Agostino Et Al-2014-Cochrane Database of Systematic Reviews

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Cochrane Database of Systematic Reviews

Orthodontic treatment for posterior crossbites (Review)
Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P
Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P.

Orthodontic treatment for posterior crossbites.
Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD000979.
DOI: 10.1002/14651858.CD000979.pub2.
www.cochranelibrary.com

Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
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TABLE OF CONTENTS
HEADER......................................................................................................................................................................................................... 1
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 8
OBJECTIVES.................................................................................................................................................................................................. 9
METHODS..................................................................................................................................................................................................... 9
RESULTS........................................................................................................................................................................................................ 11
Figure 1.................................................................................................................................................................................................. 12
Figure 2.................................................................................................................................................................................................. 15
DISCUSSION.................................................................................................................................................................................................. 18
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 19
ACKNOWLEDGEMENTS................................................................................................................................................................................ 19
REFERENCES................................................................................................................................................................................................ 20
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 22
DATA AND ANALYSES.................................................................................................................................................................................... 41
Analysis 1.1. Comparison 1 Fixed rapid (Haas) versus fixed rapid (Hyrax), Outcome 1 Molar expansion (3 months after completion 42
of expansion phase)..............................................................................................................................................................................
Analysis 2.1. Comparison 2 Fixed slow (quad-helix) versus removable slow (expansion plate), Outcome 1 Crossbite correction.... 42
Analysis 2.2. Comparison 2 Fixed slow (quad-helix) versus removable slow (expansion plate), Outcome 2 Molar expansion........ 42
Analysis 2.3. Comparison 2 Fixed slow (quad-helix) versus removable slow (expansion plate), Outcome 3 Canine expansion....... 43
ADDITIONAL TABLES.................................................................................................................................................................................... 43
APPENDICES................................................................................................................................................................................................. 46
WHAT'S NEW................................................................................................................................................................................................. 48
HISTORY........................................................................................................................................................................................................ 48
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 49
DECLARATIONS OF INTEREST..................................................................................................................................................................... 49
SOURCES OF SUPPORT............................................................................................................................................................................... 49
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 50
INDEX TERMS............................................................................................................................................................................................... 50
Orthodontic treatment for posterior crossbites (Review) i

Informed decisions.

[Intervention Review]
Orthodontic treatment for posterior crossbites
Paola Agostino1, Alessandro Ugolini2, Alessio Signori3, Armando Silvestrini-Biavati2, Jayne E Harrison4, Philip Riley5
1Private practice, Chiavari, Italy. 2Orthodontics Department, University of Genoa, Genoa, Italy. 3Unit of Biostatistics, Health Sciences
Department, University of Genoa, Genoa, Italy. 4Orthodontic Department, Liverpool University Dental Hospital, Liverpool, UK. 5Cochrane
Oral Health Group, School of Dentistry, The University of Manchester, Manchester, UK
Contact address: Alessandro Ugolini, Orthodontics Department, University of Genoa, Largo Rosanna Benzi 10, Genoa, 16132, Italy.
alexugolini@yahoo.it.
Editorial group: Cochrane Oral Health Group

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 8, 2014.
Citation: Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P. Orthodontic treatment for posterior crossbites.
Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD000979. DOI: 10.1002/14651858.CD000979.pub2.
ABSTRACT
Background
A posterior crossbite occurs when the top back teeth bite inside the bottom back teeth. When it affects one side of the mouth, the lower
jaw may have to move to one side to allow the back teeth to meet together. Several treatments have been recommended to correct this
problem. Some treatments widen the upper teeth while others are directed at treating the cause of the posterior crossbite (e.g. breathing
problems or sucking habits). Most treatments have been used at each stage of dental development. This is an update of a Cochrane review
first published in 2001.
Objectives
To assess the effects of orthodontic treatment for posterior crossbites.
Search methods
We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 21 January 2014), the Cochrane
Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1), MEDLINE via OVID (1946 to 21 January 2014), and
EMBASE via OVID (1980 to 21 January 2014). We searched the US National Institutes of Health Trials Register and the World Health
Organization (WHO) Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication
when searching the electronic databases.
Selection criteria
Randomised controlled trials (RCTs) of orthodontic treatment for posterior crossbites in children and adults.
Data collection and analysis

Two review authors, independently and in duplicate, screened the results of the electronic searches, and extracted data and assessed
the risk of bias of the included studies. We attempted to contact the first named authors of the included studies for missing data and for
clarification. We used risk ratios (RR) and 95% confidence intervals (CIs) to summarise dichotomous (event) data, and mean differences
(MD) with 95% CIs to summarise continuous data. We performed meta-analyses using fixed-effect models (we would have used random-
effects models if we had included four or more studies in a meta-analysis) when comparisons and outcomes were sufficiently similar.
Main results
We included 15 studies, of which two were at low risk of bias, seven were at high risk of bias and six were unclear.
Fixed appliances with mid-palatal expansion
Orthodontic treatment for posterior crossbites (Review) 1

Informed decisions.

Nine studies tested fixed appliances with mid-palatal expansion against each other. No study reported a difference between any type of
appliance.
Fixed versus removable appliances
Fixed quad-helix appliances may be 20% more likely to correct crossbites than removable expansion plates (RR 1.20; 95% CI 1.04 to 1.37;
two studies; 96 participants; low-quality evidence).
Quad-helix appliances may achieve 1.15 mm more molar expansion than expansion plates (MD 1.15 mm; 95% CI 0.40 to 1.90; two studies;
96 participants; moderate-quality evidence).
There was insufficient evidence of a difference in canine expansion or the stability of crossbite correction.
Very limited evidence showed that both fixed quad-helix appliances and removable expansion plates were superior to composite onlays
in terms of crossbite correction, molar and canine expansion.
Other comparisons
Very limited evidence showed that treatments were superior to no treatment, but there was insufficient evidence of a difference between
any active treatments.
Authors' conclusions
There is a very small body of low- to moderate-quality evidence to suggest that the quad-helix appliance may be more successful than
removable expansion plates at correcting posterior crossbites and expanding the inter-molar width for children in the early mixed dentition
(aged eight to 10 years). The remaining evidence we found was of very low quality and was insufficient to allow the conclusion that any
one intervention is better than another for any of the outcomes in this review.
PLAIN LANGUAGE SUMMARY
Orthodontic treatment for posterior crossbites
Review question
We conducted this review to assess the effects of different orthodontic treatments for correcting posterior crossbites.
Background
Posterior crossbite is when the top back teeth bite down inside the bottom back teeth. It occurs when the top teeth or jaw are narrower
than the bottom teeth and can happen on one or both sides of the mouth. The condition affects between 1% and 16% of children who
only have their baby teeth. Most posterior crossbites (50% to 90%) remain even when the permanent teeth erupt. In a minority of children,
the problem self corrects.
In order to obtain a more comfortable bite, the lower jaw shifts to one side into a position that allows more teeth to come into contact.
However, this shifting of the lower jaw may lead to tooth grinding, and this may lead to other dental problems including the tooth surface
being worn away, abnormal growth and development of the teeth and jaws, and jaw joint problems.
Therefore, we need to find safe and effective treatments to correct posterior crossbites or expand the top back teeth, or both. One way of
doing this is using orthodontic treatments. This can be more effective in children because the two halves of the roof of the mouth have not
fully joined yet, so the top back teeth can be expanded more easily. Orthodontic treatments can also be used to treat posterior crossbites
in adults, but they are more likely to need surgical treatments, which are not the focus of this review.
Study characteristics
Authors from the Cochrane Oral Health Group carried out this review update of existing studies and the evidence is current up to 21 January
2014. It includes 15 studies published from 1984 to 2013. Nine of these studies compared fixed (always in the mouth) appliances either
against different fixed appliances, or against the same fixed appliance but comparing different rates of expansion. Two studies compared
a fixed appliance with a removable appliance. The remaining four studies evaluated other comparisons that were more difficult to classify.
Key results
There is some evidence to suggest that the quad-helix (fixed) appliance may be more successful than removable expansion plates at
correcting posterior crossbites and expanding the top back teeth for children with a mixture of baby and adult teeth (aged eight to 10
years). The remaining evidence we found did not allow the conclusion that any one treatment is better than another.
Quality of the evidence

Informed decisions.

The evidence presented is mostly of low to very low quality due to the small amount of available studies and issues with the way in which
they were conducted.

SUMMARY OF FINDINGS

Summary of findings for the main comparison. Fixed appliances compared with other fixed appliances for treating posterior crossbites
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Fixed appliances compared with other fixed appliances for treating posterior crossbites
Patient or population: Children with posterior crossbites (adults would be included in the review but no studies with adults were found)
Settings: Typically university orthodontic/dental clinics
Better health.
Informed decisions.
Trusted evidence.
Intervention: Fixed appliance
Comparison: The same fixed appliance attached differently or expanded at different speeds or a different fixed appliance
Outcomes Illustrative comparative risks Relative ef- No of partici- Quality of the Comments
(95% CI) fect pants evidence
(95% CI) (studies) (GRADE)
Assumed risk Correspond-
ing risk
Group A Group B
Molar expansion N/A N/A N/A 53 ⊕⊝⊝⊝ 2 studies (1 high risk of bias; 1 unclear), which were
(2) very low not possible to pool in a meta-analysis due to no re-
(mm) porting of variance in 1 study. Imprecision due to
low sample sizes. Different timings of follow-up after
(rapid expansion) banded
completion of expansion. Both studies reported no
Hyrax (tooth borne) versus
difference in molar expansion
bonded Hyrax (tooth/tis-
sue borne)
Molar expansion The mean The mean ex- N/A 27 ⊕⊝⊝⊝ 2 studies at unclear risk of bias with serious inconsis-
expansion pansion in the (2) very low tency (I2 = 94%) and imprecision due to low sample
(mm) ranged across Hyrax groups size

the Haas was
(3 months after completion
groups from 0.7 mm lower
of expansion phase)
6.5 to 8.49 (1.66 lower to
(rapid expansion) tooth- mm 0.25 higher)
tissue borne (Haas) versus
tooth borne (Hyrax)
N/A N/A N/A N/A N/A N/A The remaining comparisons were all single stud-
ies (Additional Table 1). The quality of the evidence
(GRADE) for all comparisons and outcomes in Ad-
ditional Table 1 is ⊕⊝⊝⊝ very low (all at unclear or
4

high risk of bias with imprecision due to low sample
sizes). None of these studies showed a statistically
significant difference for any outcome
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CI: confidence interval; N/A: not applicable.
GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Better health.
Informed decisions.
Trusted evidence.
Very low quality: We are very uncertain about the estimate.

Summary of findings 2. Fixed appliances compared with removable appliances for treating posterior crossbites
Fixed appliances compared with removable appliances for treating posterior crossbites
Settings: Public Dental Health Service and university orthodontic/dental clinics
Intervention: Fixed appliance
Comparison: Removable appliance
Outcomes Illustrative comparative risks* (95% CI) Relative ef- No of partici- Quality of the Comments
fect pants evidence
Assumed risk Corresponding risk (95% CI) (studies) (GRADE)
Removable - slow Fixed - slow expansion

expansion (expan- (quad-helix)
sion plate)

Crossbite correc- 833 per 1000 1000 per 1000 RR 1.2 (1.04 96 ⊕⊕⊝⊝ 2 studies at low risk of bias, but with seri-
tion (867 to 1000) to 1.37) (2) low ous inconsistency (I2 = 68%) and impreci-
sion due to low sample size
(Follow-up after
retention period,
therefore, it was vari-
able)
Molar expansion The mean expansion The mean expansion N/A 96 ⊕⊕⊕⊝ 2 studies at low risk of bias, but with im-
ranged across the re- in the fixed appliance (2) moderate precision due to low sample size
(mm) movable appliance group was
5

(Follow-up after groups from 3.09 to 1.15 mm higher
retention period, 3.5 mm (0.4 to 1.9 higher)
therefore, it was vari-
able)
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Canine expansion The mean expansion The mean expansion N/A 96 ⊕⊕⊝⊝ 2 studies at low risk of bias, but with seri-
ranged across the re- in the fixed appliance (2) low ous inconsistency (I2 = 91%) and impreci-
(mm) movable appliance group was sion due to low sample size
groups from 1.43 to 0.19 mm higher
(Follow-up after
Better health.
Informed decisions.
Trusted evidence.
2.7 mm (0.47 lower to 0.85 high-
retention period,
er)
therefore it was vari-
able)
N/A N/A N/A N/A N/A N/A 1 of the 2 studies in this comparison al-
so measured stability of crossbite correc-
tion (relapse 12 months after correction).
No statistically significant difference was
found (Additional Table 2)
The other study also compared the fixed

and removable appliances to composite
onlays for crossbite correction, molar ex-
pansion and canine expansion. All results
were statistically significant in favour of
fixed and removable appliances (Addition-
al Table 2)
The quality of the evidence (GRADE) for all

comparisons and outcomes in Additional
Table 2 is ⊕⊝⊝⊝ very low
*The basis for the assumed risk is the removable group event rate. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the compari-
son group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; N/A: not applicable; RR: risk ratio.


6

Summary of findings 3. Other comparisons for treating posterior crossbites
Other comparisons for treating posterior crossbites
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Settings: Public Dental Health Service and university/hospital orthodontic/dental clinics
Outcomes Illustrative comparative risks Relative ef- No of partici- Quality of the Comments
(95% CI) fect pants evidence
Better health.
Informed decisions.
Trusted evidence.
(95% CI) (studies) (GRADE)
Assumed risk Correspond-
ing risk
Group A Group B
N/A N/A N/A N/A N/A N/A The comparisons were all single studies (Additional Table 3). The
quality of the evidence (GRADE) for all comparisons and outcomes
in Additional Table 3 is ⊕⊝⊝⊝ very low (all at high risk of bias with
imprecision due to low sample sizes)
• 1 study compared a removable appliance with spring-loaded

screw against a conventional screw but the results were inade-
quately reported
• 1 study compared quad-helix plus multi-bracket against expan-
sion arch plus multi-bracket for molar/canine expansion with no
statistically significant results
• The final 2 studies showed statistically significant results against
no treatment for fixed bonded Hyrax appliance followed by U-
bow activator (molar/canine expansion), and for grinding or
grinding plus expansion plate (crossbite correction)


CI: confidence interval; N/A: not applicable.

7

Informed decisions.

BACKGROUND (upper jaw) arch, removal of any occlusal interferences and

elimination of the functional displacement of the mandible.
Description of the condition
Maxillary expansion treatment initiated during the early mixed
Posterior crossbite is the term used to describe the situation dentition stage (children younger than eight years of age) may
when the top back teeth bite inside the bottom back teeth. A require the use of lower forces to achieve expansion of the upper
posterior crossbite occurs when the top teeth or jaw are narrower arch because the mid-line bony suture has not yet fused. However,
than the bottom teeth and can happen on one (unilateral) or obtaining co-operation with treatment may be more difficult in
both (bilateral) sides of the mouth. The prevalence of posterior younger children and treatment may be complicated by the loss
crossbites is between 1% and 16% of children who only have their of deciduous teeth. In older children (aged 12 years and above)
baby teeth, and is likely to be higher in white populations compared who are in the early permanent dentition, greater forces may
with children of African or Asian ethnicity (Malandris 2004). Most be required to achieve maxillary expansion. Maxillary expansion
posterior crossbites (50% to 90%) persist when the permanent can be achieved using either fixed or removable appliances and
teeth erupt, though, in a minority of children, the malocclusion self expansion can be either rapid or slow. Expansion of the top jaw
corrects. is termed 'rapid' when expansion takes place at a rate of 0.5 mm
per day, and 'slow' when expansion takes place at a rate of 0.5 mm
A functional posterior crossbite occurs when there is an
per week. Braces that can bring about this expansion are fixed to
interference between two or more teeth when an individual closes
the back teeth by either metal bands around the individual teeth
their jaws together. In order to obtain a more comfortable bite, the
(banded rapid/slow maxillary expansion) or acrylic splints over
mandible (lower jaw) shifts to one side into a position that allows
several teeth (bonded rapid/slow maxillary expansion) joined by
more teeth to come into contact. However, this displacement may
a wire framework attached to a screw in the mid-line that can be
increase the likelihood of the individual developing bruxism (tooth
opened to expand the top jaw.
grinding), which may lead to other dental problems including the
tooth surface being worn away (Malandris 2004), abnormal growth Removal of occlusal interferences involves grinding of teeth
and development of the teeth and jaws, and jaw joint problems. (usually deciduous teeth) to enable the jaws to bite together in a
more normal position. The reported success rate of this approach
While it is unlikely that young children with a posterior crossbite
varied widely between 27% and 64% (Kennedy 2005; Lindner 1989).
will experience any pain or have problems with chewing, there
Alternatively, composite onlays can be placed to prevent the jaw
has been concern that the abnormal movement of the lower
from shifting when interferences exist.
jaw associated with a crossbite could potentially have long-term
effects on the growth and development of the teeth and jaws. Where functional displacement of the mandible is associated with
The strain on the jaw muscles and joints due to the abnormal reversible causes such as non-nutritive sucking habits (sucking on
movement and position of the lower jaw may lead to skeletal facial a dummy, thumb, finger(s), etc.), eliminating the causal behaviour
asymmetries that can be corrected during adulthood only by means is a desirable adjunct to orthodontic treatment.
of a combination of orthodontics and maxillofacial surgery.
How the intervention might work
Some studies have reported a correlation between posterior
crossbite with a shift on closure and temporomandibular joint Expansion of the maxillary arch can be achieved through use
problems in later life, for example pain, clicking or locking of of either fixed or removable appliances (see Appendix 1 for a
the jaw joints. Such problems have many causes but studies of description of appliances). These have expansion screws that are
teenagers and adults have shown that some people with a crossbite adjusted during treatment to increase the width of the maxillary
may have an increased risk of developing jaw joint problems and arch. Expansion may be either rapid (one-quarter turn of the
show more signs and symptoms of these problems (Egermark expansion screw one or two times per day, giving 0.5 mm expansion
1990; McNamara 1997; Ninou 1994; O'Bryn 1995; Pullinger 1993). per day) over two to six weeks or slow (one-quarter turn twice per
However, some more recent studies have been less conclusive week, giving 0.5 mm expansion per week) over six to 12 weeks.
regarding an association between posterior crossbites and jaw Overexpansion may be appropriate to allow for some relapse after
problems (Gesch 2004; Iodice 2013; Thilander 2002; Thilander the appliance is removed. The use of maxillary expansion at the
2012). stage of the early mixed dentition may also have the benefit of
reducing crowding of the permanent dentition.
A posterior crossbite may develop or improve at any time from
when the deciduous (baby) teeth come into the mouth to when the Orthodontic appliances may also be used to correct the sideways
permanent (adult) teeth come through (Heikinheimo 1987; Kurol displacement of the mandible, which may reduce the pressure on
1992; Leighton 1966; Thilander 1984). It is unclear what causes the temporomandibular joint.
posterior crossbites but they may be due to skeletal, soft tissue,
dental or respiratory factors, or develop as the result of a habit (e.g. Why it is important to do this review
thumb sucking) or some pathology (Bresolin 1983; Cheng 1988; A crossbite is a common transverse feature seen in malocclusions
Modeer 1982; Ogaard 1994; Subtelny 1980). in the posterior region of the dental arch. There is still debate
about the optimum timing of orthodontic treatment, the use of
Description of the intervention either fixed or removable appliances, and the type of appliance that
As described above, a posterior crossbite may self correct but, leads to the best outcomes for the person. This updated systematic
as self correction occurs in only a very small minority of cases, review will summarise the evidence available from randomised
treatment of this malocclusion can be recommended. Treatment controlled trials to inform treatment decision making. The
of a posterior crossbite usually involves expansion of the maxillary Cochrane Oral Health Group recently carried out a prioritisation
Informed decisions.

exercise for their portfolio of orthodontic reviews, and this review March 2011) (Higgins 2011). Details of the MEDLINE search are
was ranked in the top 10 most important orthodontic reviews by provided in Appendix 2. The search of EMBASE was linked to the
an international panel of oral health professionals, the majority of Cochrane Oral Health Group filter for identifying RCTs.
whom were extremely experienced and internationally renowned
orthodontists. Electronic searches
We searched the following electronic databases:
This is an update of a Cochrane review first published in 2001.
• the Cochrane Oral Health Group's Trials Register (to 21 January
OBJECTIVES 2014) (Appendix 3);
To assess the effects of orthodontic treatment for posterior • the Cochrane Central Register of Controlled Trials (CENTRAL)
crossbites. (The Cochrane Library, 2014, Issue 1) (Appendix 4);
• MEDLINE via OVID (1946 to 21 January 2014) (Appendix 2)
METHODS • EMBASE via OVID (1980 to 21 January 2014) (Appendix 5).
Criteria for considering studies for this review We manually checked all the references lists of the included studies
Types of studies to identify any additional studies.
We included randomised controlled trials (RCTs) of parallel design We placed no restrictions on the language or date of publication
that assessed orthodontic treatments to correct a posterior when searching the electronic databases.
crossbite or expand the top back teeth, or both. We included studies
irrespective of language or publication status. Searching other resources
We searched the following databases for ongoing trials (see
Types of participants
Appendix 6 for the search strategy):
We included RCTs of children and adults with a posterior crossbite,
without a Class III skeletal relationship, cleft lip or palate (or both) • US National Institutes of Health Trials Register (clinicaltrials.gov)
or other syndrome associated with craniofacial anomalies. (to 21 January 2014);
• The WHO Clinical Trials Registry Platform (apps.who.int/
Types of interventions trialsearch/default.aspx) (to 21 January 2014).
We included studies of any orthodontic or dentofacial orthopaedic We handsearched the following journals from 1970 to 2012:
(not surgical) treatment used to correct posterior crossbites or
expand the top back teeth, or both, when compared against • European Journal of Orthodontics;
another such treatment or no treatment. • American Journal of Orthodontics and Dentofacial Orthopedics;
Types of outcome measures • Orthodontics and Craniofacial Research;
• The Angle Orthodontist.
Primary
• Correction of the posterior crossbite. In the previous version of this review we also handsearched:
Secondary • British Journal of Orthodontics;

• Journal of Orthodontics.
• Expansion of the upper jaw/teeth measured as changes in the
width between the molars or canines, or both. We also searched personal references. We contacted the
• Stability of crossbite correction. investigators of the included studies by email to ask for additional
• Signs and symptoms of temporomandibular joint dysfunction details of their trials and for any information they may have about
(e.g. pain, clicking, locking of the jaw joints, problems eating). any further published and unpublished trials.
• Signs and symptoms of respiratory disease (e.g. mouth Data collection and analysis
breathing, nasal airway resistance).
• Quality of life (using any validated measurement tool). Selection of studies
Two review authors screened the titles and abstracts of the
Search methods for identification of studies results of the searches, independently and in duplicate. We
For the identification of studies included or considered for this obtained full-text copies of all studies that appeared to meet
review, we developed detailed search strategies for each database the inclusion criteria, and of all those that were unclear due
searched. These were based on the search strategy developed to insufficient information in the title or abstract, or both. Two
for MEDLINE (OVID) but revised appropriately for each database. review authors assessed the full-text papers independently and in
The search strategy used a combination of controlled vocabulary duplicate in order to ensure that they met the inclusion criteria.
and free-text terms and was linked with the Cochrane Highly We contacted study authors for clarification or missing information
Sensitive Search Strategy (CHSSS) for identifying RCTs in MEDLINE: where necessary and possible. We resolved any disagreements by
sensitivity maximising version (2008 revision) as referenced in discussion. A member of The Cochrane Collaboration translated
Chapter 6.4.11.1 and detailed in box 6.4.c of the Cochrane Handbook any non-English language studies. We recorded any studies that did
for Systematic Reviews of Interventions Version 5.1.0 (updated not meet the inclusion criteria at this stage, along with the reasons,
in the Characteristics of excluded studies table.
Informed decisions.

Data extraction and management • Unclear risk of bias (plausible bias that raises some doubt about
the results) if one or more key domains were assessed as at
Two review authors extracted data from the included studies,
unclear risk of bias.
independently and in duplicate, using a piloted data extraction
form. We resolved any disagreements through discussion. We • High risk of bias (plausible bias that seriously weakens
contacted study authors for clarification or missing information confidence in the results) if one or more key domains were
where necessary and possible. assessed as at high risk of bias.
We entered the following extracted data into the Characteristics of We have presented the results of our risk of bias assessments
included studies table. graphically.
• Study design, location, number of centres, recruitment period, Measures of treatment effect
funding, experience level of clinician. For dichotomous outcomes (e.g. posterior crossbite corrected
• Inclusion and exclusion criteria, age, gender, number of or not), we expressed the estimate of treatment effect as risk
participants randomised to each group, number of participants ratios (RR) with 95% confidence intervals (CI). For continuous
evaluated. outcomes (e.g. width between the molars), we used the means and
• Details of the type of intervention/comparator, timing, duration. standard deviations (SD) reported in the studies to calculate mean
• Details of the outcomes reported, including method of differences (MD) with 95% CIs.
assessment, and time(s) assessed.
Dealing with missing data
• Sample size calculations, any other notable details.
Where possible, we attempted to contact the author(s) of studies to
Assessment of risk of bias in included studies obtain missing data or for clarification. We performed the analyses
using only the available data (ignoring missing data); however, we
Two review authors assessed the risk of bias of each included
intended to use methods for estimating missing SDs as described
study, independently and in duplicate, following the domain-based
in Section 7.7.3 of the Cochrane Handbook for Systematic Reviews
two-part tool described in the Cochrane Handbook for Systematic
of Interventions (Higgins 2011), if appropriate. We did not use any
Reviews of Interventions (Higgins 2011). We contacted study
further statistical methods or carry out any further imputation to
authors for clarification or missing information where necessary
account for missing data.
and possible. We compared our assessments and discussed and
resolved any inconsistencies between the review authors. Assessment of heterogeneity
We assessed the following six domains of risk of bias for each Where meta-analyses were performed, we assessed heterogeneity
included study. by visual inspection of the forest plots. If there was a lack of overlap
of the CIs, we considered heterogeneity to be present. We assessed
• Random sequence generation (selection bias). heterogeneity statistically by means of a Chi2 test, where a P value
• Allocation concealment (selection bias). < 0.1 indicated statistically significant heterogeneity. We quantified
• Blinding of outcome assessment (detection bias). heterogeneity using the I2 statistic. An approximate guide to the
• Incomplete outcome data (attrition bias). interpretation of the I2 statistic given in the Cochrane Handbook
• Selective reporting (reporting bias). for Systematic Reviews of Interventions is: 0% to 40% might not be
important; 30% to 60% may represent moderate heterogeneity;
• Other bias.
50% to 90% may represent substantial heterogeneity and 75% to
We did not consider the blinding of participants and personnel 100% may represent considerable heterogeneity (Higgins 2011).
(performance bias) as the interventions being compared in all
Assessment of reporting biases
studies were different and it would not have been possible to
blind them as to which group they were allocated. Therefore, a We have already described the assessment of within-study
risk of performance bias is possible in all of the included studies. reporting bias in the section Assessment of risk of bias in included
However, it should be possible for outcome assessors to be blinded studies.
if measuring casts/models or radiographs or both, if the appliances
had been removed. Therefore, we focused on assessing the risk of In order to assess reporting biases that can occur when the
detection bias. publishing (or not publishing) of research findings is related to
the results (e.g. a study with a non-significant result may not be
We completed a 'Risk of bias' table for each included study. For published), we would have created a funnel plot to check for
each of the above domains, we described what was reported to asymmetry (Egger 1997; Higgins 2011), provided there were more
have happened in the study and this formed the rationale for our than 10 studies in a meta-analysis.
corresponding judgement of 'low risk' of bias, 'high risk' of bias or
'unclear risk' of bias for each domain. Data synthesis
We only carried out a meta-analysis when studies of similar
We categorised overall risk of bias in any included study according
comparisons reported the same outcomes. We combined MDs for
to the following.
continuous outcomes, and RRs for dichotomous outcomes, using
• Low risk of bias (plausible bias unlikely to seriously alter the a fixed-effect model when there were fewer than four studies, or a
results) if all key domains were assessed as at low risk of bias. random-effects model when there were four or more studies. We
summarised single-study comparisons in additional tables.

Informed decisions.

Subgroup analysis and investigation of heterogeneity evidence of each of the main outcomes for each comparison as
high, moderate, low or very low.
In future updates, if sufficient data are available for each
comparison and outcome, we will conduct subgroup analyses RESULTS
according to age, gender and the degree of severity of maxillary
transversal deficiency. Description of studies
Sensitivity analysis Results of the search
In future updates, if sufficient data are available for each The electronic searches retrieved 779 references to studies. After
comparison and outcome, we will assess the robustness of the removing duplicates, this was reduced to 515. We obtained two
results by excluding studies at high and unclear risk of bias from the additional reports through other sources. After examination of the
meta-analyses. titles and abstracts of these references, we discarded all but 33
with no further assessment. We obtained full-text copies of these
Presentation of main results potentially relevant studies and we excluded 16 of them at this
We produced 'Summary of findings' tables following GRADE stage (17 references). However, we did not record 14 (15 references)
methods (GRADE 2004), and using GRADEPro software. We assessed of these in the table of excluded studies, as they were clearly not
the quality of the body of evidence by considering the overall risk eligible upon examining the full text. We linked two of the remaining
of bias of the included studies, the directness of the evidence, the 16 articles together under a single study reference. Therefore, 15
inconsistency of the results, the precision of the estimates and the studies met the inclusion criteria for this review. This process is
risk of publication bias. We categorised the quality of the body of presented as a flow chart in Figure 1.


Informed decisions.

Figure 1. Study flow diagram.

Informed decisions.

Included studies Kilic 2008; Lagravere 2010; Lamparski 2003; Oliveira 2004), one
study compared two different fixed appliances for slow palatal
Characteristics of the trial design and setting
expansion (Mossaz-Joelson 1989), and two studies compared the
Fifteen studies met the inclusion criteria and were included in this effects of fixed appliances used for differing rates of expansion
review (see Characteristics of included studies tables). (Martina 2012; Ramoglu 2010).
All studies, by necessity, were of parallel design. Nine studies Two studies compared a fixed appliance with a removable
(Asanza 1997, USA; Garib 2005, Brazil; Kilic 2008, Turkey; Lagravere appliance for slow expansion (Godoy 2011; Petrén 2008), and the
2010, Canada; Lippold 2013, Germany; Martina 2012, Italy; Mossaz- remaining studies evaluated other comparisons that were more
Joelson 1989, Switzerland; Oshagh 2012, Iran; Ramoglu 2010, difficult to classify (see below) (Lippold 2013; McNally 2005; Oshagh
Turkey) were carried out in university orthodontics departments. 2012; Thilander 1984).
One of these studies stated that the clinicians were two specialist
orthodontists (Lippold 2013), but in the remaining eight studies See Appendix 1 for a description of appliances.
it was unclear who the clinicians undertaking the treatment
1. Fixed appliance with mid-palatal expansion
were and what experience or qualifications they had. There
were three multicentre studies: one was carried out in a general Rapid expansion
hospital and a university dental hospital in the UK by experienced • Banded Hyrax (tooth borne) versus bonded Hyrax (tooth/tissue
orthodontists (McNally 2005); one was carried out in two public borne) (Asanza 1997; Kilic 2008).
dental health service clinics and one university orthodontic
• Tooth-tissue borne Haas versus tooth borne Hyrax (Garib 2005;
department in Sweden by experienced general practitioners under
Oliveira 2004).
the supervision of specialist orthodontists (Petrén 2008); and
one study was carried out in three university orthodontic clinics • Hyrax tooth-borne expander versus bone-anchored expander
and one private practice in Brazil, but it was unclear who the (Lagravere 2010).
clinicians undertaking the treatment were and what experience or • Four-point banded (Hyrax) versus two-point banded (Hyrax)
qualifications they had (Oliveira 2004). One study took place in a (Lamparski 2003).
basic dental unit in Brazil, conducted by the local university, with
Slow expansion
treatment carried out by one specialist orthodontist with over 10
years of experience (Godoy 2011). Participants in another study • Bonded Minne versus banded Minne appliances (Mossaz-
were treated in a private orthodontic practice in the USA by a Joelson 1989).
board-certified orthodontist with 27 years of experience (Lamparski
2003). The remaining study was carried out in Sweden by the public Different rates of expansion
dental health service, but the experience of the orthodontist was • Slow versus rapid expansion (two-band palatal expanders)
not reported (Thilander 1984). (Martina 2012).
Characteristics of the participants • Semi-rapid versus rapid expansion (splint type tooth- and
tissue-borne modified bonded appliances) (Ramoglu 2010).
Seven studies enrolled participants with either a unilateral or
bilateral crossbite malocclusion (Garib 2005; Martina 2012; McNally 2. Fixed versus removable
2005; Mossaz-Joelson 1989; Oliveira 2004; Petrén 2008; Ramoglu Slow expansion
2010), two studies included only participants with a unilateral
crossbite (Godoy 2011; Lippold 2013), two studies included only • Quad-helix versus expansion plate (Godoy 2011; Petrén 2008).
participants with a bilateral crossbite (Kilic 2008; Oshagh 2012),
3. Other comparisons
while the remaining four studies did not specify the type of
crossbite that participants presented with at study entry (Asanza • Early treatment with fixed bonded Hyrax appliance followed by
1997; Lagravere 2010; Lamparski 2003; Thilander 1984). U-bow activator therapy versus no treatment (Lippold 2013).
• Grinding - occlusal grinding in the primary dentition (aged
One study enrolled only children in the permanent dentition (Garib five years old) with/without an upper removable expansion
2005), two studies enrolled only children in the mixed dentition appliance in the mixed dentition versus no treatment (Thilander
(Godoy 2011; Petrén 2008), four studies enrolled children in either 1984).
the mixed or permanent dentition (Lamparski 2003; Martina 2012;
Oliveira 2004; Ramoglu 2010), one study enrolled children in either Slow expansion
the late deciduous or early mixed dentition (Lippold 2013), and
seven studies did not state the stage of dental development of the • Quad-helix plus multi-bracket versus expansion arch plus multi-
children at study entry (Asanza 1997; Kilic 2008; Lagravere 2010; bracket (McNally 2005).
McNally 2005; Mossaz-Joelson 1989; Oshagh 2012; Thilander 1984). • Conventional mid-line expansion screw versus spring-loaded
expansion screw (Oshagh 2012).
The age range of participants was from five to 16 years old
with variations between studies, but almost homogeneous within Characteristics of the outcomes
individual studies. The primary outcome of this review, correction of the posterior
crossbite, was reported by three studies (Godoy 2011; Petrén 2008;
Characteristics of the interventions and comparisons
Thilander 1984). In 11 studies, the correction of crossbite is taken
Six of the included studies evaluated two different types of fixed for granted because it was the end point of the treatment and the
appliances for rapid palatal expansion (Asanza 1997; Garib 2005; point at which activation of the appliances ceased (Asanza 1997;
Informed decisions.

Garib 2005; Kilic 2008; Lagravere 2010; Lamparski 2003; Lippold Excluded studies
2013; Martina 2012; McNally 2005; Oliveira 2004; Oshagh 2012;
We excluded two studies from this review. One of these studies
Ramoglu 2010). In the remaining study, no data were provided on
was excluded because it included a subset of participants from one
whether the expansion obtained by these appliances did correct
of the included studies (Petrén 2008), plus other participants and
the participants' crossbite (Mossaz-Joelson 1989).
matched controls (Petrén 2011). The other study was excluded after
All included studies, with the exception of Thilander 1984, reported attempting to contact the authors because the participants were
expansion of the upper jaw/teeth measured as changes in the only described as having maxillary deficiency, rather than crossbite
width between the molars or canines (or both). Two studies (Weissheimer 2011).
assessed stability of crossbite correction (Godoy 2011; Mossaz-
Joelson 1989). Risk of bias in included studies
We have based our assessment of risk of bias on the reports of
None of the included studies reported any of the other outcomes of the included studies because we could not access copies of the
this review. study protocols. Where the reports were unclear on aspects of the
methodology, we attempted to contact the study authors to obtain
clarification or missing information. We present the results of our
risk of bias assessment graphically in Figure 2.


Informed decisions.

Figure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.


Informed decisions.

Figure 2. (Continued)

Allocation them as to which group they were allocated. Therefore, a risk of
performance bias is possible in all of the included studies.
Sequence generation
Seven studies described adequate methods of sequence However, it would have been possible for an independent
generation and we judged them to be at low risk of bias for blinded person to perform the clinical, model and radiographic
this domain: three used a table of random numbers (Lagravere assessments. Therefore, we have focused on whether the included
2010; Oliveira 2004; Oshagh 2012); two used block randomisation studies minimised the possible effects of detection bias.
(Lippold 2013; Martina 2012); one used a method of drawing lots
Three studies clearly stated that the measurement of outcomes was
(Godoy 2011); and the remaining study used a similar method
blinded, so we judged these studies to be at low risk of detection
involving opaque sealed envelopes (Petrén 2008).
bias (Godoy 2011; Martina 2012; Petrén 2008).
One study used random number tables to allocate the first half of
The remaining 12 studies did not mention blinding, even though it
the participants and then allocated the remaining half to receive
was feasible that it could have occurred, and, therefore, we judged
the alternative treatment to those in the initial allocation (McNally
these studies to be at unclear risk of bias for this domain.
2005). Therefore, only half the participants were truly randomly
allocated and we judged this study to be at high risk of bias for this Incomplete outcome data
domain.
We judged eight studies to be at low risk of attrition bias as they
The remaining seven studies stated only that participants were either clearly described drop-outs (which were for similar reasons
randomly allocated and we were unable to obtain further details and in similar numbers per group), or the numbers of participants
from the authors, so we judged these studies to be at unclear risk of stated in the analyses were the same as those randomised, or
bias for this domain (Asanza 1997; Garib 2005; Kilic 2008; Lamparski an intention-to-treat analysis included all randomised participants
2003; Mossaz-Joelson 1989; Ramoglu 2010; Thilander 1984). (Asanza 1997; Godoy 2011; Kilic 2008; Lippold 2013; McNally 2005;
Oliveira 2004; Petrén 2008; Ramoglu 2010).
Allocation concealment
One study clearly described the numbers and reasons for drop-out
Four studies described adequate methods of allocation
but the high attrition rate (48% per group) meant that, if the missing
concealment and we judged them to be at low risk of bias for this
participants had higher mean scores in one group than the other,
domain (Godoy 2011; Martina 2012; Oliveira 2004; Petrén 2008).
as the attrition rate increased, so would over/understatement of
The method of sequence generation carried out in one study, as the mean difference (Martina 2012). In another study, the attrition
described above, would allow for the prediction of the allocation of rate was very different between the treated group (3%) and the
half of the participants, and therefore we judged this study to be at untreated group (18%) (Thilander 1984). Therefore, we judged
high risk of bias for this domain (McNally 2005). these two studies to be at high risk of attrition bias.
The remaining 10 studies did not mention any method of allocation The remaining five studies did not report whether or not there
concealment, so we judged these studies to be at unclear risk of were any drop-outs and it was unclear how many participants were
bias for this domain (Asanza 1997; Garib 2005; Kilic 2008; Lagravere included in the outcome assessment. Therefore, we judged these
2010; Lamparski 2003; Lippold 2013; Mossaz-Joelson 1989; Oshagh studies to be at unclear risk of attrition bias (Garib 2005; Lagravere
2012; Ramoglu 2010; Thilander 1984). 2010; Lamparski 2003; Mossaz-Joelson 1989; Oshagh 2012).
Blinding of outcome assessment (detection bias) Selective reporting
We did not consider the blinding of participants and personnel Eleven studies reported all outcome measures described in the
(performance bias) as the interventions being compared in all corresponding methods sections in full and we assessed them as
studies were different and it would not have been possible to blind being at low risk of reporting bias (Garib 2005; Godoy 2011; Kilic
2008; Lagravere 2010; Martina 2012; McNally 2005; Mossaz-Joelson
1989; Oliveira 2004; Petrén 2008; Ramoglu 2010; Thilander 1984).
Informed decisions.

We judged the remaining four studies to be at high risk of reporting No other outcomes of the review were assessed in this comparison.
bias for the following reasons: no measure of variance reported
(Asanza 1997; Lippold 2013); one outcome was not reported by Hyrax tooth-borne expander versus bone-anchored expander
group and the other was reported without a measure of variance One study at unclear risk of bias, analysing no more than 41
(Lamparski 2003); and the results were so inadequately reported participants (unclear attrition), assessed molar expansion at six
that we were unable to use any data (Oshagh 2012). and 12 months after completion of the expansion phase (Lagravere
2010). There were no statistically significant differences at either
Other potential sources of bias time point (Additional Table 1).
In one study, there were imbalances between the treatment groups
in terms of numbers of participants and gender, possibly indicating No other outcomes of the review were assessed in this comparison.
a problem with the randomisation (Oshagh 2012). We assessed this Four-point banded (Hyrax) versus two-point banded (Hyrax)
study as being at high risk of bias for this domain. We did not
identify any other potential sources of bias in any of the remaining One study at high risk of bias, analysing no more than
14 studies and, therefore, we judged them to be at low risk of bias 30 participants (unclear attrition), assessed molar and canine
for this domain. expansion at three months after completion of the expansion phase
(Lamparski 2003). There were no statistically significant differences
Overall risk of bias for either outcome (Additional Table 1).
• Two studies were at low risk of bias (Godoy 2011; Petrén 2008). No other outcomes of the review were assessed in this comparison.
• Seven studies were at high risk of bias (Asanza 1997; Lamparski
2003; Lippold 2013; Martina 2012; McNally 2005; Oshagh 2012; Slow expansion
Thilander 1984). Bonded Minne versus banded Minne appliances
• Six studies were at unclear risk of bias (Garib 2005; Kilic 2008;
Lagravere 2010; Mossaz-Joelson 1989; Oliveira 2004; Ramoglu One study at unclear risk of bias, analysing no more than
2010). 10 participants (unclear attrition), assessed molar and canine
expansion seven to 15 weeks after the start of treatment, and
Effects of interventions stability (relapse of molar and canine expansion) 24 weeks
after completion of the expansion phase (Mossaz-Joelson 1989).
See: Summary of findings for the main comparison Fixed There were no statistically significant differences for any outcome
appliances compared with other fixed appliances for treating (Additional Table 1).
posterior crossbites; Summary of findings 2 Fixed appliances
compared with removable appliances for treating posterior No other outcomes of the review were assessed in this comparison.
crossbites; Summary of findings 3 Other comparisons for treating
posterior crossbites Different rates of expansion
Slow versus rapid expansion (two-band palatal expanders)
See Appendix 1 for a description of appliances.
One study at high risk of bias, analysing 26 participants, assessed
1. Fixed appliance with mid-palatal expansion molar expansion seven months after the start of treatment (Martina
Rapid expansion 2012). There was no statistically significant difference (Additional
Table 1).
Banded Hyrax (tooth borne) versus bonded Hyrax (tooth/tissue borne)
No other outcomes of the review were assessed in this comparison.
We included two studies, one at unclear and one at high risk of
bias, analysing 53 participants, in this comparison (Asanza 1997; Semi-rapid versus rapid expansion (splint type tooth- and tissue-
Kilic 2008). Due to problems with reporting of the data in one study borne modified bonded appliances)
(Asanza 1997), we were unable to combine the results in a meta-
analysis. Both studies assessed molar expansion and reported no One study at unclear risk of bias, analysing 35 participants,
statistically significant difference (Table 1). One study measured the assessed molar and canine expansion (Ramoglu 2010). There
outcomes three months after completion of the expansion phase were no statistically significant differences for either outcome
(Asanza 1997), while the other study measured it one week after (Additional Table 1).
completion of the expansion phase (Kilic 2008).
2. Fixed versus removable
Tooth-tissue borne Haas versus tooth borne Hyrax Slow expansion
Two studies, both at unclear risk of bias, analysing 27 participants, Quad-helix versus expansion plate
assessed molar expansion (Garib 2005; Oliveira 2004). The pooled
mean difference (MD) was 0.7 mm (95% confidence interval (CI) We included two studies, both at low risk of bias, analysing 96
-0.25 to 1.66) in favour of Haas appliances at three months after participants, in this comparison (Godoy 2011; Petrén 2008). The two
completion of the expansion phase, but the difference was not studies included children in the early mixed dentition (aged eight
statistically significant (Analysis 1.1). As the sample size was so to 10 years). For the outcome crossbite correction, the pooled risk
small, and there was considerable heterogeneity (I2 = 94%), this ratio (RR) suggests that fixed quad-helix appliances may be 20%
result should be interpreted with caution. more likely to correct crossbites than removable expansion plates
(RR 1.20; 95% CI 1.04 to 1.37) (Analysis 2.1). The 95% CI indicates
Informed decisions.

that the true effect estimate lies somewhere between a 4% and Conventional mid-line expansion screw versus spring-loaded
37% better correction rate for quad-helix appliances. However, the expansion screw
sample size was small and there was substantial heterogeneity (I2 One study at high risk of bias assessed molar and canine expansion
= 68%), so this result should be interpreted with caution, and the but we were unable to extract any data from the study report
results may not be the same in the permanent dentition. (Oshagh 2012).
For the outcome molar expansion, the pooled MD suggests that DISCUSSION
quad-helix appliances can achieve 1.15 mm more expansion than
expansion plates (MD 1.15 mm; 95% CI 0.40 to 1.90) (Analysis 2.2). Summary of main results
The 95% CI indicates that the true effect estimate lies somewhere
between 0.4 mm and 1.9 mm in favour of quad-helix appliances. The objective of this review was to evaluate the effects of different
While there was no heterogeneity (I2 = 0%), the result should be orthodontic treatments for correcting posterior crossbites. We
interpreted with caution as the sample size was small and the included 15 randomised controlled trials (RCTs) that met the
follow-up times differed between the studies. inclusion criteria for this review. We assessed the body of evidence
for each comparison and outcome using GRADE, which takes into
For the outcome canine expansion, the pooled MD was 0.19 mm account the risk of bias of the included studies, the directness of
(95% CI -0.47 to 0.85) in favour of quad-helix appliances, but the evidence, the inconsistency of the results, the precision of the
the difference was not statistically significant (Analysis 2.3). Due estimates and the risk of publication bias (GRADE 2004). The body
to considerable heterogeneity (I2 = 91%), small sample size and of evidence for all comparisons and outcomes in this review was
different follow-up times, the result should be interpreted with very small.
caution.
Fixed appliance with mid-palatal expansion
One study also assessed the stability of crossbite correction The body of evidence for all comparisons and outcomes in this
(relapse 12 months after correction) (Godoy 2011). There was no group was rated as very low quality (Summary of findings for the
statistically significant difference (Additional Table 2). main comparison). In all cases, the evidence was insufficient to
determine a difference between any one type of appliance and
another for any outcome.
One study also compared both appliances in this comparison
Fixed versus removable appliance
against composite onlays (Petrén 2008). There were statistically
significant differences for the outcomes crossbite correction, molar We found low-quality evidence to suggest that crossbite correction
expansion and canine expansion in favour of the fixed and is more successful when using a fixed quad-helix appliance than
removable appliances (Additional Table 2). when using a removable expansion plate for slow maxillary
expansion (Summary of findings 2). For the same comparison,
3. Other comparisons moderate-quality evidence suggested that molar expansion is
Early treatment with fixed bonded Hyrax appliance followed by greater for fixed quad-helix appliances, and further low-quality
U-bow activator therapy versus no treatment evidence was insufficient to determine a difference in canine
expansion. It should be noted that the two studies included
One study at high risk of bias, analysing 66 participants, assessed children in the early mixed dentition (aged eight to 10 years) and
molar and canine expansion 12 months after the start of treatment the results may not be the same for people in the permanent
(Lippold 2013). Statistically significant differences were reported dentition. There was also very low quality evidence that was
for both outcomes in favour of treatment (Additional Table 3). insufficient to determine a difference in stability of crossbite
correction between fixed quad-helix appliances and removable
No other outcomes of the review were assessed in this comparison. expansion plates. Further very low quality evidence suggested
Grinding - occlusal grinding in the primary dentition (at age five that fixed quad-helix appliances and removable expansion plates
years) with/without subsequent upper removable expansion are superior to composite onlays for crossbite correction, molar
appliance in the mixed dentition versus no treatment expansion and canine expansion.
One study at high risk of bias, analysing 61 participants, assessed Others interventions
crossbite correction after one, two, five and eight years (Thilander We found very low quality evidence to suggest that both tooth
1984). A statistically significant difference was reported in favour of grinding, with or without an expansion plate and fixed bonded
treatment (Additional Table 3). Hyrax followed by U-bow activator are superior to no treatment
Slow expansion for the outcomes crossbite correction and molar/canine correction
respectively (Summary of findings 3). We also found very low
Quad-helix plus multi-bracket versus expansion arch plus multi- quality evidence that was insufficient to determine a difference
bracket in molar or canine expansion between quad-helix plus multi-
One study at high risk of bias assessed molar (analysing 55 bracket and expansion arch plus multi-bracket. Finally, there was
participants) and canine (analysing 52 participants - lower number no evidence regarding the comparison of removable appliances
due to unerupted canines) expansion 12 weeks after the start of with either spring-loaded or conventional screws.
treatment (McNally 2005). There were no statistically significant
differences for either outcome (Additional Table 3).

Informed decisions.

Overall completeness and applicability of evidence (Zuccati 2013). The authors of the review assessed the studies
using the Consolidated Standards of Reporting Trials (CONSORT)
The studies identified in this review are insufficient to address the statement. In similarity with our review, they argued that there
question of what is the best treatment for posterior crossbites. was substantial evidence of bias, which reduced the quality of the
Although we were able to include 15 studies, there were many evidence; the randomisation process was poorly described and loss
different comparisons of appliances or other treatments and, to follow-up was unclear in many of the included studies. Their
therefore, there was minimal pooling of data. This is unfortunate review also called for future trials to be carefully planned and
as one of the advantages of a systematic review is the ability to reported using universal guidelines.
pool multiple studies in order to increase the power to detect
a difference confidently, and thus to inform clinical practice AUTHORS' CONCLUSIONS
better. Furthermore, there were very limited data available for the
outcome stability of crossbite correction, and no studies assessed Implications for practice
signs and symptoms of temporomandibular joint dysfunction/
respiratory disease or quality of life. However, this was perhaps There is a very small body of low- to moderate-quality evidence to
because all the studies included only children. This highlights suggest that fixed quad-helix appliances may be more successful
another shortcoming in the overall completeness of the evidence, than removable expansion plates at correcting posterior crossbites
which is that there is no evidence on orthodontic treatments for and expanding the inter-molar width in children with early mixed
adults with posterior crossbites. The lack of evidence regarding dentition (aged eight to 10 years). The remaining evidence that we
adults in this review is probably because the majority of studies on found was of very low quality and was insufficient to allow the
adults with a posterior crossbite compare orthodontic treatments conclusion that any one intervention is better than another for any
with orthodontic-surgical interventions, but we excluded surgical of the outcomes in this review.
treatments from this review.
Implications for research
Quality of the evidence More randomised controlled trials are required to address the
The body of evidence identified does not allow for any robust question of what is the best treatment for posterior crossbites
conclusions to be made regarding the objective of this review. The in children, adolescents and adults. The studies should be large
sample sizes were consistently small (as low as eight participants), enough to detect a difference, if one exists, and should assess
and this fact, combined with the lack of pooling of data in meta- appropriate outcomes. We believe that 'correction of crossbite'
analyses, meant that the power to detect statistically and clinically needs to be the primary outcome for all studies addressing
significant differences, with confidence, was limited. Another this research question. In studies where all the crossbites were
problem was inconsistency as three of the four meta-analyses corrected (as with most studies in this review), 'time to correction'
displayed statistically significant heterogeneity. While there were and 'pain' would be of increased importance as outcomes.
two low risk of bias studies that we were able to pool, the results
High-quality work should be carried out to develop core outcome
cannot be relied upon due to the problems already mentioned. The
sets for orthodontics/areas of orthodontics. Such work should be
remaining studies were either at high risk of bias (seven studies) or
carried out in association with the COMET (Core Outcome Measures
the risk of bias was unclear (six studies). Most of the comparisons
in Effectiveness Trials) Initiative (www.comet-initiative.org), using
included in the review were assessed by very small single studies,
robust methodology suggested by those working with the COMET
which do not allow any conclusions to be drawn as to the effects of
Initiative so far (Williamson 2012). These core outcome sets should
the interventions studied.
subsequently be the minimum set of outcomes that are measured
Potential biases in the review process in all clinical trials and systematic reviews (including this Cochrane
review).
We made every attempt to limit bias in the review process by
ensuring a comprehensive search for potentially eligible studies. Future randomised controlled trials must be well designed,
The authors' independent assessments of study eligibility and well conducted and adequately delivered with subsequent
subsequent data extraction and risk of bias assessment minimised reporting, including high-quality descriptions of all aspects of
the potential for additional bias beyond that detailed in the 'Risk of methodology. Reporting should conform to the Consolidated
bias' tables in the Characteristics of included studies section. The Standards of Reporting Trials (CONSORT) statement (www.consort-
incompleteness of some of the reports and our inability to obtain statement.org), which will enable appraisal and interpretation
clarification of certain trial details or to resolve ambiguities in the of results, and accurate judgements to be made about the risk
reports may have contributed to some bias in their assessment, of bias and the overall quality of the evidence. Although it is
but where these conditions applied this was explicitly stated in the uncertain whether reported quality mirrors actual study conduct,
text of our review. Finally, we attempted to minimise bias further it is noteworthy that studies with unclear methodology have been
by changing our inclusion criteria to only include RCTs which, when shown to produce biased estimates of treatment effects (Schulz
performed to a high standard, should be less biased than other 1995).
study designs.
ACKNOWLEDGEMENTS
Agreements and disagreements with other studies or
The review authors would like to thank the Cochrane Oral Health
reviews
Group and referees for their help in conducting this systematic
Another systematic review of maxillary expansion arches for review.
treating crossbites included studies published from 1999 to 2011

Informed decisions.

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* Oliveira NL, Da Silveira AC, Kusnoto B, Viana G. Three-
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Thilander 1984 {published data only}
Lamparski 2003 {published data only}
Thilander B, Wahlund S, Lennartsson B. The effect of early
Lamparski DG Jr, Rinchuse DJ, Close JM, Sciote JJ. Comparison interceptive treatment in children with posterior cross-bite.
of skeletal and dental changes between 2-point and 4-point European Journal of Orthodontics 1984;6:25-34.
rapid palatal expanders. American Journal of Orthodontics and
Dentofacial Orthopedics 2003;123(3):321-8.
References to studies excluded from this review
Lippold 2013 {published data only}
Petrén 2011 {published and unpublished data}
Lippold C, Stamm T, Meyer U, Végh A, Moiseenko T, Danesh G.
Early treatment of posterior crossbite - a randomised clinical Petrén S, Bjerklin K, Bondemark L. Stability of unilateral
trial. Trials 2013;14:20. posterior crossbite correction in the mixed dentition: a
randomised clinical trial with a 3-year follow-up. American
Martina 2012 {published data only} Journal of Orthodontics and Dentofacial Orthopedics
Martina R, Cioffi I, Farella M, Leone P, Manzo P, Matarese G, et 2011;139:e73-81.
al. Transverse changes determined by rapid and slow maxillary
Weissheimer 2011 {published data only}
expansion. A low-dose CT-based randomised controlled trial.
Orthodontics & Craniofacial Research 2012;15:159-68. Weissheimer A, de Menezes LM, Mezomo M, Dias DM,
de Lima EM, Rizzatto SM. Immediate effects of rapid maxillary
McNally 2005 {published and unpublished data} expansion with Haas-type and hyrax-type expanders: a
McNally MR, Spary DJ, Rock WP. Randomized controlled randomized clinical trial. American Journal of Orthodontics and
trial comparing the quadhelix and the expansion arch Dentofacial Orthopedics 2011;140(3):366-76.
for the correction of crossbite. Journal of Orthodontics

2005;32(1):29-35.
Additional references
Mossaz-Joelson 1989 {published and unpublished data} Bresolin 1983
Mossaz-Joelson K, Mossaz C. Slow maxillary expansion: a Bresolin D, Shapiro PA, Shapiro GG, Chapko MK, Dassel S. Mouth
comparison between bonded and banded appliances. European breathing in allergic children: its relationship to dentofacial
Journal of Orthodontics 1989;11:67-76. development. American Journal of Orthodontics 1983;83:334-40.

Informed decisions.

Cheng 1988 Lindner 1989

Cheng M-C, Enlow DH, Papsidero M, Broardbent BH, Oyen O, Lindner A. Longitudinal study on the effect of early interceptive
Sabat, M. Developmental effects of impaired breathing treatment in 4-year-old children with unilateral cross-bite.
in the face of the growing child. The Angle Orthodontist Scandinavian Journal of Dental Research 1989; Vol. 97, issue
1988;58:309-20. 5:432-8.
Egermark 1990 Malandris 2004

Egermark-Eriksson I, Carlsson GE, Magnusson T, Thilander B. Malandris M, Mahoney EK. Aetiology, diagnosis and treatment
A longitudinal study on malocclusion in relation to signs and of posterior cross-bites in the primary dentition. International
symptoms of cranio-mandibular disorders in children and Journal of Paediatric Dentistry 2004; Vol. 14, issue 3:155-66.
adolescents. European Journal of Orthodontics 1990;12:399-407.
McNamara 1997
Egger 1997 McNamara JA Jr, Turp JC. Orthodontic treatment and
Egger M, Davey Smith G, Schneider M, Minder C. Bias in temporomandibular disorders: is there a relationship?. Journal
meta-analysis detected by a simple, graphical test. BMJ of Orofacial Orthopedics 1997;58:74-89.
1997;315(7109):629-34.
Modeer 1982
Gesch 2004 Modeer T, Odenrick L, Lindner A. Sucking habits and their
Gesch D, Bernhardt O, Kirbschus A. Association of malocclusion relationship to posterior crossbites in 4-year-old children.
and functional occlusion with temporomandibular disorders Scandinavian Journal of Dental Research 1982;90:323-8.
(TMD) in adults: a systematic review of population-based
studies. Quintessence International 2004;35(3):211-21. Ninou 1994
Ninou S, Stephens C. The early treatment of posterior
GRADE 2004 crossbites: a review of continuing controversies. Dental Update
GRADE Working Group. Grading quality of evidence and 1994;21:420-6.
strength of recommendations. BMJ 2004;328(7454):1490.
O'Bryn 1995
Heikinheimo 1987 O'Bryn BL, Sadowsky C, Schneider B, BeGole EA. An evaluation
Heikinheimo K, Salmi K, Myllarniemi S. Long term evaluation of mandibular asymmetry in adults with unilateral posterior
of orthodontic diagnosis made at the ages of 7 and 10 years. crossbite. American Journal of Orthodontics and Dentofacial
European Journal of Orthodontics 1987;9:151-9. Orthopedics 1995;107:394-400.
Higgins 2011 Ogaard 1994

Higgins JPT, Green S (editors). Cochrane Handbook for Ogaard B, Larsson E, Lindsten R. The effects of sucking habits,
Systematic Reviews of Interventions Version 5.1.0 [updated cohort, sex, intercanine arch widths, and breast or bottle
March 2011]. The Cochrane Collaboration, 2011. Available from feeding on posterior crossbite in Norwegian and Swedish
www.cochrane-handbook.org. 3-year-old children. American Journal of Orthodontics and
Dentofacial Orthopedics 1994;106:161-6.
Iodice 2013
Iodice G, Danzi G, Cimino R, Paduano S, Michelotti A. Pullinger 1993
Association between posterior crossbite, masticatory muscle Pullinger AG, Seligman DA, Gornbein JA. A multiple
pain, and disc displacement: a systematic review. European logistic regression analysis of the risk and relative odds of
Journal of Orthodontics 2013;35(6):737-44. temperomandibular disorders as a function of common
occlusal factors. Journal of Dental Research 1993;72:968-79.
Kennedy 2005
Kennedy DB, Osepchook M. Unilateral posterior crossbite with Schulz 1995
mandibular shift: a review. Journal of the Canadian Dental Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence
Association 2005;71(8):569-73. of bias. Dimensions of methodological quality associated
with estimates of treatment effects in controlled trials. JAMA
Kurol 1992 1995;273(5):408-12.
Kurol J, Berglund L. Longitudinal and cost-benefit analysis
of the effect of early treatment of posterior cross-bites in Subtelny 1980
the primary dentition. European Journal of Orthodontics Subtelny JD. Oral respiration: facial maldevelopment and
1992;14:173-9. corrective dentofacial orthopedics. The Angle Orthodontist
1980;50:147-64.
Leighton 1966
Leighton BC. The early development of cross-bites. Dental Thilander 2002
Practitioner 1966;17:145-52. Thilander B, Rubio G, Pena L, de Mayorga C. Prevalence of
temporomandibular dysfunction and its association with
malocclusion in children and adolescents: an epidemiologic

Informed decisions.

study related to specified stages of dental development. The Zuccati 2013

Angle Orthodontist 2002;72(2):146-54. Zuccati G, Casci S, Doldo T, Clauser C. Expansion of maxillary
arches with crossbite: a systematic review of RCTs in the last 12
Thilander 2012
years. European Journal of Orthodontics 2013;35(1):29-37.
Thilander B, Bjerklin K. Posterior crossbite and
temporomandibular disorders (TMDs): need for
orthodontic treatment?. European Journal of Orthodontics References to other published versions of this review
2012;34(6):667-73.
Harrison 2001
Williamson 2012 Harrison JE, Ashby D. Orthodontic treatment for posterior
Williamson PR, Altman DG, Blazeby JM, Clarke M, Devane D, crossbites. Cochrane Database of Systematic Reviews 2001, Issue
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issues to consider. Trials 2012;13:132.

* Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Asanza 1997
Methods Study design: RCT (2 arms)
Location: Orthodontics Department, Albert Einstein College of Medicine and Montefiore Medical Cen-
ter, New York, USA
Number of centres: 1
Recruitment period: Not stated
Funding source: Not stated but study part of a Master's thesis
Clinician experience: Not stated
Participants Inclusion criteria: Children with posterior crossbites
Exclusion criteria: None stated
Age: 8.5 to 16 years
Gender: M/F 7/7
Number randomised: 14 (Gp A: 7; Gp B: 7)
Number evaluated: 14 (Gp A: 7; Gp B: 7)
Interventions Comparison: (Fixed appliances) (rapid expansion) banded Hyrax (tooth borne) versus bonded
Hyrax (tooth/tissue borne)
Gp A (n = 7): Conventional Hyrax expander with mid-palatal jackscrew assembly and 4 rigid steel wires
that were soldered to the bands on abutment teeth usually first premolars and first molars
Gp B (n = 7): Same Hyrax expander jackscrew assembly as Gp A but wires were soldered to 0.036 wire
loops bent circumferentially at the height of contour of the abutment teeth. The acrylic portion en-
cased the occlusal, lingual and buccal surfaces of the abutment teeth
Participants in both groups were instructed to turn screw twice per day (0.5 mm). After expansion, ap-
pliances remained for a 3-month retention phase
Outcomes Lateral and posterior-anterior cephalometric assessment of angular and linear skeletal and dental
changes
Molar expansion

Informed decisions.

Asanza 1997 (Continued)
Notes No sample size calculation reported
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence genera- Unclear risk Quote: "Appliances were randomly assigned"
tion (selection bias)
Comment: Insufficient information on the method of sequence generation
Allocation concealment Unclear risk Quote: "Appliances were randomly assigned"

(selection bias)
Comment: Not mentioned
Blinding of outcome as- Unclear risk Not mentioned

sessment (detection bias)
All outcomes
Incomplete outcome data Low risk No drop-outs reported. Data in Table 5 implied that there were no drop-outs
(attrition bias)
All outcomes
Selective reporting (re- High risk No measures of variance were reported, so we were unable to analyse the data
porting bias)
Other bias Low risk No other sources of bias identified

Garib 2005
Location: Orthodontics Department, Bauru School of Dentistry, University of Sao Paulo, Brazil
Funding source: Not stated
Participants Inclusion criteria: Females presenting with Class I or Class II malocclusion with unilateral or bilateral
crossbite
Exclusion criteria: age below 11 and above 14 years, persistence of any primary tooth, absence of max-
illary posterior permanent teeth, metallic restorations on the maxillary posterior teeth, previous peri-
odontal disease, previous orthodontic treatment and M sex
Age: Gp A: mean 12.4 years (range 11.4-13.6); Gp B: mean 12.6 years (range 11.5-13.9)
Gender: 100% F
Number evaluated: Not stated
Interventions Comparison: (Fixed appliances) (rapid expansion) tooth-tissue borne Haas versus tooth borne
Hyrax

Informed decisions.

Garib 2005 (Continued)
Gp A (n = 4): Tooth-tissue borne palatal acrylic Haas type expander
Gp B (n = 4): Tooth-borne Hyrax expander (no palatal acrylic)
Both groups had the screw activated by a complete turn after placement, followed by a one-quarter
turn morning and evening of each day (0.5 mm/day) until full expansion on day 16 (total of 7 mm ex-
pansion). Appliance was then kept as a retainer for a further 3 months and then removed, at which
point the outcomes were measured
Outcomes Transverse maxillary expansion
Maxillary posterior teeth axial inclination
Notes Casual and systematic errors were calculated comparing the first measurement with Dahlberg's formu-
la and second measurement with dependent t-test at a significance level of 5%
No sample size calculation reported, but authors suggest that study is probably underpowered
Risk of bias
Random sequence genera- Unclear risk Quote: "...sample of eight patients, who were randomly assigned to two
tion (selection bias) groups"
Allocation concealment Unclear risk Quote: "...sample of eight patients, who were randomly assigned to two
(selection bias) groups"
Blinding of outcome as- Unclear risk It appears that it would have been possible to blind outcome assessors as the
sessment (detection bias) appliances were removed before final measurements were made. However, it
All outcomes was not mentioned
Incomplete outcome data Unclear risk No indication of whether or not there were any drop-outs. Unclear how many
(attrition bias) participants were included in the outcome assessment
All outcomes
Selective reporting (re- Low risk Outcome measures described in the methods section were reported in full
porting bias)

Godoy 2011
Location: Dental clinic of Santo Amaro by the University of Pernambuco, Brazil
Funding source: University of Pernambuco and research grant from the Ministry of Education of Brazil
(CAPES)
Clinician experience: Specialist orthodontist with over 10 years of experience

Informed decisions.

Godoy 2011 (Continued)
Participants Inclusion criteria: Children had both unilateral posterior dental and functional crossbites in the mixed
dentition; all had skeletal posterior crossbite diagnosed by examining the casts, models and anterio-
posterior cephalometric radiographs
Exclusion criteria: Sucking habits, previous orthodontic treatment, Class III malocclusion
Gp A: mean age 8.00 years (SD 0.79); M/F 7/26
Gp B: mean age 7.82 years (SD 0.85); M/F 15/18
Gp C: mean age 8.09 years (SD 0.81); M/F 19/14
Number randomised: 99 (Gp A: 33; Gp B: 33; Gp C: 33)
Number evaluated: 99 (Gp A: 33; Gp B: 33; Gp C: 33)
Interventions Comparison: (Fixed versus removable appliances) (slow expansion) quad-helix versus expansion
plate versus untreated control group
Gp A (n = 33): Quad-helix fixed appliance with stainless steel bands bonded to teeth (tooth borne). Ap-
pliance was activated once a month until crossbite was corrected
Gp B (n = 33): Expansion plate removable appliance with mid-line screw and acrylic covering (tooth-tis-
sue borne). Appliance worn day and night and removed for teeth brushing. Appliance was activated a
one-quarter rotation of the screw once a week (0.25 mm)
Gp C (n = 33): No treatment
Gps A and B were evaluated every 4 weeks, no overcorrection was produced and once correction was
achieved each child had a retention plate to be used 24 hours/day for 3 months and then only at night
for a further 3 months
Outcomes Correction of crossbite
Maxillary and mandibular inter-molar and inter-canine expansion
Length of treatment
Cost-benefit
Success rate (stability)
Number of complications
(Evaluation after crossbite correction, after 6-month retention, after retention removal)
Notes "The sample size calculation established an error of 5% and a power of 95%. To detect any differences
in length of treatment between the 2 methods, the means and standard deviations were calculated
based on the data from the study of Hermanson et al (8.00 ± 3.00 for the QH [quad-helix]; 12.00 ± 5.00
for the EP [expansion plate]). The sample should include 27 patients per group to show a statistically
significant difference"
Email sent to authors 22 November 2012, reply received 23 November 2012
Risk of bias
Random sequence genera- Low risk Quote: "For randomization, numbers were randomly drawn from a plastic bag.
tion (selection bias) Each child received a number from 1 to 99"
From email correspondence: "Each child received a number according to the

clinical examination order. When all 99 children had a number, a helper took

Informed decisions.

Godoy 2011 (Continued)
the 99 pieces of papers numbering from 1 to 99 from the bag. The first number
to be taken would belong to QDH [quad-helix] group, the second one to the EP
[expansion plate] group, the third one to the untreated group, the fourth to the
QDH group..."
Allocation concealment Low risk The method described above would not allow anybody involved in the study
(selection bias) to know their treatment allocation until they had been allocated
Blinding of outcome as- Low risk Quote: "Palatal expansion and crossbite correction were measured on the
sessment (detection bias) study casts by 1 masked investigator... The investigator was unaware of the
All outcomes type of appliance used by the patient and the length of treatment (pretreat-
ment, after expansion, after 6 months of retention, or 6 months after removal
of the retention plate)"
Incomplete outcome data Low risk "Dropouts and treatments not completed within 12 months were classified as
(attrition bias) unsuccessful"
All outcomes
Intention-to-treat analysis included all randomised participants
porting bias)

Kilic 2008
Location: Department of Orthodontics, Faculty of Dentistry, Atatürk University, Erzurum, Turkey
Participants Inclusion criteria: Participants with severe maxillary arch width deficiency, bilateral crossbite and deep
palatal vault
Exclusion criteria: People with mucosal swelling during maxillary expansion
Age: Gp A: 13.75 years (SD 17 months); Gp B: 13.5 years (SD 12 months)
Gender: M/F 10/29
Interventions Comparison: (Fixed appliances) (rapid expansion) banded Hyrax (tooth borne) versus bonded
Hyrax (tooth/tissue borne)
Gp A (n = 21): Conventional Hyrax tooth-borne appliance for rapid maxillary expansion
Gp B (n = 18): Acrylic bonded appliance for rapid maxillary expansion
Appliances were activated twice a day, one-quarter turn each time (0.5 mm/day)

Informed decisions.

Kilic 2008 (Continued)
Outcomes Maxillary molar expansion
Molar crown tipping
Alveolar inclination
Email sent 22 November 2012
Risk of bias
Random sequence genera- Unclear risk Quote: "Randomly assigned to two groups"
Allocation concealment Unclear risk Quote: "Randomly assigned to two groups"

(selection bias)
Blinding of outcome as- Unclear risk It may have been possible to blind outcome assessors if the appliances were
sessment (detection bias) removed before final measurements were made. However, this was not men-
All outcomes tioned
Incomplete outcome data Low risk No drop-outs reported. Numbers of participants per group reported in the re-
(attrition bias) sults tables matches the numbers that were randomised
All outcomes
porting bias)

Lagravere 2010
Location: Orthodontic clinic at the University of Alberta in Edmonton, Alberta, Canada
Recruitment period: 18-month recruitment period
Participants Inclusion criteria: People needing maxillary expansion with posterior crossbite
Number randomised: 62 (Gp A: 20; Gp B: 21; Gp C: 21)

Informed decisions.

Lagravere 2010 (Continued)
Interventions Comparison: (Fixed appliances) (rapid expansion) Hyrax tooth-borne expander versus bone-an-
chored expander versus untreated control group
Gp A (n = 20): Tooth anchored maxillary expander (TAME) Hyrax with bands on the first permanent mo-
lars and first premolars. Activated 0.5 mm per day until posterior dental crossbite over correction was
achieved
Gp B (n = 21): Bone-anchored maxillary expander (BAME) composed of 2 custom-milled stainless steel

onplants, 2 miniscrews and an expansion screw. A healing period of 1 week was allowed before ac-
tivation of the expander. Activation consisted of 0.25 mm every other day until overcorrection was
achieved
Gp C (n = 21): Treatment delayed for 12 months to serve as a control group
In Gps A and B, the appliance was removed after overcorrection was achieved and left without reten-
tion for an additional 6 months
Outcomes Molar expansion
Inclination
Pain
Risk of bias
Random sequence genera- Low risk Quote: "Subjects were randomized into the groups by using a random num-
tion (selection bias) bers generated list"
Allocation concealment Unclear risk Quote: "Subjects were randomized into the groups by using a random num-
(selection bias) bers generated list"
All outcomes
porting bias)

Lamparski 2003
Location: Private practice, Natrona Heights, PA, USA
Informed decisions.

Lamparski 2003 (Continued)
Clinician experience: Board-certified orthodontist with 27 years of experience
Participants Inclusion criteria: Crossbite; mixed or permanent dentition
Exclusion criteria: Systemic disease, dental pathology; maxillary tori
Gp A: mean age 11.33 years (range 7.75-13.92); M/F 9/6
Gp B: mean age 10.8 years (range 6.58-14.58); M/F 6/9
Interventions Comparison: (Fixed appliances) (rapid expansion) 4-point expansion appliance (Hyrax) versus 2-
point expansion appliance
Gp A (n = 15): The 4-point expansion appliance consisted of a Hyrax expansion screw with bands ce-
mented to the maxillary first permanent molars and either the maxillary first premolars or the maxillary
deciduous first molars. Activated 0.5 mm per day until posterior dental crossbite overcorrection was
achieved
Gp B (n = 15): The 2-point expander was banded only to the maxillary first permanent molars and had a
jackscrew (a typical Hyrax appliance with both anterior wires removed). Activated 0.5 mm per day until
posterior dental crossbite overcorrection was achieved
Outcomes Molar, canine and sutural expansion
Risk of bias
Random sequence genera- Unclear risk Quote: "The subjects were randomly assigned"
Allocation concealment Unclear risk Quote: "The subjects were randomly assigned"
(selection bias)
All outcomes
Selective reporting (re- High risk Outcomes planned in the methods section were reported in the results. How-
porting bias) ever, means and SDs in each group were not reported

Informed decisions.

Lippold 2013
Location: Orthodontics Department, Münster University's Medical Sciences Division and University
Hospital Münster, Germany
Clinician experience: "Two specialists in orthodontics"
Participants Inclusion criteria: Functional unilateral posterior crossbite in the late deciduous or early mixed denti-
tion
Exclusion criteria: mid-line deviation during orthodontic treatment; persisting habits; general diseases
with permanent medication (e.g. diabetes mellitus); syndromes; cleft lip and palate; general impair-
ments; structural orthopaedic diseases
Age: Gp A: mean 7.3 years (SD 2.2); Gp B: mean 7.2 years (SD 2)
Gender: "The gender ratio was nearly equal at the beginning of the study"
Number randomised: 82 (Gp A: 40; Gp B: 42). However, 5 participants dropped out after randomisation
but before treatment (Gp A: 37; Gp B: 40)
Interventions Comparison: (Slow expansion) early treatment with fixed bonded Hyrax appliance followed by U-
bow activator therapy versus no treatment
Gp A (n = 37): Bonded Hyrax appliance worn 24 hours per day. Once per day activation (0.2 mm) was
mandatory and the maxillary expansion was achieved in a mean of 3.2 weeks (SD 1.2). This was fol-
lowed by a retention period of a mean of 12.6 weeks (SD 1.8). The U-bow activator was then applied for
a mean of 36.8 weeks (SD 5.4). This was a double-plate activator combined with eponymous U-shaped
wire bows on each side (protrusive and labial bows on the upper and lower jaws). The maxillary plate
had an additional transversal expansion screw for retention of the achieved expansion
Gp B (n = 40): No treatment (after the final follow-up point, these children received the same treatment
as those in the therapy group)
Outcomes Sagittal, vertical and transversal dimensions of the maxilla and mandible
Mid-line deviation between the anterior teeth of the maxilla and mandible
Sagittal overjet and vertical overbite
Outcomes were measured 1 year after the start of treatment
Risk of bias
Random sequence genera- Low risk Quote: "Block randomisation with a block length of 20 and an allocation ratio
tion (selection bias) of 1:1"
Allocation concealment Unclear risk Quote: "Block randomisation with a block length of 20 and an allocation ratio
(selection bias) of 1:1"

Informed decisions.

Lippold 2013 (Continued)
sessment (detection bias) appliances could have been removed before final measurements were made.
All outcomes In contrast, the children's group may have been obvious due to there being an
untreated control group whose crossbites would not be properly corrected.
However, it was not mentioned
Incomplete outcome data Low risk Numbers of drop-outs and reasons were clearly described in a study workflow
(attrition bias) (Figure 1), and were sufficiently similar in each group
All outcomes
Selective reporting (re- High risk No SD for mean change from baseline reported
porting bias)

Martina 2012
Location: Department of Oral Science, University of Naples Federico II, Italy
Recruitment period: May 2006 to October 2007
Funding source: Grant from the Italian Ministry of University and Research
Participants Inclusion criteria: Children up to 13 years old (M) and 12 years old (F), with erupted permanent first mo-
lars and unilateral or bilateral full cusp posterior crossbite
Exclusion criteria: Severe periodontal disease (probing depth > 4 mm), congenital syndromes, defects,
previous orthodontic treatment

Number randomised: 50 (Gp A: 23; Gp B: 27). However, 9 children dropped out after randomisation but
before treatment (Gp A: 19; Gp B: 22)
Interventions Comparison: (Fixed appliances) slow versus rapid expansion

A 2-band palatal expander was used for both groups
Gp A (n = 12): Slow expansion, the screw was turned twice a week (0.50 mm activation per week)
Gp B (n = 14): Rapid expansion, screw was initially turned 8 times (2.0-mm screw activation) at chair
side 2 hours after curing. Thereafter, the children's parents were trained to turn the screw 3 times per
day (0.75 mm activation per day)
In both groups, the jackscrew was activated until a 2 mm molar transverse overcorrection was
achieved. After the required expansion was achieved, the screw was locked with light-cure flow com-
posite. The appliances were removed 7 months after treatment started, at which point the outcomes
were measured
Outcomes Molar expansion at molar cusp
Antero and posterior maxillary expansion

Informed decisions.

Martina 2012 (Continued)
Pterygoid expansion
Molar tipping
Notes The power calculation was based upon previous estimates of rapid maxillary expansion transverse
skeletal effects. This indicated that 12 children were needed for each treatment group (to detect 2.5
mm difference, SD = 2.0 mm, significance level = 0.05, power 80%)
Risk of bias
Random sequence genera- Low risk Quote: "Balanced block randomisation using gender as a stratifying factor"
Allocation concealment Low risk Quote: "A single operator allocated the patients by means of a custom-made
(selection bias) Java script and was responsible for the allocation concealment, that is, the al-
location was disclosed only when a new patient was enrolled in the trial"
Blinding of outcome as- Low risk Measurements were made by a single operator blinded to participant alloca-
sessment (detection bias) tion
All outcomes
Incomplete outcome data High risk Numbers of drop-outs and reasons were clearly described in a study workflow
(attrition bias) (Figure 4), and were similar. However, dropout rate was very high (Gp A: 48%;
All outcomes Gp B: 48%). If the missing participants had higher mean scores in 1 group than
the other, as the attrition rate increased, so would over/understatement of the
mean difference
porting bias)

McNally 2005
Location: Queen's Hospital, Burton on Trent and The University of Birmingham, School of Dentistry,
Birmingham
Funding source: 3M Unitek supplied the quad-helix arches used in this study
Clinician experience: The authors had used expansion arches of the type tested for a number of years
Participants Inclusion criteria: Either a unilateral or bilateral crossbite that required correction according to the
consultant orthodontist
Age: 11-16 years (not reported by group)
Gender: M/F 30/30 (not reported by group)

Informed decisions.

McNally 2005 (Continued)
Number evaluated: 55 (Gp A: 28; Gp B: 27) for molar expansion; 52 (Gp A: 26; Gp B: 26) for canine expan-
sion (the lower numbers were due to unerupted canines)
Interventions Comparison: (Slow expansion) quad-helix + multi-bracket versus expansion arch + multi-bracket
Gp A (n = 30): Quad-helix plus multi-bracket
Gp B (n = 30): Expansion arch plus multi-bracket
In both groups the appliance was activated in order to deliver 1.8-N expansion force
Outcomes Molar and canine expansion
Comfort
Outcomes were measured 4, 8 and 12 weeks after the start of treatment
Notes Altman nomogram for an SD of 1.5 mm at 80% power and 1% significance level suggests a total sample
size of 46 children, with 23 in each group
Risk of bias
Random sequence genera- High risk Quote: "Using random number tables the first 30 participants were allocated
tion (selection bias) for treatment with either appliance according to an odd or even number. The
next 30 were then allocated in order to receive the alternative treatment to
those in the initial allocation"
Comment: This does not represent a truly random sequence generation
Allocation concealment High risk Quote: "Using random number tables the first 30 participants were allocated
(selection bias) for treatment with either appliance according to an odd or even number. The
next 30 were then allocated in order to receive the alternative treatment to
those in the initial allocation"
Comment: Potential to foresee group allocation
Blinding of outcome as- Unclear risk Quote: "The group of the participant was obvious from the model since the
sessment (detection bias) imprint of each type of appliance could be seen. However, since all measure-
All outcomes ments were made without reference to previous values, there could be no
bias"
Comment: We cannot completely rule out the possibility of bias in this situa-
tion
Incomplete outcome data Low risk Numbers of drop-outs and reasons are clearly described in a study workflow
(attrition bias) (Figure 4), and are sufficiently similar in each group
All outcomes
porting bias)

Mossaz-Joelson 1989
Methods Study design: Reclassified as RCT following correspondence (2 arms)

Informed decisions.

Mossaz-Joelson 1989 (Continued)
Location: Department of Orthodontics, Dental School, University of Geneva, Switzerland
Participants Inclusion criteria: Children with bilateral or functional unilateral crossbite. No further definition provid-
ed
Age: Gp A: 8.6-10.8 years; Gp B: 8.7-12 years
Gender: M/F 6/4 (not reported by group)
Interventions Comparison: (Fixed appliances) (slow expansion) bonded Minne versus banded Minne appliances
Gp A (n = 5): Conventional Minne expander embedded in acrylic and bonded to upper deciduous first
and second molars (or first and second premolars)
Gp B (n = 5): Conventional Minne expander soldered to bands to the upper first primary molars (or first
permanent premolars) and upper first molars
A continuous 2-pound (0.9-kg) force coil spring was used to obtain expansion. The spring was re-acti-
vated every other week. The slow expansion period lasted 7-15 weeks. After expansion was complete,
the fixed appliances were removed, apart from the bonded vertical tubes in Gp A, and the maxillary first
molar bands in Gp B. Conventional maxillary retainer worn full time for 12 weeks (retention period).
There was then 12 more weeks of observation without the retainers to evaluate relapse
Angular changes
Cephalometric variables
Stability (relapse of molar and canine expansion)
Risk of bias
Random sequence genera- Unclear risk From correspondence with study authors: "...randomly divided into two
tion (selection bias) groups..."
Allocation concealment Unclear risk From correspondence with study authors: "...randomly divided into two
(selection bias) groups..."

Informed decisions.

Mossaz-Joelson 1989 (Continued)
(attrition bias) children were included in the outcome assessment
All outcomes
porting bias)

Oliveira 2004
Location: Department of Orthodontics and the Craniofacial Center, University of Illinois at Chicago,
USA
Number of centres: 3 university orthodontic clinics and 1 private practice
Funding source: Partially funded by a grant from the American Association of Orthodontists Foundation
Participants Inclusion criteria: Growing children who had maxillary permanent first premolars or non-mobile maxil-
lary deciduous first molar and unilateral or bilateral crossbite
Exclusion criteria: Any craniofacial anomaly
Gp A: mean age 11.9 years (range 10.7-13.4); M/F 5/4
Gp B: mean age 11.1 years (range 7.3-14.6); M/F 1/9
Interventions Comparison: (Fixed appliances) (rapid expansion) tooth-tissue-borne Haas versus tooth-borne
Hyrax
Gp A (n = 9): Tooth-tissue-borne palatal acrylic Haas type expander
Gp B (n = 10): Tooth-borne Hyrax expander (no palatal acrylic)
Appliances were activated twice a day, one-quarter turn each time (0.5 mm/day) until overcorrection
was obtained. Appliance was then kept as a retainer for a further 3 months and then removed, at which
point the outcomes were measured
Outcomes Molar expansion
Anteroposterior cephalometry
Notes "...projected sample size of 50 subjects" - sample size not met
Risk of bias

Informed decisions.

Oliveira 2004 (Continued)
Random sequence genera- Low risk Quote: "Randomization was carried out by using a table of random numbers"
Allocation concealment Low risk Quote: "A staff member in the clinic was informed about every new patient
(selection bias) suitable for the study and assigned the type of expander following the list or-
der"
Comment: It appears that allocation was done by someone not involved in the
study. Probably done
(attrition bias) sults tables matched the numbers that were randomised
All outcomes
porting bias)

Oshagh 2012
Location: Orthodontic Department, School of Dentistry, Shiraz University of Medical Sciences, Iran
Participants Inclusion criteria: Healthy children with posterior bilateral crossbites and with growth potential
Exclusion criteria: Systemic diseases, previous orthodontic treatment, requiring headgear or an auxil-
iary component, cleft palate, anterior crossbite, children with extractions
Interventions Comparison: (Removable split acrylic plates) (slow expansion) conventional mid-line expansion
screw versus spring-loaded expansion screw
Gp A (n = 25): Conventional screw activated by parent with a one-quarter turn twice per week (total 0.5
mm)
Gp B (n = 10): Spring-loaded screw activated by the orthodontist each month

Informed decisions.

Oshagh 2012 (Continued)
Both groups were treated by the same orthodontist following the same protocol. Active expansion con-
tinued until overcorrection (mean duration of treatment 5.3 months)
Arch size changes
Participant discomfort
Risk of bias
Random sequence genera- Low risk Quote: "Randomization was accomplished by a randomization table"
Allocation concealment Unclear risk Quote: "Randomization was accomplished by a randomization table"
(selection bias)
sessment (detection bias) appliances were removed before casts were made. However, it was not men-
All outcomes tioned
(attrition bias) children were included in the outcome assessment
All outcomes
Selective reporting (re- High risk Poor reporting of results. Only the overall mean monthly changes were report-
porting bias) ed. The authors did not report the mean and SD for changes between the base-
line and final measurement
Other bias High risk Imbalance in the numbers per group (Gp A: 25; Gp B: 10) and gender (Gp A: M/F
6/19; Gp B: M/F 5/5) suggests a problem with the randomisation

Petrén 2008
Location: Public Dental Health Service, Skane County Council, Sweden, and the Department of Ortho-
dontics, Faculty of Odontology, Malmö University, Malmö, Sweden
Recruitment period: 2001-2005
Funding source: Supported by the Swedish Dental Society, Skane County Council, and the Faculty of
Odontology, Malmö University, Sweden
Clinician experience: 5 experienced general practitioners under the supervision of specialist orthodon-
tists
Participants Inclusion criteria: Mixed dentition (all incisors and first molars erupted); unilateral posterior crossbite
Exclusion criteria: Sucking habits or sucking habit discontinued at less than 1 year before the trial; pre-
vious orthodontic treatment

Informed decisions.

Petrén 2008 (Continued)
Gp D: mean age 8.8 years (SD 0.7); M/F 7/8
Number randomised: 60 (15 per group)
Number evaluated: 60 (15 per group)
Interventions Comparison: (Fixed versus removable appliances) (slow expansion) quad-helix versus expansion
plate versus composite onlays versus untreated control group
Gp A (n = 15): The quad-helix consisted of a standard stainless steel arch with stainless steel bands at-
tached with glass ionomer cement on the maxillary first molars. The quad-helix was activated 10 mm
before placement and then re-activated every 6 weeks until a crossbite correction. The treatment re-
sult was retained for 6 months
Gp B (n = 15): The expansion plate consisted of acrylic with an expansion screw and stainless steel
clasps on the deciduous and permanent first molars. The plate was activated 0.2 mm once a week by
the child until a normal transverse relationship was achieved. The treatment result was retained for 6
months
Gp C (n = 15): The composite onlay technique was based on the theory that bite raising will inhibit the
forced lateral movement and consequently allow the maxilla to grow and develop in the transverse di-
mension without locking the mandible in occlusion. The bite raising was achieved by bonding compos-
ite on the occlusal surfaces on both mandibular first molars. The composite onlay was checked every 6
weeks and removed after 1 year
Gp D (n = 15): No treatment
Outcomes Crossbite correction
Molar and canine expansion
Time to correction
Notes The sample size for each group had previously been calculated and was based on a significance level
5% and a power of 90%, to detect a mean inter-group difference in expansion of 2 mm (SD 1.5 mm). The
sample size calculation showed that each group needed a minimum of 12 children. The sample size tar-
get was met
Risk of bias
Random sequence genera- Low risk Quote: "The subjects were randomized as follows: 4 opaque envelopes were
tion (selection bias) prepared with 20 sealed notes in each (5 notes for each group). Thus, for every
new patient in the study, a note was extracted from the first envelope. When
the envelope was empty, the second envelope was opened, and the 20 new
notes were extracted as patients were recruited to the study. This procedure
was then repeated 2 more times"
Allocation concealment Low risk Quote: "The envelope was in the care of 1 investigator...who was contacted
(selection bias) and randomly extracted a note and informed the dentist which treatment
strategy to use"
Blinding of outcome as- Low risk Quote: "Measurements were blinded; the examiner was unaware of which
sessment (detection bias) treatment the patients had received or which models were taken at T0 and T1"

Informed decisions.

Petrén 2008 (Continued)
All outcomes
Incomplete outcome data Low risk Quote: "Data on all patients were analyzed on an intention-to-treat (ITT) ba-
(attrition bias) sis... all patients, successful or not, were included in the final analysis" and "all
All outcomes patients finished the trial (Fig 5)"
porting bias)

Ramoglu 2010
Methods Study design: RCT
Location: Department of Orthodontics of Selçuk University, Turkey
Funding source: Selçuk University Research Projects (2003-2004)
Participants Inclusion criteria: Functional unilateral or bilateral posterior crossbite with transverse deficiency; erup-
tion of the first permanent molars
Exclusion criteria: Sagittal skeletal problem; more than 1 missing maxillary tooth in the right and left
sides of the dentition
Interventions Comparison: (Fixed appliances) semi-rapid versus rapid expansion
A splint type tooth- and tissue-borne modified bonded appliance was used for both groups
Gp A (n = 18): Semi-rapid maxillary expansion activation was two-quarter turns per day for the first
week followed by one-quarter turn per day every other day. The mean treatment time was 57.16 days
(SD 21.52)
Gp B (n = 17): Rapid maxillary expansion activation was two-quarter turns per day throughout treat-
ment, and the mean treatment time was 21.23 days (SD 8.36)
Screw activation was ended when approximately 2 mm of overcorrection was achieved, and the screw
was fixed by a ligature wire
Cephalometric treatment effects
Risk of bias

Informed decisions.

Ramoglu 2010 (Continued)
Random sequence genera- Unclear risk Quote: "The subjects were randomly divided into two groups"
Allocation concealment Unclear risk Quote: "The subjects were randomly divided into two groups"
(selection bias)
Blinding of outcome as- Unclear risk It may have been possible to blind outcome assessors if the appliances were
sessment (detection bias) removed before final measurements were made. However, this was not men-
All outcomes tioned
(attrition bias) sults tables matches the numbers that were randomised
All outcomes
porting bias)

Thilander 1984
Methods Study design: RCT
Location: Public Dental Health Service, Enköping, Sweden
Recruitment period: 1965-1967
Funding source: Grant of Swedish Medical Research Council
Participants Inclusion criteria: Children with posterior crossbites. No further definition provided
Gp A: All children 5 years of age, M/F 13/20
Gp B: All children 5 years of age, M/F 11/17
Interventions Comparison: Grinding or grinding + expansion plate versus no intervention
Gp A (n = 34): Treatment procedure comprised interceptive measures in 2 steps: grinding and, in the
event of unsatisfactory results, expansion plates
Gp B (n = 34): No treatment
Gp A were treated with grinding at age 5 years. Gp B remained untreated until the study finished 8 years
later at age 13 years. Follow-up measurements to assess crossbite correction were made at age 6, 7, 10
and 13 years

Informed decisions.

Thilander 1984 (Continued)
Outcomes Correction of crossbite
Risk of bias
Random sequence genera- Unclear risk Quote: "68 children...were randomly divided into two groups"
Allocation concealment Unclear risk Quote: "68 children...were randomly divided into two groups"
(selection bias)
Blinding of outcome as- Unclear risk Not mentioned

sessment (detection bias)
All outcomes
Incomplete outcome data High risk The dropout rate was very different between the treated group (3%) and the
(attrition bias) untreated group (18%). Reasons reported were lack of interest in the untreat-
All outcomes ed group and relocation from the town
porting bias)
F: female; Gp: group; M: male; N: number; RCT: randomised controlled trial; SD: standard deviation.

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion
Petrén 2011 Study including some of the participants from Petrén 2008 plus other participants and matched
controls
Weissheimer 2011 Participants with maxillary deficiency, not crossbite

DATA AND ANALYSES

Comparison 1. Fixed rapid (Haas) versus fixed rapid (Hyrax)
Outcome or subgroup title No. of No. of Statistical method Effect size

studies partici-
pants
1 Molar expansion (3 months after completion of 2 27 Mean Difference (IV, Fixed, 95% 0.70 [-0.25,
expansion phase) CI) 1.66]

Informed decisions.


Analysis 1.1. Comparison 1 Fixed rapid (Haas) versus fixed rapid (Hyrax),
Outcome 1 Molar expansion (3 months after completion of expansion phase).
Study or subgroup Haas Hyrax Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) Fixed, 95% CI Fixed, 95% CI
Garib 2005 4 6.5 (1) 4 6.7 (0.4) 81.76% -0.2[-1.26,0.86]
Oliveira 2004 9 8.5 (2.3) 10 3.7 (2.6) 18.24% 4.76[2.53,6.99]

Total *** 13 14 100% 0.7[-0.25,1.66]
Heterogeneity: Tau2=0; Chi2=15.47, df=1(P<0.0001); I2=93.54%
Test for overall effect: Z=1.45(P=0.15)
Favours Hyrax -20 -10 0 10 20 Favours Haas

Comparison 2. Fixed slow (quad-helix) versus removable slow (expansion plate)
Outcome or subgroup title No. of No. of Statistical method Effect size

studies partici-
pants
1 Crossbite correction 2 96 Risk Ratio (M-H, Fixed, 95% CI) 1.20 [1.04, 1.37]
2 Molar expansion 2 96 Mean Difference (IV, Fixed, 95% CI) 1.15 [0.40, 1.90]
3 Canine expansion 2 96 Mean Difference (IV, Fixed, 95% CI) 0.19 [-0.47, 0.85]

Analysis 2.1. Comparison 2 Fixed slow (quad-helix) versus
removable slow (expansion plate), Outcome 1 Crossbite correction.
Study or subgroup Quad-helix Expan- Risk Ratio Weight Risk Ratio
sion plate
n/N n/N M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Godoy 2011 33/33 30/33 74.39% 1.1[0.97,1.24]
Petrén 2008 15/15 10/15 25.61% 1.48[1.02,2.13]

Total (95% CI) 48 48 100% 1.2[1.04,1.37]
Total events: 48 (Quad-helix), 40 (Expansion plate)
Heterogeneity: Tau2=0; Chi2=3.15, df=1(P=0.08); I2=68.28%
Favours expansion plate 0.1 0.2 0.5 1 2 5 10 Favours quad-helix

removable slow (expansion plate), Outcome 2 Molar expansion.
Study or subgroup Quad-helix Expansion plate Mean Difference Weight Mean Difference
Godoy 2011 33 4.3 (2.4) 33 3.1 (2.4) 41.97% 1.22[0.06,2.38]
Favours expansion plate -2 -1 0 1 2 Favours quad-helix

Informed decisions.

Petrén 2008 15 4.6 (1.2) 15 3.5 (1.5) 58.03% 1.1[0.12,2.08]

Total *** 48 48 100% 1.15[0.4,1.9]
Heterogeneity: Tau2=0; Chi2=0.02, df=1(P=0.88); I2=0%
Test for overall effect: Z=3.01(P=0)

removable slow (expansion plate), Outcome 3 Canine expansion.
Godoy 2011 33 3 (2.5) 33 1.4 (1.8) 40.07% 1.53[0.49,2.57]
Petrén 2008 15 2 (1.2) 15 2.7 (1.2) 59.93% -0.7[-1.55,0.15]

Total *** 48 48 100% 0.19[-0.47,0.85]
Heterogeneity: Tau2=0; Chi2=10.55, df=1(P=0); I2=90.52%

ADDITIONAL TABLES

Table 1. Fixed versus fixed with mid-palatal expansion (single study comparisons)
Study Outcome Group A Group B Results
Asanza Molar expansion (3 months after Hyrax banded: Mean 6 Hyrax bonded: Mean 5.9 P value = NS (as reported in
1997 completion of expansion phase) mm (min 4.3 mm - max mm (min 3.2 mm - max the study - no SD reported)
7.2 mm) 7.7 mm)
Kilic 2008 Molar expansion (1 week after Hyrax banded: Mean 7.67 Hyrax bonded: Mean MD 0.36 (95% CI -0.72 to
completion of expansion phase) mm (SD 1.99) 7.31 mm (SD 1.45) 1.44)
P value = 0.51
Lagravere Molar expansion (6 months after Hyrax tooth-borne ex- Bone-anchored ex- MD 0.08 (95% CI -1.00 to
2010 completion of expansion phase) pander: Mean 5.83 mm pander: Mean 5.75 mm 1.16)
(SD 1.54) (SD 1.98)
P value = 0.88
Molar expansion (12 months Hyrax tooth-borne ex- Bone-anchored ex- MD 0.21 (95% CI -0.77 to
after completion of expansion pander: Mean 4.24 mm pander: Mean 4.03 mm 1.19)
phase) (SD 1.69) (SD 1.49)
P value = 0.67
Lamparski Molar expansion (3 months after 4-point expansion appli- 2-point expansion ap- P value = "No significant dif-
2003 completion of expansion phase) ance (Hyrax): Not report- pliance: Not reported ferences were found"
ed by group by group

Informed decisions.

Table 1. Fixed versus fixed with mid-palatal expansion (single study comparisons) (Continued)
Canine expansion (3 months 4-point expansion appli- 2-point expansion ap- P value = 0.331 (as reported
after completion of expansion ance (Hyrax): Mean 3.034 pliance: Mean 1.7 mm in the study - no SD report-
phase) mm ed)
Martina Molar expansion (7 months after Slow maxillary expan- Rapid maxillary expan- MD 0.60 (95% CI -0.85 to
2012 start of treatment) sion: sion: 2.05)
Mean 6.3 mm (SD 2.1) Mean 5.7 mm (SD 1.6) P value = 0.42
Mossaz- Molar expansion (7-15 weeks af- Bonded Minne: Mean 7.9 Banded Minne: Mean P value = NS (as reported in
Joelson ter start of treatment) mm (SD 1.5) 8.3* mm (SD 1.1) the study - number of par-
1989 ticipants included in analy-
sis not reported)
Canine expansion (7-15 weeks Bonded Minne: Mean 6.4 Banded Minne: Mean P value = NS (as reported in
after start of treatment) mm (SD 1.1) 5.3 mm (SD 1.9) the study - number of par-
ticipants included in analy-
sis not reported)
Stability: relapse of molar ex- Bonded Minne: Mean 2.3 Banded Minne: Mean P value = NS (as reported in
pansion (24 weeks after com- mm (SD 0.8) 2.5 mm (SD 0.6) the study - number of par-
pletion of expansion phase) ticipants included in analy-
sis not reported)
Stability: relapse of canine ex- Bonded Minne: Mean 1.6 Banded Minne: Mean P value = NS (as reported in
pansion (24 weeks after com- mm (SD 0.5) 1.2 mm (SD 0.3) the study - number of par-
pletion of expansion phase) ticipants included in analy-
sis not reported)
Ramoglu Molar expansion Semi-rapid maxillary ex- Rapid maxillary expan- MD 0.60 (95% CI -0.55 to
2010 pansion: Mean 5.71 mm sion: Mean 5.11 mm (SD 1.75)
(SD 1.66) 1.81)
P value = 0.31
Canine expansion Semi-rapid maxillary ex- Rapid maxillary expan- MD 0.36 (95% CI -0.64 to
pansion: Mean 5.13 mm sion: Mean 4.77 mm (SD 1.36)
(SD 1.47) 1.53)
P value = 0.48
CI: confidence interval; MD: mean difference; min: minimum; max: maximum; NS: not significant; RR: risk ratio; SD: standard deviation.
* There is a discrepancy between the mean reported in Table 1 (5.3) and the text (8.3). The latter must be the actual mean as the text reports
that there is no significant difference, whereas if the mean were 5.3, the P value is < 0.05 (based on assumption of no drop-outs).

Table 2. Fixed versus removable (single study comparisons)
Godoy Stability of crossbite Quad-helix: Removable expansion plate: RR 1 (95% CI 0.43 to 2.32)
2011 correction (relapse
12 months after cor- 3/33 3/33 P value = 1
rection)
Petrén Crossbite correction Quad-helix: 15/15 Composite onlays: 2/15 RR 6.20 (95% CI 1.98 to 19.43)
2008
P value = 0.002
Molar expansion Quad-helix: Mean 4.6 mm Composite onlays: Mean 0.5 MD 4.10 (95% CI 3.45 to 4.75)
(SD 1.19) mm (SD 0.46)

Informed decisions.

Table 2. Fixed versus removable (single study comparisons) (Continued)

P value < 0.00001
Canine expansion Quad-helix: Mean 2 mm (SD Composite onlays: Mean 0.63 MD 1.37 (95% CI 0.68 to 2.06)
1.18) mm (SD 0.7)
P value = 0.0001
Crossbite correction Removable expansion Composite onlays: 2/15 RR 5 (95% CI 1.31 to 19.07)
plate: 10/15
P value = 0.02
Molar expansion Removable expansion Composite onlays: Mean 0.5 MD 3.00 (95% CI 2.19 to 3.81)
plate: Mean 3.5 mm (SD mm (SD 0.46)
1.54) P value < 0.00001
Canine expansion Removable expansion Composite onlays: Mean 0.63 MD 2.07 (95% CI 1.37 to 2.77)
plate: Mean 2.7 mm (SD 1.2) mm (SD 0.7)
P value < 0.00001
CI: confidence interval; MD: mean difference; NS: not significant; RR: risk ratio; SD: standard deviation

Table 3. Other single study comparisons
Lippold Molar expansion (12 Fixed bonded Hyrax appliance No treatment: Mean P value < 0.001 (as report-
2013 months after start of treat- followed by U-bow activator: 0.8 mm ed in the study - no SD for
ment) Mean 5.1 mm mean change from baseline
reported)
Canine expansion (12 Fixed bonded Hyrax appliance No treatment: Mean P value < 0.001 (as report-
months after start of treat- followed by U-bow activator: 1 mm ed in the study - no SD for
ment) Mean 3.6 mm mean change from baseline
reported)
McNally Molar expansion (12 weeks Quad-helix + multi-bracket: Mean Expansion arch + MD -0.55 (95% CI -1.34 to
2005 after start of treatment) 4.54 mm (SD 1.27) multi-bracket: Mean 0.24)
5.09 mm (SD 1.67)
P value = 0.17
Canine expansion (12 Quad-helix + multi-bracket: Mean Expansion arch + MD -0.72 (95% CI -1.52 to
weeks after start of treat- 1.4 mm (SD 1.75) multi-bracket: Mean 0.08)
ment) 2.12 mm (SD 1.11)
P value = 0.08
Oshagh Molar and canine expan- Removable with conventional Removable with Results inadequately re-
2012 sion screw spring-loaded screw ported
Thilander Crossbite correction Grinding or grinding + expansion No treatment: RR 3.68 (95% CI 1.77 to 7.64)
1984 plate:
6/28 P value = 0.0005
26/33
CI: confidence interval; MD: mean difference; NS: not significant; RR: risk ratio; SD: standard deviation.


Informed decisions.

APPENDICES
Appendix 1. Description of appliances that can be used to treat posterior crossbite

Fixed appliances (with mid-palatal screw)
Bonded (acrylic splint)
An alternative to the banded design, this fixed expander uses posterior acrylic coverage that is bonded directly to the teeth. The posterior
bite blocks free up the occlusion by removing cuspal interferences.
Bone-anchored expander
The bone-anchored expander is composed of 2 custom-milled stainless steel onplants, 2 miniscrews and an expansion screw. The
expansion screw placed in palatal mid-line is anchored directly to the palatal surfaces of the maxilla (top jaw) with either bioglass-coated
aluminium oxide implants or osteosynthesis plates.
Expansion arch
The expansion arch is made from 1.135 mm round stainless steel wire bent into the shape of a dental arch and inserted into the extra-oral
traction tubes on the first molar bands.
Haas
A fixed maxillary expander that uses acrylic pads and heavy lingual wires to apply pressure to both the teeth and the palatal tissue during
expansion. The lingual wires are soldered to bands on the first bicuspids and the first molars and extend into the palate where they are
embedded in the acrylic pads.
Hyrax
A fixed metal expander soldered to bands on the first molars (2 points) or first molars and first bicuspids (4 points) with an 0.036-mm lingual
wire connecting the bands.
Minne expander
This is a tooth-borne appliance without any acrylic palatal covering. This design makes use of a spring loaded screw called a Minne
expander. The first premolars and molars are banded. Metal flanges are soldered onto the bands on the buccal and lingual sides. The
expander consists of a coil spring having a nut that can compress the spring. This coil spring is made to extend between the lingual metal
flanges that have been soldered. The expander is activated by closing the nut so that the spring is compressed.
Quad helix
This fixed metal expander (also available as a fixed/removable) is capable of applying forces in numerous directions depending upon how
it is activated. The 4 helical loops (2 in the first bicuspid region and 2 in the second molar region) can be activated in unison or individually
to achieve the desired results. The appliance is soldered to bands on the first molars and lingual arms run from the bands forwards to the
cuspids or first bicuspids as desired.
Removable appliances
Upper removable appliance
The upper removable appliance is an expansion plate made of acrylic, with an expansion screw and steel clasps on the first deciduous
and permanent molars.
Appendix 2. MEDLINE via OVID search strategy

1. (cross-bite$ or crossbite$).mp.
2. (posterior adj8 (teeth or tooth or dental)).mp.
3. (anteroposterior adj8 (teeth or tooth or dental)).mp.
4. "dentoalveolar inclin$".mp.
5. ((palat$ or maxilla$) adj3 (expand$ or expansion)).mp.
6. or/1-5
7. exp Orthodontics, corrective/
8. exp Orthodontics, interceptive/
9. (expan$ and (appliance$ or device$)).mp.
10. ((transpalatal or trans-palatal) and arch$).mp.
11. ("mandibular arch$" and contract$).mp.
12. (ipomaxilla$ and (correct$ or therap$)).mp.
13. ("criss-cross elastic$" or "criss cross elastic$").mp.
14. (occlusal and grind$).mp.
15. or/7-14
16. 6 and 15

Informed decisions.

The above subject search was linked to the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in MEDLINE:
sensitivity maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of theCochrane Handbook for
Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011] (Higgins 2011).
1. randomized controlled trial.pt.

2. controlled clinical trial.pt.
3. randomized.ab.
4. placebo.ab.
5. drug therapy.fs.
6. randomly.ab.
7. trial.ab.
8. groups.ab.
9. or/1-8
10. exp animals/ not humans.sh.
11. 9 not 10
Appendix 3. The Cochrane Oral Health Group's Trials Register search strategy
1 ((crossbite* or cross-bite* or "cross bite*"):ti,ab) AND (INREGISTER)
2 (("posterior teeth" or "posterior tooth"):ti,ab) AND (INREGISTER)
3 ((posterior and dental):ti,ab) AND (INREGISTER)
4 ((anteroposterior):ti,ab) AND (INREGISTER)
5 ("dentoalveolar inclin*":ti,ab) AND (INREGISTER)
6 (((palat* or maxilla*) AND (expand* or expansion)):ti,ab) AND (INREGISTER)
7 (#1 or #2 or #3 or #4 or #5 or #6) AND (INREGISTER)
8 ((orthodontic* or interceptive):ti,ab) AND (INREGISTER)
9 ((expan* and (appliance* or device*)):ti,ab) AND (INREGISTER)
10 (((transpalatal or trans-palatal) and arch*):ti,ab) AND (INREGISTER)
11 (("mandibular arch*" and contract*):ti,ab) AND (INREGISTER)
12 ((ipomaxilla* and (correct* or therap*)):ti,ab) AND (INREGISTER)
13 (("criss-cross elastic*" or "criss cross elastic*"):ti,ab) AND (INREGISTER)
14 ((occlusal and grind*):ti,ab) AND (INREGISTER)
15 (#8 or #9 or #10 or #11 or #12 or #13 or #14) AND (INREGISTER)
16 (#7 and #15) AND (INREGISTER)
Appendix 4. The Cochrane Central Register of Controlled Trials (CENTRAL) search strategy
#1 (cross-bite* in All Text or crossbite* in All Text or "cross bite*" in All Text)
#2 ((posterior in All Text near/6 teeth in All Text) or (posterior in All Text near/6 tooth in All Text) or (posterior in All Text near/6 dental in
All Text))
#3 ((anteroposterior in All Text near/6 teeth in All Text) or (anteroposterior in All Text near/6 tooth in All Text) or (anteroposterior in All Text
near/6 dental in All Text))
#4 "dentoalveolar inclin*" in All Text
#5 ((palat* in All Text or maxilla* in All Text) and (expand* in All Text or expansion in All Text))
#6 (#1 or #2 or #3 or #4 or #5)
#7 MeSH descriptor Orthodontics, corrective explode all trees
#8 (orthodontic* in All Text or interceptive in All Text)
#9 (expan* in All Text and (appliance* in All Text or device* in All Text))
#10 ((transpalatal in All Text or trans-palatal in All Text) and arch* in All Text)
#11 ("mandibular arch*" in All Text and contract* in All Text)
#12 (ipomaxilla* in All Text and (correct* in All Text or therap* in All Text))
#13 ("criss-cross elastic*" in All Text or "criss cross elastic*" in All Text)
#14 (occlusal in All Text and grind* in All Text)
#15 (#7 or #8 or #9 or #10 or #11 or #12 or #13 or #14)
#16 (#6 and #15)
Appendix 5. EMBASE via OVID search strategy

1. (cross-bite$ or crossbite$).mp.
2. (posterior adj8 (teeth or tooth or dental)).mp.
3. (anteroposterior adj8 (teeth or tooth or dental)).mp.
4. "dentoalveolar inclin$".mp.
5. ((palat$ or maxilla$) adj3 (expand$ or expansion)).mp.
6. or/1-5
Informed decisions.

7. (expan$ and (appliance$ or device$)).mp.

8. ((transpalatal or trans-palatal) and arch$).mp.
9. ("mandibular arch$" and contract$).mp.
10. (ipomaxilla$ and (correct$ or therap$)).mp.
11. ("criss-cross elastic$" or "criss cross elastic$").mp.
12. (occlusal and grind$).mp.
13. Orthodontics/
14. or/7-13
15. 6 and 14
The above subject search was linked to the Cochrane Oral Health Group filter for identifying randomised controlled trials in EMBASE via
OVID:
1. random$.ti,ab.
2. factorial$.ti,ab.
3. (crossover$ or cross over$ or cross-over$).ti,ab.
4. placebo$.ti,ab.
5. (doubl$ adj blind$).ti,ab.
6. (singl$ adj blind$).ti,ab.
7. assign$.ti,ab.
8. allocat$.ti,ab.
9. volunteer$.ti,ab.
10. CROSSOVER PROCEDURE.sh.
11. DOUBLE-BLIND PROCEDURE.sh.
12. RANDOMIZED CONTROLLED TRIAL.sh.
13. SINGLE BLIND PROCEDURE.sh.
14. or/1-13
15. (exp animal/ or animal.hw. or nonhuman/) not (exp human/ or human cell/ or (human or humans).ti.)
16. 14 NOT 15
Appendix 6. US National Institutes of Health Trials Register and the World Health Organization (WHO) International
Clinical Trials Registry Platform search strategy
orthodontic AND posterior AND crossbite
WHAT'S NEW

Date Event Description
4 April 2014 New search has been performed Searches updated to 21 January 2014.
4 April 2014 New citation required and conclusions Inclusion criteria changed to only include randomised controlled
have changed trials (RCTs). Therefore we have discarded six of the controlled
clinical trials included in the previous version. To the remaining
three RCTs we have added 12 new included RCTs in this update.
All sections updated to reflect up-to-date Cochrane review

methodology and methodological expectations of Cochrane in-
tervention reviews (MECIR). Risk of bias assessment of included
studies carried out and summary of findings tables added.

HISTORY
Protocol first published: Issue 1, 1998
Review first published: Issue 4, 1998

Informed decisions.

Date Event Description
23 June 2008 Amended Converted to new review format.
16 November 2000 New citation required but conclusions Substantive amendment. A further CCT has been found on two-
have not changed point versus four-point expansion (Schneiderman 1990) and fol-
low-up data on the treatment group from Lindner 1989 (Tsarap-
atsani 1999). Conclusions remain largely unchanged.

CONTRIBUTIONS OF AUTHORS
Jayne Harrison (JH) and Deborah Ashby wrote the protocol and previous versions of the review.
For the update:
• screening the search results and retrieving the papers: Paola Agostino (PA), Alessandro Ugolini (AU), Armando Silvestrini-Biavati (ASB);
• data extraction and risk of bias assessment: PA, AU, ASB, Alessio Signori (AS), Philip Riley (PR);
• analysing the data and interpreting the results: PA, AU, PR, AS, Jayne Harrison (JH);
• creating the 'Summary of findings' (GRADE) tables: PR;
• writing the results, discussion and conclusions: PA, AU, PR, JH.
DECLARATIONS OF INTEREST
Paola Agostino, Alessio Signori, Armando Silvestrini-Biavati, Alessandro Ugolini, Jayne E Harrison, Philip Riley: no interests to declare.
SOURCES OF SUPPORT
Internal sources
• Department of Surgical and Diagnostic Sciences, University of Genoa, Italy.
Provision of IT support and open access to the university library.

• Royal Liverpool and Broadgreen University Hospitals Trust (RLBUHT)/NHS, UK.
• School of Dentistry, The University of Manchester, UK.
• MAHSC, UK.
The Cochrane Oral Health Group is supported by the Manchester Academic Health Sciences Centre (MAHSC) and the NIHR Manchester
Biomedical Research Centre.
External sources
• National Health Service (NHS), UK.
Jayne Harrison received research and development grant funding support for previous versions of this review.
• Cochrane Oral Health Group Global Alliance, UK.
All reviews in the Cochrane Oral Health Group are supported by Global Alliance member organisations (British Association of Oral
Surgeons, UK; British Orthodontic Society, UK; British Society of Paediatric Dentistry, UK; British Society of Periodontology, UK;
Canadian Dental Hygienists Association, Canada; Mayo Clinic, USA; National Center for Dental Hygiene Research & Practice, USA; New
York University College of Dentistry, USA; and Royal College of Surgeons of Edinburgh, UK) providing funding for the editorial process
(http://ohg.cochrane.org/).
• National Institute for Health Research (NIHR), UK.
CRG funding acknowledgement:

The NIHR is the largest single funder of the Cochrane Oral Health Group.
Disclaimer:
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the
Department of Health.

Informed decisions.

DIFFERENCES BETWEEN PROTOCOL AND REVIEW
• The original protocol and previous versions of this review included controlled clinical trials (CCTs) and quasi-RCTs. In order to attempt
to limit bias, we only included RCTs in this update.
• We clarified that 'correction of crossbite' is the primary outcome of this review by listing is as such in the 'Methods' section.
INDEX TERMS
Medical Subject Headings (MeSH)

Orthodontic Appliances; Orthodontic Retainers; Orthodontics, Corrective [*methods]; Overbite [*therapy]; Palatal Expansion
Technique; Randomized Controlled Trials as Topic; Temporomandibular Joint Dysfunction Syndrome [therapy]
MeSH check words

Adolescent; Child; Child, Preschool; Humans


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Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P

Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P.

Orthodontic treatment for posterior crossbites (Review) i

Orthodontic treatment for posterior crossbites

Editorial group: Cochrane Oral Health Group

Data collection and analysis

Fixed appliances with mid-palatal expansion

Orthodontic treatment for posterior crossbites (Review) 1

Fixed versus removable appliances

Orthodontic treatment for posterior crossbites

Quality of the evidence

Orthodontic treatment for posterior crossbites (Review) 2

Orthodontic treatment for posterior crossbites (Review) 3

Settings: Typically university orthodontic/dental clinics

Cochrane Database of Systematic Reviews

GRADE Working Group grades of evidence

Settings: Public Dental Health Service and university orthodontic/dental clinics

Intervention: Fixed appliance

Comparison: Removable appliance

Removable - slow Fixed - slow expansion

Cochrane Database of Systematic Reviews

The other study also compared the fixed

The quality of the evidence (GRADE) for all

Cochrane Database of Systematic Reviews

GRADE Working Group grades of evidence

Other comparisons for treating posterior crossbites

Settings: Public Dental Health Service and university/hospital orthodontic/dental clinics

• 1 study compared a removable appliance with spring-loaded

GRADE Working Group grades of evidence

Cochrane Database of Systematic Reviews

CI: confidence interval; N/A: not applicable.

BACKGROUND (upper jaw) arch, removal of any occlusal interferences and

Secondary • British Journal of Orthodontics;

Orthodontic treatment for posterior crossbites (Review) 10

Orthodontic treatment for posterior crossbites (Review) 11

Figure 1. Study flow diagram.

Orthodontic treatment for posterior crossbites (Review) 12

Orthodontic treatment for posterior crossbites (Review) 14

Orthodontic treatment for posterior crossbites (Review) 15

Blinding of outcome assessment (detection bias) Selective reporting

Orthodontic treatment for posterior crossbites (Review) 18

Orthodontic treatment for posterior crossbites (Review) 19

Orthodontic treatment for posterior crossbites (Review) 20

Cheng 1988 Lindner 1989

Egermark 1990 Malandris 2004

Higgins 2011 Ogaard 1994

Orthodontic treatment for posterior crossbites (Review) 21

study related to specified stages of dental development. The Zuccati 2013

Characteristics of included studies [ordered by study ID]

Recruitment period: Not stated

Funding source: Not stated but study part of a Master's thesis

Clinician experience: Not stated

Participants Inclusion criteria: Children with posterior crossbites

Exclusion criteria: None stated

Age: 8.5 to 16 years

Gender: M/F 7/7

Number randomised: 14 (Gp A: 7; Gp B: 7)

Number evaluated: 14 (Gp A: 7; Gp B: 7)

Orthodontic treatment for posterior crossbites (Review) 22

Bias Authors' judgement Support for judgement

Allocation concealment Unclear risk Quote: "Appliances were randomly assigned"

Blinding of outcome as- Unclear risk Not mentioned

Other bias Low risk No other sources of bias identified