CLINICIAN’S CORNER

A bonded functional ramp to aid in asymmetric

expansion of unilateral posterior crossbites
Christian R. Kenworthy, DDS, and Rose D. Sheats, DMD, MPH
Rochester, Minn

Unilateral posterior crossbite is a common finding in patients seeking orthodontic treatment. When treating this
condition with a rapid maxillary expander, clinicians occasionally observe no resolution of the crossbite and
document an unnecessary overexpansion of the contralateral dentition. This article describes a method for
treating unilateral posterior crossbite and, specifically, the lack of crossbite correction after expansion with a
rapid maxillary expander. A composite ramp is bonded to the mesial buccal cusp of the maxillary first molar in
crossbite. The necessary materials and instruments are typically found in an orthodontic office. This adjunctive
procedure requires no more than 5 extra minutes during an examination, and no additional appointments are
necessary. (Am J Orthod Dentofacial Orthop 2001;119:320-2)

CASE REPORT

U
nilateral posterior crossbite is common in
patients seeking orthodontic treatment. The
condition may result from dental tipping,
skeletal deficiency, or cleft palate. It is almost univer-
sally associated with an asymmetrical mandibular
condylar position or with a lateral functional shift that
adapts favorably to the expanded maxillary arch.1-3 A
maxillary crossbite may be treated with many modali-
ties, ranging from a removable plate expanded 0.25
mm per week to a bonded or banded rapid maxillary
expander (RME) expanded 0.5 mm per day. Although
many methods have resulted in satisfactory expan-
sion,1-6 expansion does not always correlate with com-
plete crossbite correction.
When using an expander without occlusal cover-
age, clinicians occasionally notice adequate maxillary
expansion with persistence of the crossbite and excess
buccal overjet of the noncrossbite side. Asymmetric
expansion can be managed in several ways. One can
continue the expansion and anticipate an eventual
bilateral crossbite correction. Alternatively, one can
cease expansion and treat the crossbite with buccal-to-
lingual posterior elastics after placing upper and lower
full fixed appliances. This report describes a third
option: adding a functional ramp to induce desirable
displacement of the remodeling maxillary sutures with
masticatory forces.
From the Division of Orthodontics, Mayo Clinic and Mayo Foundation,
Rochester, Minn.
Reprint requests to: Rose D. Sheats, Mayo Clinic, 200 First St SW, Rochester,
MN 55905.
Submitted, August 2000; revised and accepted, September 2000.
Copyright © 2001 by the American Association of Orthodontists.
0889-5406/2001/$35.00 + 0 8/1/112117
doi:10.1067/mod.2001.112117
320
An 11-year-old girl was referred by her general den-
tist for the correction of a unilateral posterior crossbite
(Fig 1). Her medical and dental histories were unremark-
able. A slight (1-mm) anterior centric relation–centric
occlusion shift was detected, but no lateral shift, discom-
fort, or joint sounds were detected. The mandibular den-
tal midline was slightly to the patient’s right relative to
the maxillary midline, and the left permanent first molars
were in crossbite. A transitional Class I malocclusion
with left-sided posterior crossbite was diagnosed. Her
treatment plan included 2 phases. During the first phase,
the crossbite was treated with an RME for 6 months. Dur-
ing the second phase, the final detailing with fixed appli-
ances was performed after the permanent dentition had
erupted. Only the first phase is described here.
After the RME was cemented, the patient was
directed to activate the device 0.5 mm per day for 7
days. When the patient returned 1 week later, there was
3.5 mm of expansion, but the left molars remained in
crossbite (Fig 2). The mesial buccal cusp of the maxil-
lary left first molar was then etched, rinsed, and dried.
Adhesive and resin (Transbond LR, 3M Unitek, Mon-
rovia, Calif) were added to lengthen the cusp by
approximately 3 mm. This ramp guided the mandible
into a bilateral noncrossbite occlusion with noncoinci-
dent midlines (Fig 3). The ramp remained on the tooth
during the expansion phase.
The patient continued to activate the RME for 7
more days at a rate of 0.25 mm per day until she had
achieved 5.25 mm of expansion, at which point the
RME was secured with a steel ligature. Two months
later, the patient was comfortable with the new habitual
closing position, the bilateral crossbite correction, and
the slight resolution of the midline discrepancy (Fig 4).
American Journal of Orthodontics and Dentofacial Orthopedics Kenworthy and Sheats 321
Volume 119, Number 3

Fig 1. Pretreatment records of 11-year-old girl with unilateral posterior crossbite.

Fig 2. One week after rapid maxillary expander was activated 0.5 mm per day; left
molars remained in crossbite.

Fig 3. A bonded 3-mm ramp lengthened the buccal cusp of the maxillary left first molar
and guided mandible into bilateral noncrossbite occlusion with noncoincident midlines.

Fig 4. Bilateral crossbite correction 2 months after treatment began with rapid
maxillary expander and bonded ramp.

Fig 5. Two months after settling began, left maxillary molar had settled 1 mm.
322 Kenworthy and Sheats
A B
Fig 6. Posteroanterior cephalograms. A, Pretreatment;
B, posttreatment.
The appliance and ramp were removed, and the patient
was given an upper Hawley retainer and instructed to
wear it full time. At her 2-month observation appoint-
ment, the left maxillary molar had settled approxi-
mately 1 mm buccally to the retainer and the dental
midlines had returned to their pretreatment position
(Fig 5). Use of the retainer was discontinued. No cen-
tric relation–centric occlusion shift was detected.
A new posteroanterior cephalogram was obtained,
digitized, and compared with the pretreatment record
(Fig 6). Comparison of the mandibular molars revealed
no change in torque with an expansion of 1.5 mm (uncor-
rected for magnification). The maxillary molars had 6
mm of uncorrected expansion at the buccal cusps, and
although no torque difference was measured on the right,
the left molar crown was torqued buccally 20° from the
facial midline. Relative to the cranial base, the mandibu-
lar midline was not altered during this phase of treatment.
DISCUSSION
Presumably, the maxillary sutures were remodeling
while the RME was actively expanding; therefore, we
American Journal of Orthodontics and Dentofacial Orthopedics
March 2001
reasoned that they might respond to lateral forces from
a functional ramp. We recognized the transient
mandibular shift that occurred immediately after ramp
placement. Our aim was to induce expansion of the
crossbite side by using masticatory forces as the
mandible resumed a normal closing pattern over time.
If the midpalatal and zygomatic-maxillary sutures were
actively remodeling, the maxilla would be more
responsive to these forces than the mandible. This
would eventually induce the maxilla to change and the
mandible to return to its original position.
CONCLUSIONS
This article presents a method for treating unilateral
crossbite with a conservative and reversible mechanism
that has been successful for many patients. The advan-
tages include no need for patient compliance, no need
for additional supplies or equipment, no additional
appointments, and no additional laboratory costs. This
procedure may be contraindicated for patients in whom
prolonged significant signs or symptoms of a temporo-
mandibular disorder develop after ramp fabrication.
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