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Case Report

Management of Class I Type 3 Malocclusion Using Simple Removable

Appliances
Neha Bhati, Zhora Jabin

Department of Pedodontics According to Dewey’s modification of angle’s malocclusion, Class  I Type 3

Abstract
and Preventive Dentistry,
D.J College of dental science
and Research, Ghaziabad,
Uttar Pradesh, India
malocclusion is the Class I malocclusion with anterior crossbite. This case
report illustrates the treatment of the 13‑year‑old patient, with a crossbite of
the maxillary right permanent central and lateral incisors. Two upper acrylic
removable appliances, each with an expansion jackscrew, were used to correct
the crossbite. The total active treatment time was 6 months, and the treatment
outcome was successfully maintained for the subsequent 6 months. General and
pediatric dentists, as well as orthodontists, may find this technique useful in
managing crossbite cases of the permanent dentition by the removable appliance
and utilizing the discussion and illustrations for further clinical guidance.

Keywords: Crossbite, expansion screw, malocclusion, removable appliance

Clinical Relevance to Interdisciplinary Dentistry

Dentist may find this as easy, effective and less expensive approach for correction
of cross-bite cases.

Introduction replace Angle’s classification. This has resulted in many

A malocclusion is a misalignment or incorrect relation
between the teeth of the two dental arches when
they approach each other as the jaws close. It can
broadly be classified as an intra-arch malocclusion,
inter-arch malocclusion, and skeletal malocclusion.
Depending on the sagittal relations of teeth and jaws,
malocclusions can be divided mainly into three types
according to Angle’s classification system published 1899.
This classification is based on, where the buccal groove
of the mandibular first molar contacts the mesiobuccal
cusp of the maxillary first molar:
• On the cusp  (class  I, neutroclusion, or normal
occlusion)
• Distal to the cusp by at least the width of a
premolar (Class II, distocclusion)
• Mesial to the cusp (Class III, mesiocclusion).
However, there are also other conditions, for example,
crowding of teeth, not directly fitting into this
classification. Many authors have tried to modify or
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subtypes and new systems.
Dewey’s modification of angles Class‑I malocclusion
• Type 1 ‑ Anterior teeth crowding
• Type 2 ‑ Maxillary incisor proclination
• Type 3 ‑ Anterior cross bite
• Type 4 ‑ Posterior cross bite
• Type 5 ‑ Permanent molar drifts mesially.
Crossbite is a term used to describe abnormal
malocclusion in the transverse plane. It has a reported
incidence of 4%–5% and usually becomes evident during
the early mixed dentition period.[1] Anterior crossbite is
defined as a situation in which one or more primary or
permanent mandibular incisors occlude labially to their
antagonists (or when one or more maxillary incisors are
lingual to their antagonists).[2] It can be a major esthetic
Address for correspondence: Dr. Neha Bhati,
Department of Pedodontics and Preventive Dentistry, D.J College
of Dental Science and Research, Ghaziabad, Uttar Pradesh, India.
E‑mail: neha_bhati1987@yahoo.co.in
This is an open access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non-commercially, as long as the author is credited and the new
creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Bhati N, Jabin Z. Management of Class I Type 3
10.4103/jid.jid_79_16 malocclusion using simple removable appliances. J Interdiscip Dentistry
2017;7:72-5.

72 © 2017 Journal of Interdisciplinary Dentistry | Published by Wolters Kluwer - Medknow

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Bhati and Jabin: Management of unilateral anterior crossbite
and functional concern and may lead to abnormal enamel
abrasion or proclination of the mandibular incisors,
which, in turn, leads to thinning of the labial alveolar
plate and/or gingival recession. Mandibular shift caused
by abnormal mandibular movements may place strain
on the orofacial structures, causing adverse effects on
the temporomandibular joints and masticatory system.
Spontaneous correction of such malocclusion has been
reported to be too low to justify nonintervention,[3] and
the rate of self‑correction was shown to range from
0% to 9%.[3] Therefore, interceptive treatment is often
advised to normalize the occlusion and create conditions
for normal occlusal development.
Bonding brackets to the four maxillary incisors in
combination with banding the two maxillary permanent
first molars (2  ×  4 fixed appliance) are one of the
methods used for the correction of anterior crossbite
with fixed appliances. It has been reported to effectively
manage anterior crossbite in the mixed dentition as
well as in the adult dentition.[4] This method has the
advantages of requiring little or no patient compliance
or alteration of speech. Other reported treatment
modalities for the correction of anterior crossbite include
rare earth magnetic appliances, fixed acrylic inclined
planes, bonded resin composite slopes, and multiple sets
of Essix‑based appliances.[5]
Removable appliances have the advantages of easier
maintenance and oral hygiene care for young patients,
utilization of palatal anchorage, and the ability to move
a selected block of teeth.[6] The literature includes
management techniques for unilateral crossbite using
removable appliances with mid‑sagittal expansion screws.
This case report aims to provide general and pediatric
dentists with a simple technique to manage anterior
crossbite in the permanent dentition. Illustrations of
treatment progress and appliance design are included for
further clinical guidance.
Case Report
A 13‑year‑old boy came to the Department of Pedodontics
and preventive dentistry of D.J College of Dental Science
and Research with the complaint of irregularly arranged
teeth. Extraorally, he had a balanced face with a pleasant
profile. Intraorally, he presented in the permanent
dentition stage with Class I Type 3 malocclusion (Class I
molar relationship on both sides, with the right maxillary
incisors tipped palatally) and dental maxillary midline
shifting towards the right side . The overbite was deep
(100% on the left maxillary central incisor), and an
anterior crossbite of the maxillary right permanent central
and lateral incisors was evident [Figure 1a‑c].
Journal of Interdisciplinary Dentistry  ¦  Volume 7  ¦  Issue 2  ¦  May-August 2017
a b
c
Figure 1: (a) Preoperative. (b) Preoperative study model in occlusion.
(c) Preoperative maxillary study model to carry out carey’s space analysis
Treatment planning and progress
Based on the above findings, the patient was scheduled
for treatment to restore normal occlusion and alleviate
the underlying functional shift. The study model
was made and Carey's space analysis was done and
accordingly the appliance design was formulated.
At preoperative stage, the tooth material and arch space
discrepancy as according to Carey ’s space analysis
was 3mm, henceforth an appliance with mid-palatal jack
screw was de signed, in which two finger spring were
incorporated to control the deviation of left central and
lateral incisors toward right side and posterior bite plane
(about 4 mm thick) to disengage the bite and facilitate
tooth movement [Figure  2a]. This first removable
appliance was activated in the department quarter turn
twice a week for 3 months. Once the cross bite appeared
to be corrected the bite plane was reduced and slowly got
removed to achieve posterior occlusion [Figure 3a‑c].
After 3 months the first appliance was replaced by
another removable appliance which is simple hawley’s
with a midpalate jackscrew [Figure 2b]. This was to
further expand the maxilla and labial bow to align the
maxillary teeth. At this operative stage, the tooth material
and arch space discrepancy according to Carey's space
analysis was 1mm. This appliance was also activated
twice a week quarter turn for next 3 months, till the
desired result achieved [Figure 4a‑c].
Hence, the patient was asked to visit the department
every twice a week for activating the jackscrew a
quarter turn and the patient was instructed to wear the
appliance full-time (day and night) except for eating and
teeth cleaning. The patient was also instructed to clean
the appliance as well, and handle it gently, avoid holding
its wire extensions or edges while cleaning.
Upon treatment completion, the second appliance was
planned to replace as a retainer to ensure the stability of
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Bhati and Jabin: Management of unilateral anterior crossbite
a b
Figure 2: (a) Removable appliance 1. (b) Removable appliance 2
a b
c discrepancy is usually reduced to less than a full bilateral
Figure 3: (a) Crossbite correction after 3 months. (b) Study model after
3 months. (c) Maxillary study model after 3 months
a b
c for improved patient comfort and acceptance. Other
Figure 4: (a) Postoperative intaoral maxillary occlusion. (b) Postoperative
study model. (c) Postoperative study model
the corrected malocclusion. The parents consented to the
treatment plan. Follow up was done once in a month for
next 6 months. After 6 months retainer was removed and
the patient was recalled for follow-up after 3 months for
next 6 months.
Discussion
In cases of unilateral crossbite, determining the correct
treatment approach for each individual case is the key
74 Journal of Interdisciplinary Dentistry  ¦  Volume 7  ¦  Issue 2  ¦  May-August 2017
to treatment success and stability. The clinician must
first distinguish crossbites of dental origin from those
of skeletal origin. Dental crossbite involves localized
tipping of a tooth or teeth and does not involve the
basal bone.[7] Pseudo Class III malocclusion is another
example of dental anterior crossbite that needs to be
differentiated from sagittal skeletal discrepancies. It
involves retroclination of maxillary incisors that cause
the mandible to shift forward.[7] That is why treatment
of these cases should aim to correct maxillary incisor
inclination.[8]
The maxillary arch displayed an asymmetric shape due
to palatal tipping of the right central and lateral incisor.
The mesial and distal line angles of the respective
maxillary and mandibular left central incisors acted as a
guide plane during the development of the shift, resulting
in an axial tipping of these teeth. Therefore, treatment
was geared to alleviate the anterior crossbite first and
then control the remaining transverse discrepancy. It
should be noted that cases with symmetrical arches
could benefit from symmetric expansion even in the
presence of unilateral crossbite and mandibular shift.
In such cases, the amount of intermaxillary transverse
crossbite.
In regard to the bite plane, clear instructions should be
included to specify the thickness of the acrylic and the
amount of tooth separation. For the first appliance, an
acrylic thickness of 4  mm was specified  (i.e.,  barely
enough to disengage the anterior crossbite tooth).
Increased and unnecessary amounts of bite opening
may lead alteration of the vertical relationship and the
patient’s decreased compliance.
In general, the recommended activation frequency of
similar appliances is every second or third day.[9] In this
case, we followed a quarterly twice a week activation
protocol, which was found to be efficient and effective
in the management of this case. Activation every
3rd day is recommended during the 1st week of therapy
authors advocate activation twice a week and once a
week.[10]
The duration of treatment with removable appliances
is reported to range from 6 to 12 weeks.[9] With a
slower expansion rate, treatment can take up to 6 and
12 months.[10] The first and second appliance therapies
lasted for 3 months, respectively, which is in agreement
with the above‑mentioned range.
The Hawley retainer was used for 6 months. The
recommended retention period for similarly treated
cases is 4–6 months (or for a period at least equal to
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Bhati and Jabin: Management of unilateral anterior crossbite
that required for crossbite correction).[9] After being
out of retention for 4 months, the case demonstrated
good stability. Increased treatment time and cost
have been associated with the use of removable
appliances versus fixed  (e.g.,  quad‑helix) for crossbite
correction. Nevertheless, treatment of the present
case was confined to the expected treatment time and
matched the reported treatment duration using similar
removable appliances. This highlights the importance
of case selection and the necessity of enlisting patient
and parental compliance before the start of treatment.
In case of relapse, fixed orthodontics along with other
orthopedic appliance may be required to complete the
case.
Conclusions
A simple removable appliance for the correction of
anterior unilateral crossbite with functional shift was
presented. Thorough clinical assessment and accurate
diagnosis must be performed to plan proper treatment
strategies and appliance design. General practitioners
and pediatric dentists can utilize this technique to
manage cases with similar malocclusions.
Financial support and sponsorship
Nil.
Journal of Interdisciplinary Dentistry  ¦  Volume 7  ¦  Issue 2  ¦  May-August 2017
Conflicts of interest
There are no conflicts of interest.
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