most challenging
aspects of orthodontic therapy.

 Diagnosis of certain craniofacial structural variations in

transverse dimension is quite simple, but some underlying
asymmetries may be masked by dental compensations.

 Depending upon the structures involved, these problems

may be primarily dental, skeletal, functional in origin or
may even have combination of these factors present.
TRANSVERSE GROWTH
SUTURAL
MAXILL
A PERIOSTEA
L
MAXILLARY AND MANDIBULAR
DENTAL ARCHES
 McNamara
 Inter molar distance
Mandibular arch width – increased till 12 (males
1mm till 12-18)
Maxillary arch width – increased till 12 (males
1.4mm till 12-18)
 Inter canine distance
both arches - increased till 12 years and was
stable after that

 McNamara and Brudon

 Genders combined, the transpalatal width
Pitch, Roll and Yaw
BUCCOLINGUAL INCLINATION OF
MOLARS WITH GROWTH

 Maxillary molars erupt with buccal inclination

and become more upright with age
 Mandibular molars erupt with lingual
inclination and become more upright with age

Chung, C.H., 2019, March. Diagnosis of transverse

problems. In Seminars in Orthodontics (Vol. 25, No. 1,
ETIOLOGY
 Genetic alterations
 Syndromes
 Morphological variations
 Trauma
 Intrauterine pressure during pregnancy and
significant pressure in the birth canal during
parturition
 Congenitally missing teeth, supernumerary teeth
or ectopic eruptions
 Adverse oral habits
 TMJ disorders
 Types of transverse discrepancies
 Dental asymmetries in one or both arches

 Skeletal asymmetries involving maxilla

and/or mandible
 Functional mandibular shifts causing

asymmetric maxillo-mandibular
relationships
 Muscular asymmetries
DENTAL ASYMMETRIES

 Premature loss of deciduous teeth.

 Congenitally missing single tooth or group of

teeth.
 Habits like thumb sucking or tongue thrusting.

These dental asymmetries essentially involve

midline deviations, asymmetric posterior tooth
positions, asymmetric arch forms and diverging
occlusal planes.
 SINGLE
TOOTH
ANTERIOR
SEGMENTAL
(REVERSED
OVERJET)
CROSS BITE

UNILATERAL

POSTERIOR

BILATERAL
Midline deviations
CLINICAL SITUATIONS
 Maxillary midline is coincident with

facial midline and the mandibular

dental midline is shifted either to
the left or right side
 Mandibular midline is normally

positioned, but the maxillary

midline is deviated to the left or
right sides
 It could be the combination of

both.
FUNCTIONAL
ANALYSIS
Cross-bite cases with lateral
shifting of the mandibular
midline can be,

• Latero-occlusion

• Laterognathy
Skeletal transverse
discrepancies
 Transverse skeletal discrepancies may involve

either the maxilla or the mandible or a

combination of both.
 The maxillary problems in a transverse

dimension usually result from a symmetric or

an asymmetric constriction of the basal arch,
with or without posterior crossbite depending
upon the severity of the condition.
The maxilla can undergo some rotational changes relative
to the cranial base producing an asymmetric occlusal
relationship
 Most people have some facial asymmetry, and

asymmetric development of the jaws, though rare,

does produce transverse problems.
 Severe skeletal problems in a transverse dimension

are often produced by some congenital anomalies

like facial clefts, and trauma or infection.
 Patients with cleft lip and palate pose a unique

problem, requiring extensive and prolonged

orthodontic care.
Muscular asymmetries
 Any deviation from normal muscle function

plays an important role in the development of

skeletal and dental transverse discrepancies.
 Muscular asymmetry, as commonly observed in

hemifacial atrophy or cerebral palsy is one of

the factors responsible for facial disproportions
and midline discrepancies.
 Sometime facial transverse problems are

confined mainly to the soft tissues due to

Functional transverse problems

 Functional transverse discrepancies are often

caused by deflections of the mandible due to

occlusal interferences.
 The functional mandibular deviations are

caused by a malposed tooth or by a symmetric

or an asymmetric constricted maxillary arch.
During mandibular closure, the abnormal
initial tooth contact in centric relation results
in subsequent mandibular displacement
laterally or anteroposteriorly, leading to
 Sometimes TMJ disorders

may lead to midline

discrepancy during
opening as the displaced
disc interferes with the
normal forward mandibular
translation as on the
unaffected side.
CLINICAL EXAMINATION
Andrews’s WALA ridge
 Primary landmark for assessing

mandibular arch width and shape is

the WALA Ridge.
 WALA – Will Andrews and Larry

Andrews, who defined the ridge as the

most prominent portion of a
mandible’s mucogingival junction
 the distance of FA point of the first

molar to WALA Ridge should be 2 mm.

Chung, C.H., 2019, March. Diagnosis of transverse

problems. In Seminars in Orthodontics (Vol. 25, No. 1,
 Yonsei Transverse
Index (YTI)

Koo, Yun-Jin et al., (2017). Maxillomandibular arch width differences at estimated

centers of resistance: Comparison between normal occlusion and skeletal Class III
malocclusion. The Korean Journal of Orthodontics. 47. 167. 10.4041/kjod.2017.47.3.167.
RADIOGRAPHIC
EXAMINATION
Lateral ceph

PA ceph

OPG

CBCT
POSTEROANTERIOR CEPHALOMETRIC
ANALYSIS
Purposes of PA ceph in diagnosis of transverse problems:
• To determine transverse skeletal and dentoalveolar
dimension and assess skeletal and dental interarch
relation and quantify the discrepancy if any.
• To detect, localize and quantify any skeletal or
dentoalveolar asymmetry and midline shifts.
RICKETTS ANALYSIS
• Also known as ‘The Rocky Mountain
(RM) analysis’, 1972
• Computerized analysis, using lateral
and frontal cephalometric tracing for
the diagnosis of transverse
relationships between the jaws
• Quantitative analysis based on 15
factors that are grouped into 5 fields
• It includes norms from ages 9 through
16 years

Ricketts, R.M., Roth, R.H., Chaconas, S.J., Schulhof, S.J. and Engel,
G.A., 1982. Orthodontic diagnosis and planning: Their roles in
preventive and rehabilitative dentistry (Volume 1). Denver: Rocky
 Ricketts gave a normative data of parameters
measured, which is helpful in determining the
vertical, transverse, skeletal and dental
problems
Dental
 It has the Relatio
following components:
ns
Skeleta
l
Relatio
Dental
ns
to
Skeleta
Jawl to
Craniu
m
Interna
l
structu
res
 DENTAL RELATIONS:

Molar relations :
 Difference in width between the upper and
lower molars measured at the most
prominent buccal contour of each tooth

Intermolar width :
 From buccal surface of mandibular left to
right molar
Intercanine width :
From tip of mandibular right to left canine

Denture symmetry:
Midline of upper arch to lower arch
SKELETAL RELATIONS:

Maxillomandibu Maxillomandibu Maxillary and

lar width : lar midline: Mandibular
From the Jugal angle formed by width:
process to the the ANS- Me Indicates
fronto facial plane plane to a plane transverse
perpendicular to maxillary growth
ZA-AZ
 DENTAL TO
SKELETAL
RELATIONS:
Occlusal plane
tilt:
Lower molar to Denture- jaw
jaw left and right: midline: Difference of the
height of the
B6 to J-Ag line left Midline of denture
occlusal plane to
and right to ANS-Me
the ZFL-ZFR
plane
JAW TO CRANIUM
RELATIONS:
 Postural symmetry :
Difference between angles Z-AG-ZA on left and
Z-AG-ZA on right side
INNER STRUCTURE
PROBLEMS:
Nasal width :
Measured from the
widest portion of
nasal capsule

Nasal height :The

distance between
the anterior nasal
spine (ANS) and
the Z - Z plane

Maxillary and
Mandibular width :
Maxilla: J-J
Mandible: Ag-Ag
 LITERATURE REVIEW

Chung, C.H., 2019, March. Diagnosis of transverse problems.

In Seminars in Orthodontics (Vol. 25, No. 1, pp. 16-23). WB
Burstone, C.J., 1998, September. Diagnosis and treatment planning ofpatients with
asymmetries. In Seminars in orthodontics (Vol. 4, No. 3, pp. 153-164). WB Saunders.
Burstone, C.J., 1998, September. Diagnosis and treatment planning ofpatients with
asymmetries. In Seminars in orthodontics (Vol. 4, No. 3, pp. 153-164). WB Saunders.
CONCLUSION

• Transverse discrepancies warrant special consideration in

the orthodontic diagnosis and treatment planning. Patients
with these problems pose special diagnostic and
biomechanical challenges to the clinician.

• Determination of the underlying cause of the asymmetric

or symmetric transverse problem must be an important
ingredient in the process of formulation of an appropriate
treatment plan.
MANAGEMENT OF TRANSVERSE
DISCREPANCY
Its best corrected in growing patients .
CLASSIFICATION OF MAXILLARY
EXPANSION
RAPID MAXILLARY
EXPANSION
 Emerson C. Angell documented the first case of
orthodontic maxillary expansion to correct a transverse
deficiency in 1860.
 INDICATIONS FOR R.M.E.
 Rapid maxillary expansion has been carried out for dental
as well as medical purposes.
 Posterior crossbite associated with real or relative
maxillary deficiencies is the prime indication for rapid
maxillary expansion.
 A real maxillary deficiency is associated with an
undersized / narrow maxilla. Relative maxillary deficiency
is characterized by normal maxilla but oversized mandible.
 Rapid maxillary expansion is also indicated in cleft palate
patients who have collapsed maxillary arch
R.M.E is also indicated along with reverse
pull headgears. It helps to loosen the
maxillary sutural attachments so as to
facilitate protraction.
The medical indications for rapid maxillary
expansion include nasal stenosis, poor
nasal airway, septal deformities, recurrent
ear and nasal infection, allergic rhinitis,
D.N.S., e.t.c
Effects of R.M.E
 Effect on maxilla
 Opening of the mid - palatal suture.
 Downwards and forward maxillary movement.
 Effect on maxillary teeth
 Midline spacing between the two maxillary central incisors.
 Maxillary posterior teeth show buccal tipping and extrusion.
 Effect on mandible
 Downward and backward rotation of the mandible.
 Increase in face height.Reduction in overbite.
 Effect on nasal cavity
 Reduced resistance to nasal air flow.
 Increase in intra-nasal space.
 Effects of RME on maxillary complex Maxillary
halves Displaced downward and forward
Fulcrum of rotation –frontomaxillary suture
 Tipping :- -1 to 8 Sutural opening :- ≤ one half
the amount of dental arch expansion
 Palatine process of maxilla – lowered
 Palatal dome – remained the same

 Bishara , S.E. and Staley, R.N., 1987. Maxillary expansion: clinical implications. American journal of
orthodontics and dentofacial orthopedics, 91(1), pp.3-14

Alveolar process Bone is resilient Later
al bending
of alveolar process
Applied force dissipate within 5-6 weeks
If stabilization terminated Residual force in
displaced tissue Rebound
 CLINICAL TIP
Need for overcorrection – to compensate
for subsequent uprighting of buccal
segment
. Palatal vault • Fried and Haas reported
that the palatine processes of the maxilla
were lowered as a result of the outward
tilting of the maxillary halves
 Maxillary anterior teeth • Opening of a
diastema between the maxillary central
incisors.
• The maxillary central incisors tend to be
extrude relative to the S-N plane and in
76% of the cases they upright or tip
lingually.. The lingual tipping of the incisors
is due to the stretched circumoral
musculature
 . Maxillary posterior teeth •
 Angulation between the right and left molars increased
from I deg to 24 deg during expansion which is caused
by alveolar bending, but is also due to tipping of the
teeth in the alveolar bone. Palatal mucoperiosteum,
periodontal tissues, and root resorption.
 • Maxillary expansion tend to stretch the fibres of
palatal mucosa which in turn is also responsible for the
10 degree tip in maxillary molars
 • Maxillary expansion is also associated with the root
resorption in the buccal aspects
 Efects of RME on the mandible.
 • There is a concomitant tendency for the
mandible to swing downward and backward.
 • It is due to disruption of occlusion caused by
extrusion and tipping of maxillary posterior
teeth along with alveolar bending.
 Mandibular teeth ; Stay upright or relatively
stable over treatment period
 • Mandibular intermolar width change – 0.4mm
– 1mm
 Effects of RME on adjacent facial
structures. All craniofacial bones directly
articulating with the maxilla were displaced
except the sphenoid bone
• The cranial base angle remained constant
• Displacement of the maxillary halves was
asymmetric
• The sphenoid bone, not the zygomatic
arch: was the main buttress against
maxillary expansion.
• Gardner and Kronman, found that the
lambdoid, parietal and midsagittal sutures
REMOVABLE RME
APPLIANCES
It can be used during deciduous or ealrly
mixed dentition is considred more
favourable in producing appreciable
skeletal effects.
The disadvantaage of a removable
appliance ,patient compliance and difficulty
in retaining the plate inside the mouth.
FIXED RME APPLIANCE
TOOTH AND TISSUE BORNE APPLIANCE
Derichsweiler type
Hass type
HASS TYPE
TOOTH BORNE APPLIANCES
Isaacson type
Hyrax type
Banded Hyrax appliance
Bonded Hyrax appliance
Activation schedule
 A. Schedule by Timms
 Up to 15 years: 180 degrees daily rotation of
the screw can be met with a turn of 90 degrees
both during morning and evening (one quarter
turn 90 degrees equivalent to 0.25 mm).
 Over 15 years: Increasing resistance to
maxillary separation may cause a force build-up
and pain to patients in this age group with turns
of 90 degrees, so the total overall daily rotation
of 180 degrees is split into four turns of 45
degrees in a day.
. B. Schedule by Zimring and Isaacson
 • Young growing patients: Two turns each
day for 4– 5 days and later one turn/day till
the desired expansion is achieved (two
turns equivalent to 180 degrees, 0.5 mm).
• Non-growing adults: Two turns each day
for first 2 days, one turn/day for next 5–7
days and one turn every alternate day till
desired expansion is achieved
SLOW EXPANSION
APPLIANCES
Coffin spring introduced by Walter Coffin in 1877
W ARCH
QUAD HELIX
FIXED SLOW EXPANSION
APPLIANCES
SPRING JET
NITI EXPANDER
The Nickel Titanium Palatal Expanders were
introduced by Wendell V30 (Fig. 9). It
generates optimal, constant expansion
forces. The central component is made of a
thermally activated NiTi alloy and rest of
component is made of stainless steel.