Management of crossbite in mixed dentition
- 1. CROSS BITE MANAGEMENT IN MIXED DENTITION Riwa Kobrosli – 201202978 – PEDIATRIC DENTISTRY INTERCEPTIVE ORTHODONTICS – PROF. ALI OTHMAN
- 2. OUTLINE Introduction Definition Types of cross bite Etiology Rationale for early treatment Contra-indications Diagnosis Treatment Appliances Case reports Conclusion References
- 3. INTRODUCTION Early treatment of crossbite during the mixed dentition stage is extremely important as it provides the correct positioning of osseous bases, teeth, and the TMJ when the stomatognathic system is in growth and development Early interceptive orthodontic treatment can potentially eliminate the need for future complicated and costly orthodontic treatment.
- 4. CLINICAL QUESTIONS How to recognize and diagnose the different types of crossbite? What are the types that can be treated by early intervention? What is the importance of timely intervention of crossbite in children? How can early treatment of crossbite in children be managed successfully?
- 5. DEFINITION Under normal circumstances, maxillary arch overlaps mandibular arch both labially and buccally. But when mandibular teeth overlap maxillary teeth labially or buccally, crossbite exists. Cross bite is the deviation of the normal faciolingual relationship of teeth when arches set in Centric Occlusion. Normal buccolingual or labiolingual relationships are reversed.
- 6. CLASSIFICATION OF CROSSBITES According to the location in the arch Anterior Posterior According to the nature of crossbite Skeletal Dental Functional crossbite crossbite crossbite
- 7. I.ANTERIOR CROSSBITE Anterior crossbite occurs when the upper anterior teeth (one or more) occlude lingual to the lower anterior teeth (anteroposterior plane). There are 3 types of anterior crossbite: Skeletal Due to the discrepancy of the underlying skeletal relationship. Early treatment may not be successful due to the unpredictability of the growth pattern. Dental Patients presented with Class I skeletal relationship with one or more teeth in crossbite Functional (Pseudo Class III) A positional malrelationship dt acquired muscular reflex caused by an occlusal interference.
- 8. Diagnostic characteristics: • Mandible can be pushed back to edge to edge (retrusion of mandible is possible) • Path of closure is deviated anteriorly (protrusive shift of mandible in centric occlusion; condyles displaced downward and forward). • Normal or edge to edge molar and canine relationship at centric relation. • Patient’s profile: straight at rest and concave in maximum occlusion. • Retroclined upper incisors (in true skeletal class 3, they are inclined labially) Habitual occlusion Centric relation
- 9. ETIOLOGY • Anterior posterior skeletal discrepancy • maxillary deficiency, mandibular excess, or a combination of both • Usually associated with family history of Class III skeletal origin Skeletal • Crowding, arch length deficiency i.e. Tooth size arch length discrepancy. • Supernumerary teeth. • Palatal eruption path of maxillary incisors (abnormal inclination). • Trauma to permanent teeth resulting in the incisors being displaced by luxation • Trauma to deciduous teeth resulting in displacement of permanent tooth germs • Delayed shedding or retained deciduous teeth. Dental (Local Factors) • Occlusal interferences which result in mandibular displacement to achieve Maximum intercuspation. Functional The possible causes of anterior crossbite include
- 10. ETIOLOGY • Cleft lip and palate • Scar tissue of the cleft repair can restrain the growth of the maxilla, resulting in a narrow maxilla. • Trauma or pathology of the temporomandibular joint can lead to restriction of the growth of mandible on one side leading to asymmetry. • Arthritis, acromegaly, condylar hyperplasia and Osteochondroma. Pathological conditions The possible causes of anterior crossbite include Ant. Crossbite in relation to Cleft Lip & Palate Condylar hyperplasia
- 11. Little possibility for self- correction Crossbite in the primary dentition is believed to transfer to the permanent dentition Postponing treatment results in prolonged treatment of greater complexity Functional crossbite can develop from cuspal interference, resulting in a mandibular shift Improve maxillary lip posture and facial appearance if corrected in the mixed dentition Provide space for eruption of canines. Lack of space in the arch could be caused by retroclined upper incisors RATIONALE FOR EARLY TREATMENT
- 12. CONSEQUENCES OF UNTREATED ANTERIOR CROSSBITE Ifleftuntreated,itmayleadto: Damage to the teeth in crossbite through attrition traumatic occlusion causing: gingival recession and loss of alveolar bone support to the lower incisors mobility of the lower incisors affected by the crossbite Influencing potential adverse growth of the mandible and maxilla TMJ dysfunction, which has been associated with childhood anterior crossbite
- 13. CONTRAINDICATIONS OF CROSSBITE TTT Patients who present skeletal discrepancy, which may require joint orthodontic surgical management Teeth where dento-alveolar compensation has taken place (proclined upper incisors, retroclined lower incisors Minimal or no overbite Non- compliant patient
- 15. DIAGNOSIS For successful treatment we should know The type of anterior cross bite Differentiate between skeletal or dental The cause of anterior cross bite
- 16. EXAMINATION 1. Patient assessment • chief complaint • crowding • no exposure of upper front teeth on smiling • gingival recession 2. History • medical/dental history • family history of a Class III skeletal pattern • social history
- 17. EXAMINATION 3. Extra-oral examination • Skeletal pattern: A-P, Vertical and Transverse relationship • TMJ: tenderness, clicking, crepitus, mobility. • Soft tissue profile: straight, convex, concave 4. Intra-oral examination • oral hygiene, gingival health and DMF • Number of teeth involved in the anterior crossbite, overjet, overbite • Signs of attrition and periodontal breakdown due to traumatic occlusion if present
- 18. EXAMINATION 5. Radiographic examination • Panoramic x-ray: presence/absence of teeth, condition of teeth and the periodontal status • Occlusal x-ray: To detect any supernumerary teeth and if pathology is suspected in the anterior region 6. Study models • Study model and wax bite registration in maximum intercuspation must be taken for diagnosis and treatment planning. • Used for space analysis.
- 19. EXAMINATION 7. Clinical photographs • Both extraorally and intraorally with standardized settings for pre- and post- treatment records.
- 20. TREATMENT OF ANTERIOR CROSSBITES • Dento-alveolar compensation: • proclination of upper teeth alone or combination of proclination of upper teeth and retroclination of lower teeth. • Maxillary protrusion • Backward rotation of mandible • Combination of 1,2 &3 TREATMENT PRINCIPLES Anterior crossbite is corrected by:
- 21. TREATMENT OF ANTERIOR CROSSBITES FACTORS TO CONSIDER PRIOR TO SELECTION OF TREAMENT MODALITIES 1. Adequate space in the arch to reposition the tooth. 2. Sufficient overbite to hold the tooth in position following correction. 3. Incisors inclination and favorable position of root apex. 4. A Class I occlusion 5. Patient compliance 6. Timing of treatment 7. Periodontal breakdown 8. Growth potential
- 22. APPLIANCES FOR ANTERIOR CROSSBITE TONGUE BLADE REMOVABLE APPLIANCE FIXED APPLIANCE INCLINED BITE PLANE FACE MASK CHIN CUP FUNCTIONAL APPLIANCES
- 23. TINGUE BLADE • Used for treatment of a developing (incipient) crossbite NO INTERLOCK. • The child is instructed to place it behind the tooth expected to become in locked. • Slight pressure is exerted on the tooth in a labial direction. • Repeated 10 minutes every hour for 10 to 14 days.
- 24. UPPER REMOVABLE APPLIANCE Removable appliances act by applying tipping forces to the crowns of the teeth. The advantages are: • simple • can be removed for oral hygiene purposes • reduced chairside time • cost-effective The disadvantages are: • highly dependent on patient’s compliance • Needs laboratory support • Only allows tipping movement. Components: 1. Active components 2. Retentive components 3. Anchorage 4. Baseplate
- 25. Expansion Screws • Used to procline two or more teeth. • Applies large intermittent force to the teeth. • Advantages: • clasp can be placed on the teeth to be moved. • useful if inadequate number of teeth for retention. • The activation is done one-quarter turn once weekly which separates the acrylic by about 0.25mm. • twice a week is possible 1.Active Components: Provide force to move teeth. Z- spring and expansion screw. Z-spring • Corrects a simple crossbite involving one tooth. • The spring has an arm and two activation coils. • The arm is placed on the palatal surface of the tooth. • Activation of spring is either by opening of the coils or pulling the outer arm of the spring forward and away from acrylic base plate. care must be taken not to overdo activation as this can cause the appliance to be ill-fitting
- 26. 2. Retentive Components (Adams and Southend clasps) If the appliance is loose, the patient may have difficulty wearing it and the active components will not work effectively in a loose appliance. 4. Baseplate hold together the other components. The posterior bite plane should be appropriate in thickness and free the occlusion to allow the tooth in crossbite to move effectively 3. Anchorage provided by the baseplate and the retentive components. • Successful correction should be achieved within 6-9 months. • No retention is required if there is positive overbite (stable result)
- 28. 2020
- 29. - 6 years old, early mixed dentition - anterior crossbite with 1 mm negative overjet - He has 3-mm deviation of the mandibular midline - During the opening of the mouth, midlines became coincident and the chin deviation disappeared. This was the sign of a functional problem and not a skeletal one EGA Used for night-time use only; it had to be fitted soon after dinner until the next morning. Early Treatment of Anterior Crossbite with Eruption Guidance Appliance: A Case Report Marianna Pellegrino et al
- 30. edge-to-edge occlusion obtained after 4 months of treatment After 7 months, the anterior crossbite was resolved. The initial negative overjet and deep bite were treated. The mandible’s functional deviation disappeared Early Treatment of Anterior Crossbite with Eruption Guidance Appliance: A Case Report Marianna Pellegrino et al
- 31. EGA is a solution to treat patients with anterior crossbite in early age, during the eruption of incisors Early Treatment of Anterior Crossbite with Eruption Guidance Appliance: A Case Report Marianna Pellegrino et al
- 32. FIXED APPLIANCE Simple fixed appliance such as the 2×4 appliance is preferred when complex movement is needed. Fixed appliance is capable of tooth movement in all three dimensions including bodily movement, root torquing, derotation and movement of multiple teeth.
- 33. 2018 Interceptive Correction of Anterior Crossbite Using Short-SpanWire-Fixed Orthodontic Appliance:A Report of Three Cases 2018 S. Nagarajan M. P. Sockalingam et al
- 34. Interceptive Correction of Anterior Crossbite Using Short-SpanWire-Fixed Orthodontic Appliance:A Report of Three Cases 2018 S. Nagarajan M. P. Sockalingam et al
- 35. INCLINED BITE PLANE Can be fixed or removable. Composite resin has been used as fixed inclined bite plane and suitable when: • the anterior crossbite is not more than 1/3 crown length • no tooth rotation • sufficient space present for labial movement. • The crossbite should be solely of dental origin. Disadvantages: causes food accumulation and gingivitis (bad oral hygiene)
- 36. The Catlan’s appliance is also known as Lower Inclined Bite Plane which is cemented onto lower incisors. - It is a lower jaw inclined plane which is based on Newton’s 3rd law of motion (natural forces) - creates a slight lingual movement in the mandibular teeth, while generating labial movement in the maxillary teeth
- 37. Pseudo class 3 8 years Palatally placed 21 8 years Single crossbite with Midline shift 9 years Treatmentafter1week Nishidha Tiwari., et al. “Management of Anterior Cross Bite in Mixed Dentition Using Catlan’s Appliance”. Acta Scientific Dental Sciences 4.2 (2020): 106-109
- 38. Anterior crossbite involving multiple teeth with gingival recession on mandibular left central incisor The lower inclined bite plane was cemented to the mandibular teeth Positive bite was noticed after 3 weeks of treatment The corrected bite was maintained during one-month review (October. 2019) Fadzlinda Baharin. “Management of Anterior Crossbite in Mixed Dentition Using Lower Inclined Bite Plane: A Case Report.” IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), vol. 18, no. 10, 2019, pp 54-57.
- 39. FUNCTIONAL APPLIANCE • Functional appliance utilizes the forces of the orofacial musculature to move teeth and modify growth to correct a malocclusion. • stimulate forward maxillary growth and restrain mandibular growth. • major effect is mostly dento-alveolar. • Function Regulator (1), Reverse Twin Block (2) and Reverse Bionator (3) used in the treatment of anterior crossbite with Class III skeletal base. (1) (2) (3)
- 40. Face Mask • The preferred treatment for skeletal maxillary retrusion is anterior movement of the maxilla. • results in the advancement of maxilla along with a backward and downward rotation of mandible and correction of anterior crossbite • For maximum skeletal effect, treatment should commence before the age of 8 years (in early mixed dentition stage). • worn at least 12 hours per day.
- 41. Chin cup • This treatment produces a backward rotation of mandible giving the appearance that the mandible has been restrained. • Can be used to treat mandibular prognathism in early mixed dentition. • The best age is before canine and premolar erupt (first growth spurt of mandible) • Indications: • 1. Mild to moderate Skeletal III, ability to achieve edge to edge incisors • 2. Short vertical facial height (Chin cup causes clockwise rotation of the mandible). • 3. Proclined or upright LI (Chin cup causes lingual tipping of the lower incisors)
- 42. Patient with anterior crossbite Dental and functional crossbite Removable appliance Fixed appliance Skeletal crossbite Mild discrepancy Deficient maxilla Facemask / functional appliance Mild to moderate mandibular prognathism Chin cup Severe discrepancy Wait for growth to stop Orthogenetic surgery
- 43. II. POSTERIOR CROSSBITE In normal circumstances, mandibular buccal cusps occlude in the central fossae of maxillary posterior teeth In posterior crossbite case, mandibular buccal cusps occlude buccal to maxillary buccal cusps This refers to an abnormal transverse relationship between upper and lower posterior teeth. . (transverse plane)
- 44. CLASSIFICATION OF POSTERIOR CROSSBITES According to the number of teeth involved single tooth segmental According to the number of arch sides unilateral bilateral
- 45. CLASSIFICATION OF POSTERIOR CROSSBITES According to the extent of crossbite Simple Buccal non-occlusion Lingual non-occlusion Maxillary posteriors occlude entirely on lingual of mandibular posteriors Maxillary posteriors occlude entirely on Buccal of mandibular posteriors Buccal cusp of max. teeth occlude lingual to buccal cusp of madibular Scissor bite
- 46. Dental • 1) Anomalies in tooth number (supernumerary, missing teeth) • 2) Anomalies in tooth size (microdontia, macrodontia) • 3) Anomalies in tooth shape • 4) Premature loss of teeth • 5) Prolonged retention of deciduous teeth • 6) Delayed eruption of permanent teeth • 7) Abnormal eruption path • 8) Ankyloses Functional • Lateral Deviation of mandible during jaw closure (with midline shift) because of: • 1) Presence of occlusal interferences. • 2) Early loss of decidous teeth • 3) Decayed teeth • 4) Ectopically erupted teeth. ETIOLOGY OF POSTERIOR CROSSBITES
- 47. Skeletal • 1) Retarded maxilla. • 2) Prognethic mandible. • 3) Unilateral hypo/hyperplastic growth of any jaw. • 4) Hereditary (Class III skeletal malocclussion). • 5) Congenital ( Cleft lip and palate). • 6) Trauma at birth (forcep injury leading to ankylosis of TMJ.) • 7) Trauma to TMJ (ankylosis) • 8) 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 muscles, which leads to narrowing of upper arch leading to posterior crossbite. ETIOLOGY OF POSTERIOR CROSSBITES Note: causes of anterior and posterior crossbite are the same except for habits, they cause only posterior crossbite.
- 48. Posterior crossbite correction in mixed dentition can be difficult and confusing. determine whether a skeletal/dental correction is necessary. in areas where mandibular shift is present it should be managed as soon as possible to prevent soft tissue and dental compensation. TREATMENT OF POSTERIOR CROSSBITES Occlusal equilibrium is done in a dental crossbite by removing the occlusal interferences usually in the cuspid area.
- 49. APPLIANCES USED IN POSTERIOR CROSSBITES Coffin spring Cross elastics / fixed Soldered W –arch (Porter appliance). Quad Helix Removable appliance Rapid maxillary expansion (hyrax) Ni-Ti expanders Oral screening
- 50. • It is a removable, omega shaped wire appliance • It produces slow and bilaterally symmetrical expansion. • 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. COFFIN SPRING
- 51. It is used to treat localized crossbites. Put hooks or button on palatal surface of the maxillary teeth and on buccal surface of the mandibular teeth. Rubber elastics are attached on the hooks (usually crossbite corrected within 3- 4 months with continuous wearing of elastics) CROSS ELASTICS / fixed orthodontic appliance Advantage: no need of retentive appliance Disadvantages: Needs patient’s cooperation Fixed orthodontic appliance are ideal for accurate placement of teeth in a dental arch as they provide a three dimensional control over the tooth
- 52. - It is an efficient appliance for the correction of posterior crossbite assosciated with thumb sucking. - Preformed stainless steel bands are adapted to the most distal tooth involved. - W-arch 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. SOLDERED W – ARCH (PORTER APPLIANCE) Retainer used for additional 3 months Appliance expands the arch approx 1mm/side/m onth
- 53. QUAD HELIX 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 mainly and maybe skeletal expansion. PROCEDURE : • Fit bands to either primary second molars or the permanent first molars. • 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, • loops or helixes and palatal portion should be 2-3 mm distal to banded teeth Loop may be added to quad helix in cases of habits. Retainer used for additional 3 months
- 54. • 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. Modification : UNEQUAL W-ARCH & UNEQUAL QUAD HELIX
- 55. REMOVABLE APPLIANCES • bilateral 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. • The conventional expansion schedule– ¼ turn every 3-4 days. • Correction is dental only. • Relapse potential is high.
- 56. Note: if the patient is young age, the appliance may do skeletal expansion by opening the sutures. REMOVABLE APPLIANCES Clinical tip: if we have anterior crowding, place the screw more anteriorly to increase the intercanine width. A wire can be soldered posteriorly joining the mesial and distal parts for stabilization of posterior teeth.
- 57. ORAL SCREEN/VESTIBULAR SCREEN - It is a myofunctional appliance – that takes form of a curved acrylic shield placed in labial vestibule. PRINCIPLE It works on principle of “PASSIVE EXPANSION” 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
- 58. ORAL SCREEN/VESTIBULAR SCREEN 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 The patient is made to wear the appliance at night and 2-3 hours during the day time and maintain lip seal
- 59. 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
- 60. 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 Cooling the expander it gets constricted and inserted into lingual tubes on the maxillary molars. As it warms to body temperature it becomes springy and exerts continuous force on teeth
- 61. 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. 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
- 62. 9-year-old patient who presented with functional unilateral posterior crossbite and was treated with a modified Hyrax expander. The case report highlights a simple, low-cost, effective treatment protocol. The malocclusion was corrected with 15 days of active use of the appliance, 5 months of use for retention purposes, and 5 years of post-treatment follow-up. de Mendonça Rogério, M., et al. "Case Report of Posterior Crossbite: Description of an Effective Treatment Protocol." Compendium of continuing education in dentistry 37.8 (2016): e13-6.
- 63. Posterior crossbite Class 1 molar 3 mm open bite moderate crowding occlusal radiography Modifoed Hyrax appliance transversal overcorrection After 15 days Retention 5 months After 1 year After 5 years Final result de Mendonça Rogério, M., et al. "Case Report of Posterior Crossbite: Description of an Effective Treatment Protocol." Compendium of continuing education in dentistry 37.8 (2016): e13-6. Grinding cusp
- 64. CONCLUSION The early and correct diagnosis of crossbite is essential to prevent the forthcoming occlusal discrepancies in the permanent dentition. It is the prime role of pediatric dentists as well as orthodontists to diagnose the case as soon as possible and treat it the correct way. Adequate curative measures and treatment modalities can be advocated to correct the crossbite
- 65. 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. 6. Interceptive Correction of Anterior Crossbite Using Short-Span Wire-Fixed Orthodontic Appliance: A Report of Three Cases 2018 S. Nagarajan M. P. Sockalingam et al 7. Nishidha Tiwari., et al. “Management of Anterior Cross Bite in Mixed Dentition Using Catlan’s Appliance”. Acta Scientific Dental Sciences 4.2 (2020): 106-109 8. Fadzlinda Baharin. “Management of Anterior Crossbite in Mixed Dentition Using Lower Inclined Bite Plane: A Case Report.” IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), vol. 18, no. 10, 2019, pp 54-57. 9. Early Treatment of Anterior Crossbite with Eruption Guidance Appliance: A Case Report Marianna Pellegrino et al, 2020. 10. de Mendonça Rogério, M., et al. "Case Report of Posterior Crossbite: Description of an Effective Treatment Protocol." Compendium of continuing education in dentistry 37.8 (2016): e13-6.