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Case Report

Taking a Glance at Anterior Crossbite in Children: Case Series

Abstract Derya Ceyhan,

Anterior crossbite is a malocclusion that takes place for various reasons, leads to major problems Canan Akdik
and may be fixed using various methods. This study aimed to provide an update regarding the Department of Paediatric
methods used for anterior crossbite treatment presenting treatments of the removable active acrylic Dentistry, Faculty of Dentistry,
appliance with bite plane. Clinical examination of aged 9–15, seven healthy children who visited Suleyman Demirel University,
our clinic due to crowding and esthetic displeasure in anterior teeth indicated that one or more Isparta, Turkey
permanent maxillar incisor teeth were positioned behind of permanent mandibular incisor teeth.
After clinical‑radiographical examinations, removable active acrylic appliances with bite plane were
decided to apply. Patients with adapted‑activated appliances were called to follow‑ups once a week.
Treatments continued 4–6 weeks in mixed dentition, 7–8 weeks in permanent dentition. In choosing
the method, advantages‑disadvantages, indications‑contraindications of methods should be discussed.
Correct indication and suitable motivation are important for the success of anterior crossbite treatment.

Keywords: Anterior crossbite, pediatric patients, removable appliance, treatment

Introduction From the past to the day, the methods

Anterior crossbite is defined as the
malocclusion that results in maxillar
anterior teeth being positioned behind of
mandibular anterior teeth.[1] Its prevalance
in different countries around the world
varies between 2.2% and 36%.[2‑5] It was
expressed that the appearance of anterior
crossbite intensifies with the eruption of
permanent teeth.[6] It is known that anterior
crossbite is caused by conditions such as
supernumerary teeth, odontomas, persistent
primary teeth, traumatized primary incisor
teeth, lip biting habit, and lack of space.[7‑9]
Early diagnosis and treatment of anterior
crossbite cases are recommended to prevent
tooth wear, anterior tooth fractures, gum
problems, and temporomandibular joint
disorders and to achieve a better functional
occlusion and esthetics.[10,11] Therefore, to
diagnose and treat the malocclusion early
and to supervise the patient properly are
important for healthy physiological and
psychological development.
The treatment is performed by fixed or
removable approaches that practice the
movement of mandibular anterior teeth
toward the lingual, the movement of
maxillar anterior teeth towards the labial, or
used for anterior crossbite treatment
included tongue blade, reversed
prefabricated stainless steel crowns,
composite inclined plane, fixed orthodontic
treatment, and removable active acrylic
appliances with bite plane.[9,12,13] Although it
has been reported that factors such as child’s
age, number of teeth to be repositioned,
total number of teeth, status of occlusion,
and motivation of child and parents should
be considered in deciding which of these
methods to be used, clinicians occasionally
experience dilemmas in choosing the
method.[12,14]
In the present study, it was aimed to present
the treatment of children with anterior
crossbite by removable active acrylic
appliance with bite plane and provide an
Address for correspondence:
update regarding the methods used for
Dr. Derya Ceyhan,
anterior crossbite treatment. Department of Paediatric
Dentistry, Faculty of Dentistry,
Case Report Suleyman Demirel University,
Isparta, Turkey.
In the clinical examination of aged E‑mail: derya_ceyhan@yahoo.
9–15 years, 7 healthy children who visited com
our clinic due to crowding and esthetic
displeasure in their anterior teeth, it was
examined that one or more permanent Access this article online
maxillary incisor teeth were positioned Website:
behind of permanent mandibular incisor
www.contempclindent.org

a combination of these.[1]
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teeth [Figures 1a, 1c, 2a, 2c, 3a, 4a and 4c]. DOI: 10.4103/ccd.ccd_633_17
Quick Response Code:
It was first checked whether the mesiodistal
distance to allow the labial movement
How to cite this article: Ceyhan D, Akdik C. Taking
a glance at anterior crossbite in children: Case series.
Contemp Clin Dent 2017;8:679-82.

679 © 2017 Contemporary Clinical Dentistry | Published by Wolters Kluwer - Medknow

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Ceyhan and Akdik: Anterior crossbite: Case series
a b
c d
Figure 1: (a) A 9-year-old male patient with crossbite of 11 numbered tooth.
(b) After 4 weeks, intraoral view of the patient following the treatment. (c)
A 9-year-old female patient with crossbite of 11 numbered tooth. (d) After
5 weeks, intraoral view of the patient following the treatment
a b
Figure 3: (a) A 10-year-old male patient with crossbite of 11 and 21 numbered
teeth. (b) After 6 weeks, intraoral view of the patient following the treatment
of maxillary permanent anterior teeth was sufficient in
children, and it was confirmed that there were no skeletal
abnormalities. After these examinations, it was decided
to apply a removable active acrylic appliance with bite
plane. Written informed consent forms were obtained
from the each of parents and patients. The appliance
planning was made on the working models obtained
by pouring hard plaster to the dental impressions taken
using the irreversible hydrocolloid impression material,
alginate (Zetalgin, Zhermack Group, Rovigo, Italy), and
the models were sent to the laboratory as soon as possible.
The prepared appliances were adapted to the mouth of the
patients and activated. The patients were informed about
taking care of their oral hygiene, using the appliance
regularly, removing it during meals, and putting it on and
off. The patients were called to follow‑ups once a week
and were evaluated on the account of oral hygiene, usage
of the appliance and movement of the teeth. Durations
of the treatments were 4–6 weeks in the mixed dentition
period [Figures 1b, 1d, 2b, 2d and 3b] and 7–8 weeks
in the permanent dentition period [Figures 4b and d]. At
the end of these durations, it was observed that maxillary
permanent incisor teeth were placed in the position they
needed to be and esthetics was achieved.
Discussion
One of the main purposes of pediatric dentistry is to prevent
malocclusions by facilitating the correct positioning of teeth
Contemporary Clinical Dentistry | Volume 8 | Issue 4 | October ‑ December 2017
a b
c d
Figure 2: (a) A 9-year-old female patient with crossbite of 11 and 21
numbered teeth. (b) After 6 weeks of treatment, intraoral view of the patient
when she was at the age of 14 years old. (c) A 10-year-old male patient with
crossbite of 11 numbered tooth. (d) After 6 weeks of treatment, intraoral
view of the patient when he was at the age of 15 years old
a b
c d
Figure 4: (a) A 12-year-old male patient with crossbite of 11 numbered tooth.
(b) After 8 weeks, intraoral view of the patient following the treatment. (c)
A 15-year-old female patient with crossbite of 11 numbered tooth. (d) After
7 weeks, intraoral view of the patient following the treatment
and healthy development of jaw arcs through tooth eruption
guidance. For children at the growth and development period,
solving problems with minor interventions affects their
social life positively. Therefore, anterior crossbite treatment
is a highly conservative approach for pediatric patients when
it is diagnosed correctly and treated appropriately.
In choosing the method, discussion related to the
advantages‑disadvantages and indications‑contraindications
of the approaches used in anterior crossbite treatment
should be carried out.
It was reported for the tongue blade method, which is
considered simple and economical, that it may be used in
the early period of tooth eruption, it is not sufficient to
repose more than one tooth, and it is difficult to provide
the patient’s compliance to the treatment.[15,16] In addition,
it has been reported that there is no accurate control of
the amount and direction of force applied.[17] McEvoy[18]
applied the tongue blade method in an 8‑year‑old child
with anterior crossbite, and she stated that this method is a
suitable approach for cooperative children whose teeth are
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Ceyhan and Akdik: Anterior crossbite: Case series
in the early period of eruption. This method was not used
for our patients because two patients had crossbite at more
than one tooth, three patients would experience difficulty
in applying this method correctly, and two patients were in
the late period of tooth eruption.
For reversed prefabricated stainless steel crown, which is
resistant and has low cost and does not require an effort by
patients, it was reported that application of the crown onto
the teeth with crossbite is difficult, the duration patients
spend on dental unit is long, and it is generally not preferred
by patients and their parents as it is unesthetic.[19] It was
not chosen for our patients due to these disadvantages.
Composite inclined plane, which does not require
laboratory procedures, does not cause pain in patients and
is esthetically acceptable, was not preferred in our patients
because it is costly, the duration patients spend on dental
unit may be long, it may affect patient’s psychology
negatively, it cannot be used in cases where the anterior
crossbite involves more than one‑third of the crown
height, and it may lead to gum problems, as well as tooth
structure loss while removing from teeth at the end of the
treatment. However, due to the disadvantages of other
treatment methods, Bayrak and Tunc[8] preferred composite
inclined plane treatment in 7–9 aged 3 pediatric patients
and reported that the teeth with crossbite were positioned
to normal position in 1 or 2 weeks, and this treatment is an
effective and simple method resulting in a short time. It is
seen that the observation of clinicians on patients and their
indication decisions are important in choosing the method.
Fixed orthodontic treatments, which are costly and
time‑consuming, require comprehensive planning and
clinician’s effort and have risk of causing gum problems,
dental caries, and pain, are preferred generally in patients
who cannot show suitable compliance to the treatment. This
treatment method was not preferred as our patients showed
suitable compliance to the treatment. On the other hand,
Wiedel and Bondemark[20] compared the fixed orthodontic
treatment with the removable active appliance with bite
plane treatment used in anterior crossbite and reported that
fixed orthodontic treatment may provide shorter treatment
duration but both methods are highly effective.
The removable active acrylic appliance with bite plane is
reported to be an easily applicable and a reliable method.[21]
Its advantages include that the duration patients spend on
dental unit is short as it is prepared in a laboratory, the patient
can remove it unsuitable social settings, it is easy to clean
and achieve oral hygiene, it does not harm soft tissues, and
it is economical.[1,7,22] In addition, with this appliance, it is
possible to control the amount of movement of tooth or teeth
with crossbite. On the other hand, the requirement of patient
cooperation and laboratory procedures, uncomfortableness
and intolerableness are considered as its disadvantages.
[23]
Ulusoy and Bodrumlu[24] applied removable active
acrylic appliance with bite plane treatment on a patient at
681 Contemporary Clinical Dentistry | Volume 8 | Issue 4 | October ‑ December 2017
the age of 8 years and reported that teeth with crossbite
were correctly positioned after 4 months, and it is a highly
effective, manageable, easily usable method that does not
harm soft tissues and may be applied to children of early
ages. Compared to our treatment durations, longer duration
of their treatment may have been caused by the occlusion
problem that included in more than one tooth and was
more complicated. Furthermore, it was reported that the
production of organic matrix in the periodontal ligament,
mitotic activities and soluble collagen levels of cells, and
osteoblastic and osteoclastic activities are decreased as
patients get older.[25,26] The duration of the treatments may
have differed among our patients due to these factors.
Due to limitations of working time on pediatric patients
and potential psychological problems that may arise from
a fixed system placed into the mouth, the removable
active appliances with bite plane were preferred in our
patients. Its preferability increased by advantages such
as its economical, harmless, and easily applicable nature.
Our patients did not complain about its uncomfortableness
and intolerableness, which are known as disadvantages
of this appliance. In our study, the patients showed good
cooperation, they did not experience difficulty in using
the appliance and achieving oral hygiene, the teeth were
correctly positioned after the treatment, esthetics was
provided, and gums were healthy.
Conclusion
When correct indication is established, and suitable
motivation is achieved, the removable active acrylic
appliance with bite plane is considered as a method that
can be easily applied by clinicians, tolerated by patients,
and resulted in a short time in anterior crossbite treatment
in pediatric patients of different ages.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal. The
patients understand that their names and initials will not
be published and due efforts will be made to conceal their
identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Park JH, Kim TW. Anterior crossbite correction with a series of
clear removable appliances: A case report. J Esthet Restor Dent
2009;21:149‑59.
2. Keski‑Nisula K, Lehto R, Lusa V, Keski‑Nisula L, Varrela J.
Occurrence of malocclusion and need of orthodontic treatment
[Downloaded free from http://www.contempclindent.org on Tuesday, March 31, 2020, IP: 125.160.67.75]
Ceyhan and Akdik: Anterior crossbite: Case series
in early mixed dentition. Am J Orthod Dentofacial Orthop
2003;124:631‑8.
3. Karaiskos N, Wiltshire WA, Odlum O, Brothwell D, Hassard TH.
Preventive and interceptive orthodontic treatment needs of an
inner‑city group of 6‑and 9‑year‑old Canadian children. J Can
Dent Assoc 2005;71:649.
4. Schopf P. Indication for and frequency of early orthodontic
therapy or interceptive measures. J Orofac Orthop
2003;64:186‑200.
5. Thilander B, Myrberg N. The prevalence of malocclusion in
Swedish schoolchildren. Scand J Dent Res 1973;81:12‑21.
6. Davis JW. Why early treatment of cross‑bites? Dent Dig
1969;75:449‑52.
7. Major PW, Glover K. Treatment of anterior cross‑bites in the
early mixed dentition. J Can Dent Assoc 1992;58:574‑5, 578‑9.
8. Bayrak S, Tunc ES. Treatment of anterior dental crossbite
using bonded resin‑composite slopes: Case reports. Eur J Dent
2008;2:303‑6.
9. Hannuksela A, Väänänen A. Predisposing factors for malocclusion
in 7‑year‑old children with special reference to atopic diseases.
Am J Orthod Dentofacial Orthop 1987;92:299‑303.
10. Estreia F, Almerich J, Gascon F. Interceptive correction of
anterior crossbite. J Clin Pediatr Dent 1991;15:157‑9.
11. Jacobs SG. Teeth in crossbite: The role of removable appliances.
Aust Dent J 1989;34:20‑8.
12. Kiyak HA. Patients’ and parents’ expectations from early
treatment. Am J Orthod Dentofacial Orthop 2006;129:S50‑4.
13. Valentine F, Howitt JW. Implications of early anterior crossbite
correction. ASDC J Dent Child 1970;37:420‑7.
14. Croll TP, Riesenberger RE. Anterior crossbite correction in
the primary dentition using fixed inclined planes. II. Further
examples and discussion. Quintessence Int 1988;19:45‑51.
Contemporary Clinical Dentistry | Volume 8 | Issue 4 | October ‑ December 2017
15. Deam JA, McDonald RE, Avery DR. Managing the developing
occlusion. In: McDonald RE, editor. Dentistry for the Child and
Adolescent. 7th ed. London: Mosby; 2000. p. 677‑741.
16. Graber TM. Orthodontics Principles and Practice. 3rd ed.
Philadelphia: W.B. Saunders; 1972. p. 673‑5.
17. Asher RS, Kuster CG, Erickson L. Anterior dental crossbite
correction using a simple fixed appliance: Case report. Pediatr
Dent 1986;8:53‑5.
18. McEvoy SA. Rapid correction of a simple one‑tooth anterior
cross bite due to an over‑retained primary incisor: Clinical
report. Pediatr Dent 1983;5:280‑2.
19. Croll TP. Correction of anterior tooth crossbite with bonded
resin‑composite slopes. Quintessence Int 1996;27:7‑10.
20. Wiedel AP, Bondemark L. Fixed versus removable orthodontic
appliances to correct anterior crossbite in the mixed dentition – A
randomized controlled trial. Eur J Orthod 2015;37:123‑7.
21. Fields HW. Treatment of nonskeletal problems in preadolescent
children. In: Proffit WR, editor. Contemporary Orthodontics.
4th ed. St. Louis, Missouri: Elsevier; 2007. p. 433‑94.
22. Fields HW. Biomechanics, mechanics, and contemporary
orthodontic appliences. In: Proffit WR, editor. Contemporary
Orthodontics. 4th ed. St. Louis, Missouri: Elsevier; 2007.
p. 397‑402.
23. Skeggs RM, Sandler PJ. Rapid correction of anterior
crossbite using a fixed appliance: A case report. Dent Update
2002;29:299‑302.
24. Ulusoy AT, Bodrumlu EH. Management of anterior dental
crossbite with removable appliances. Contemp Clin Dent
2013;4:223‑6.
25. Ren Y, Maltha JC, Hof MA, Kuijpers‑Jagtman AM. Age effect on
orthodontic tooth movement in rats. J Dent Res 2003;82:38‑42.
26. Van der Velden U. Effect of age on the periodontium. J Clin
Periodontol 1984;11:281‑94.
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