INTRODUCTION

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

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

SKELETALCROSSBITE

DENTAL CROSSBITE
 FUNCTIONAL CROSSBITE

CLASSIFICATION OF ANTERIOR CROSSBITE

1) ECTOPIC INCISORS - ECTOPIC ERUPTION IS A MALPOSITION OF A PERMANENT

TOOTH BUD RESULTING IN THE TOOTH ERUPTING IN THE WRONG PLACE.

2) SKELETAL CLASS III - AN ANTERIOR CROSSBITE MAY BE ASSOCIATED WITH

A SKELETAL CLASS III DISCREPANCY SUCH THAT, ALTHOUGH THE INCISORS ARE
POSITIONED CORRECTLY WITHIN THE ALVEOLAR RIDGES, THEY ARE IN
NEGATIVE OVERJET ON CLOSING INTO CENTRIC OCCLUSION WITH NO
DEVIATION OF MANDIBULAR CLOSURE.THE LOWER MOLAR HAS MOVED
FORWARD OF ITS NORMAL POSITION OFTEN CREATING AN ANTERIOR
CROSSBITE.THERE ARE THREE MAIN TREATMENT OPTIONS FOR SKELETAL
CLASS III MALOCCLUSION : GROWTH MODIFICATION, ORTHODONTIC
CAMOUFLAGE AND ORTHOGNATHIC SURGERY

3) PSEUDO CLASS III MALOCCLUSION - IT IS A HABITUAL ESTABLISHED

CROSSBITE OF ALL ANTERIOR TEETH, WITHOUT ANY SKELETAL DISCREPANCY,
RESULTING FROM FUNCTIONAL FORWARD POSITIONING / SHIFT OF THE
MANDIBLE ON CLOSURE.PATIENTS WITH A PSEUDO CLASS III MALOCCLUSION
CAN OFTEN PRESENT WITH AN ANTERIOR CROSSBITE ,THAT CAN BE
MANIPULATED BACK TO AN ENDTO-END INCISAL RELATIONSHIP IN CENTRIC
RELATION .

CLASSIFICATION OF POSTERIOR CROSSBITES

(1) ACCORDING TO THE NUMBER OF TEETH

 SINGLE TOOTH CROSSBITE
  SEGMENTAL 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 POSTERIOR CROSSBITE - BUCCAL CUSP OF ONE/MORE

TEETH OCCLUDE LINGUAL TO THE BUCCAL CUSP OF MANDIBULAR
POSTERIORS TEETH.

 BUCCAL NON OCCLUSION CROSSBITE- THE MAXILLARY

POSTERIORS OCCLUDE ENTIRELY ON BUCCAL ASPECT OF
MANDIBULAR POSTERIORS.ALSO KNOWN AS SCISSOR BITE.

 LINGUAL NON OCCLUSION CROSSBITE- MAXILLARY POSTERIORS

OCCLUDE ENTIRELY ON LINGUAL ASPECT OF MANDIBULAR .
ETIOLOGY
ETIOLOGY OF ANTERIOR CROSSBITES

I- DENTAL CAUSES

1. TRAUMATIC INJURY TO PRIMARY DENTITION THAT CAUSES A LINGUAL

DISPLACEMENT OF PERMANENT TOOTH BUD LEDS TO PERSISTANCE OF A
DECIDUOUS TOOTH WHICH PALATAL DEFLECTION OF ITS ERUPTING SUCCESSOR
FORM SINGLE TOOTH ANTERIOR CROSS BITE

2. SUPERNUMERARY TOOTH

3.A HABIT OF BITING THE UPPER LIP

4. CLEFT LIP

5.ARCH LENGTH INADEQUACY

II-SKELETAL CAUSES

1. GENETIC

2. DUE TO DEFICIENT ANTERIOR GROWTH OF MAXILLA

3. EXCESSIVE ABNORMAL MANDIBULAR GROWTH IN ANTERIORLY

4. COMBINATION OF BOTH 2 AND 3

III- FUNCTIONAL CAUSES

1. PSEUDO CLASS III

2. HABITUAL FORWARD POSITIONING OF THE MANDIBLE TO OBTAIN MAXIMUM

INTERCUSPATION MAY LEAD TO AN ANTERIOR CROSSBITE
ETIOLOGY OF POSTERIOR 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.
CLINICAL EXAMINATION OF CROSSBITE:
ANTERIOR CROSSBITE

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).

CENTRIC OCCLUSION THE INCISORS SHOW NEGATIVE OVERJET.

CENTRIC RELATION THE INCISORS TOUCH EDGE TO EDGE.

THE ANTEROPOSTERIOR DIFFERENCE BETWEEN CENTRIC RELATION AND

CENTRIC OCCLUSION IS KNOWN AS A FUNCTIONAL SHIFT. THE POSITION OF THE
TEETH AFFECTED THE POSITION OF THE JAW. WHEN THERE IS A PREMATURE
CONTACT (SEE THE CANINE) IT CAN CAUSE THE JAW TO SHIFT SO THAT THE
TEETH CAN CONTACT. 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.

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 MIXED DENTITION IS 1:13 OR 7.7% .

* AS WITH AN ANTERIOR CROSSBITE, PATIENTS WITH A POSTERIOR CROSSBITE

MUST BE EVALUATED FOR A FUNCTIONAL SHIFT.
*A POSTERIOR CROSSBITE IN THE PRIMARY OR MIXED DENTITION IS
FREQUENTLY ASSOCIATED A BILATERAL MAXILLARY CONSTRICTION . SUCH A
BILATERAL MAXILLARY CONSTRICTION MAY BE ACCOMPANIED WITH A
LATERAL FUNCTIONAL SHIFT.

A LATERAL FUNCTIONAL SHIFT MAY OCCUR BECAUSE CLOSURE OF THE

MANDIBLE IN CENTRIC RELATION CAUSES THE OPPOSING CUSP TIP TO CONTACT
IN A CUSP-TO-CUSP POSITION. BECAUSE THE PATIENT IS UNABLE TO OCCLUDE
WITH THE TEETH IN SUCH A POSITION, THE MANDIBLE IS SHIFTED LATERALLY
TO ALLOW CONTACT OF MORE OCCLUSAL SURFACES AND TO IMPROVE
FUNCTION.

DIAGNOSIS OF SKELETAL AND DENTAL CROSSBITE

1. HISTORY

2. CLINICAL EXAMINATION

3. STUDY MODELS

4. RADIOGRAPH

* LATERAL CEPHALOGRAM ( FOR ANTERIOR CROSSBITE )

* POSTERO-ANTERIOR (PA) VIEW OF CEPHALOGRAM ( FOR POSTERIOR

CROSSBITE )

THE CASTS ARE BROUGHT INTO OCCLUSION AND THE OCCLUSAL

RELATIONSHIPS ARE EXAMINED, BEGINNING WITH THE TRANSVERSE (
POSTERIOR CROSSBITE) PLANE OF SPACE TO ACCURATELY DESCRIBE THE
OCCLUSION AND TO DISTINGUISH BETWEEN SKELETAL AND DENTAL
CONTRIBUTIONS TO MALOCCLUSION.

DIFFERENTIATE BETWEEN DENTAL AND SKELETAL CROSSBITE

CLINICAL AND POSTERO-ANTERIOR CEPHALOGRAM

CLINICALLY

DENTAL CROSSBITE :
* IF THE BASE OF THE PALATAL VAULT IS WIDE, BUT THE T DENTOALVEOLAR
PROCESSES LEAN INWARD , THE CROSSBITE IS DENTAL IN THE SENSE THAT IT IS
CAUSED BY A DISTORTION OF THE DENTAL ARCH.

SKELETAL CROSSBITE:

* IF THE PALATAL VAULT IS NARROW AND THE MAXILLARY TEETH LEAN

OUTWARD BUT NEVERTHELESS ARE IN CROSSBITE, THE PROBLEM IS SKELETAL
IN THAT IT BASICALLY RESULT FROM THE NARROW WIDTH OF THE MAXILLA.

POSTERO-ANTERIOR CEPHALOMETRIC ANALYSIS

INDICATED IN CASES OF DENTOALVEOLAR ASYMMETRIES, DENTAL AND

SKELETAL CROSSBITE, AND FUNCTIONAL MANDIBULAR DISPLACEMENTS.
(TRANSVERSE DISCREPANCIES).

* RICKETTS GAVE A NORMATIVE DATA OF PARAMETERS MEASURED, WHICH IS

HELPFUL IN DETERMINING THE VERTICAL TRANSVERSE SKELETAL AND DENTAL
PROBLEMS.

*MOLAR RELATIONSHIP (RIGHT AND LEFT) (A6 – B6) DIFFERENCE IN WIDTH

BETWEEN THE UPPER AND LOWER MOLARS MEASURED AT THE MOST
PROMINENT BUCCAL CONTOUR OF EACH TOOTH .

* NORMAL VALUE: MAXILLARY MOLAR 1.5MM BUCCALY

* STANDARD DEVIATION: +/- 2MM

MOLAR RELATIONSHIP (RIGHT AND LEFT) (A6 – B6)

INTERPRETATION :

THIS MEASUREMENT DESCRIBES THE MOLAR RELATIONSHIP ON THE

TRANSVERSE PLAN. O LOWER NEGATIVE VALUES INDICATE A CUSP-TO-CUSP
MOLAR OR LINGUAL CROSSBITE, RESPECTIVELY. O VALUES HIGHER THAN +3
MM CORRESPOND TO BUCCAL CROSSBITE.

DENTAL RELATIONS:

INTER MOLAR WIDTH (B6 – B6) FROM BUCCAL SURFACE OF MANDIBULAR LEFT
TO RIGHT MOLAR.

* NORMAL VALUE: 55MM FOR BOYS AND 54MM FOR GIRLS

* STANDARD DEVIATION: +/-2MM

INTERPRETATION :

MEASURES THE ARCH WIDTH IN MILLIMETERS AT LEVEL OF FIRST MOLARS.

ALSO HELPFUL IN DETERMINING THE ETIOLOGY OF CROSSBITE.

SKELETAL RELATIONS:

MAXILLOMANDIBULAR WIDTH (RIGHT AND LEFT):

* NORMAL VALUE: 11MM FOR AN PATIENT AGED 8.5 YEARS

* STANDARD DEVIATION: +/- 1.5MM

INTERPRETATION :

INDICATES THE TRANSVERSE DEVELOPMENT OF THE MAXILLA, USEFUL FOR

THE DIFFERENTIAL DIAGNOSIS OF CROSSBITE
MANAGEMENT
MANAGEMENT OF ANTERIOR CROSSBITES

I- PRIMARY DENTITION ( PREVENTIVE ORTHODONTICS )

ELIMINATION OF THE FACTORS THAT MAY LEAD TO THE ANTERIOR CROSSBITE

EXAMPLES:

 REMOVAL OF OCCLUSAL PREMATURITIES.

 EXTRACTION OF SUPERNUMERARY TOOTH BEFORE THEY CAUSE
DISPLACEMENT OF OTHER TOOTH.
 HABIT BREAKING APPLIANCE.

II- IN MIXED DENTITION ( INTERCEPTIVE ORTHODONTICS )

1. USE OF TONGUE BLADE.

INDICATIONS:

 USED WHEN A CROSSBITE IS SEEN AT THE TIME PERMANENT TEETH

ARE MAKING AN APPEARANCE IN THE ORAL CAVITY.
  IT IS PLACED INSIDE THE MOUTH CONTACTING THE PALATAL ASPECT
OF THE MAXILLARY TEETH .SLIGHT CLOSURE OF JAW THE OPPOSING
SIDE OF THE STICK COME IN CONTACT ACTS AS A FULCRUM.THIS IS
CONTINUED FOR 1-2 HOURS FOR ABOUT 2 WEEKS.

DRAWBACKS OF USING TONGUE BLADE :

 ONLY EFFECTIVE TILL THE CLINICAL CROWN NOT
COMPLETELY ERUPTED IN THE ORAL CAVITY.
 USED ONLY IF SUFFICIENT SPACE IS AVAILABLE FOR THE
CORRECTION.
 PATIENTS COOPERATION IS REQUIRED.

2. CATLAN'S APPLIANCE OR LOWER ANTERIOR INCLINED PLANE:

INDICATIONS:

 USED ONLY IN THOSE CASES WHERE THE CROSSBITE IS DUE TO A

PALATALLY PLACED MAXILLARY INCISORS.
 (CONSTRUCTED AT 45 DEGREE ANGULATIONS ON THE LOWER
ANTERIOR TEETH BY ACRYLIC).

3. CANTILEVER SPRING / Z-SPRING

INDICATIONS

 USED WHEN ANTERIOR CROSSBITE INVOLVING 1 OR 2 MAXILLARY

ANTERIOR TEETH
 4. SCREW APPLIANCE
I) MICRO SCREW

 USED ON INDIVIDUAL TOOTH MULTIPLE MICRO SCREW CAN BE USED

TO CORRECT INDIVIDUAL TOOTH IN SEGMENTAL CROSSBITE.

II) MINI SCREW

 CAPABLE OF MOVING UP TO 2 TEETH.

II) MEDIUM SCREW

 USED TO CORRECT SEGMENTAL CROSSBITE

III) 3-D SCREW (3-DIMENSIONAL SCREW)
  CAPABLE OF CORRECTING POSTERIOR AS WELL AS ANTERIOR
CROSSBITE

THE INDICATIONS FOR PALATAL EXPANSION INCLUDE:

1. RELIEF OF A POSTERIOR CROSSBITE WITH A SKELETAL COMPONENT.

2. GAINING A SMALL AMOUNT OF SPACE TO RELIEVE ANTERIOR CROWDING
(USUALLY LESS THAN 4 MM).

CONCLUSION ABOUT SCREW APPLIANCES:

THE RESULTS SUGGEST THAT THE RME AND SRME HAVE A SIMILAR EFFECT ON
DENTOFACIAL STRUCTURES IN THE TRANSVERSE, VERTICAL, AND SAGITTAL
PLANES. WHETHER THE AMOUNT OF RELAPSE WOULD BE LESS WITH SRME DUE
TO A DECREASE IN RESIDUAL STRESSES IN DENTOFACIAL STRUCTURES SHOULD
BE EVALUATED FURTHER. IN THE PRESENT STUDY, TIPPING OCCURRED IN BOTH
GROUPS

5. FACE MASK/ FACE MASK ALONG WITH RME

INDICATIONS
USED TO CORRECT SKELETAL ANTERIOR CROSSBITE IE, ANTERIOR
CROSSBITE DUE TO ACTUAL SKELETAL DEFICIENCY OF THE MAXILLA.IF
MAXILLA IS NARROW RME SCREW ALSO USED FOR TRANSVERSE
EXPANSION.
 6. FRANKEL III APPLIANCE
 USED TO CORRECT SKELETAL CLASS III MALOCCLUSION

7. CHIN CAP APPLIANCE

 USED TO CORRECT OR PREVENT THE ANTERIOR CROSSBITE DUE TO A
PROMINENT MANDIBLE. CHIN CAP APPLIANCE ROTATE MANDIBLE
BACKWARD AND DOWNWARD.

III) IN PERMANENT DENTITION ( IN ADOLESCENT & ADULT)

  SCREW APPLIANCE :
 MINI SCREW
 MEDIUM SCREW
MAY BE USED TO CORRECT SINGLE TOOTH OR SEGMENTAL CROSSBITE.

 FIXED APPLIANCE :
 USED TO CORRECT SINGLE TOOTH OR MULTIPLE TEETH

POSTERIOR CROSSBITE 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.

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 IS PRESENT TREATMENT IS IMPLEMENTED TO CORRECT

THE CROSSBITE.IF MANDIBULAR SHIFT NOT PRESENT TREATMENT IS DELAYED
UNTIL THE PERMANENT FIRST MOLARS ERUPT. IF THE FIRST PERMANENT
MOLAR ERUPTS INTO CROSSBITE TREATMENT IS INITIATED (IF NO OTHER
MALOCCLUSION EXISTS).IF THE FIRST PERMANENT MOLAR ERUPTS NORMALLY
TREATMENT IS NOT INDICATED UNTIL 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

1.GENERALIZED

*UNILATERAL

*BILATERAL

2.LOCALIZED

THE VARIOUS TREATMENT MODALITIES FOR POSTERIOR CROSS BITE 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 (RME).

8) NI-TI EXPANDERS.

9) ORAL SCREENING.

10) FIXED ORTHODONTIC APPLIANCES.

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 BAND

-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.

- THE RUBBER ELASTICS USED ARE – HEAVY RUBBER ELASTICS,

0.25 I.E. 3/16 INCH 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.

- 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 AND 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

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
DIAGNOSIS IS THE GOLDEN KEY TO SUCCESS.A CASES OF CROSSBITE CAN BE
DECEPTIVE. SO,IT ISALWAYS MANDATORY TO THINK BEFORE WE LEAP INTO
CONCLUSION,WHETHER IT IS CROSSBITE OF A TRUE NATURE ORPSEUDO.TO
ACHIEVE BETTER TREATMENT FINISH,CROSSBITES SHOULD BE DEALT AS SOON
AS DETECTED & THE CHOICE OF ARMAMENTARIUM CAN BE LEFT TO CLINICIANS
DISCRETION.THE EARLY AND CORRECT DIAGNOSIS OF 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 CROSSBITE.
REFERENCES
1) S GOWRI SHANKAR – TEXTBOOK OF ORTHODONTICS (1ST REVISED EDITION
2016).

2) A TEXTBOOK OF ORTHODONTICS BY GURKEERAT SINGH (3RD EDITION).

3) HANDBOOK OF PEDIATRIC DENTISTRY BY ANGUS C CAMERON & RICHARD P

WIDMER (4TH EDITION).

4) TEXTBOOK OF PEDIATRIC DENTISTRY BY NIKHIL MARWAH (3RD EDITION).