Case Report

Early correction of anterior crossbite in deciduous dentition

Dr.Divya Reddy C1, Dr.Santhosh T Paul2, Dr.UmmeAzher3, Dr.MihirNayak4, Dr.Smitha M5
1,3 : Professor, Department of Pediatric & Preventive Dentistry, Sri Rajiv Gandhi College of Dental Sciences &
Hospital, Bengaluru, Karnataka, India – 560032.
2: Professor & Head, Department of Pediatric & Preventive Dentistry, Sri Rajiv Gandhi College of Dental
Sciences & Hospital, Bengaluru, Karnataka, India – 560032.
4,5 : Reader: Department of Pediatric & Preventive Dentistry, Sri Rajiv Gandhi College of Dental Sciences &
Hospital, Bengaluru, Karnataka, India – 560032.

Address for correspondence:

Dr. Divya Reddy C
Professor,
Department of Pediatric & Preventive Dentistry,
Sri Rajiv Gandhi College of Dental Sciences & Hospital,
Bengaluru, Karnataka, India – 560032.
Phone: +91 9886651419
Email: divyacreddy@yahoo.com

ABSTRACT:
Anterior crossbite results from lingual positioning of maxillary anteriors in relation to mandibular
anterior teeth. It can be due to either skeletal or dental problems, involving one or more teeth. These
crossbites can be considered as a functional problem in a young child, which may result in skeletal
problems as the child transitions into permanent dentition. Often there is dilemma among the clinicians
regarding the correction of these crossbites in primary and early mixed dentition periods especially
owing to the child’s age and cooperative ability. This paper aims to discuss various views on early
treatment of anterior crossbites in children, the treatment objectives and different treatment strategies
discussed in the literature.

Keywords: anterior crossbite correction, deciduous dentition, early mixed dentition, children.

INTRODUCTION teeth and inadequate arch length.2 Skeletal

Anterior crossbitecan be defined as an abnormal
labiolingual relationship between one or more
maxillary and mandibular anterior incisor teeth.1 It
is differentiated into dental, skeletal and functional
crossbite. Dental anterior crossbite is reported to be
caused by various factors such as lingual eruption
of maxillary anteriors, trauma to the deciduous
anteriors resulting in lingual displacement of
permanent tooth buds, presence of supernumerary
crossbite is associated with a discrepancy in the
size of maxilla and the mandible resulting is Class
III malocclusion. Early dental interference forcing
the mandible to move forward to obtain maximum
intercuspationresults in functional crossbite or
pseudo Class III.3
An anterior crossbite in primary dentition is usually
identified by the dentists during the routine dental

54 RGUHS Journal of Dental Sciences, July 2019 / Vol-11 / Issue-2

visits or by parents, who upon noticing often
enquire as to whether treatment is required or not.
Early correction of crossbite is often considered
as a controversial issue with few investigators
considering it to be of primary importance
while others believe that these crossbites show
spontaneous correction during the transition to
permanent dentition.
This paper aims at presenting various views on
early treatment of anterior crossbites in children,
the treatment objectives and different treatment
strategies discussed in the literature.
Dilemma on correction of crossbite in primary
and early mixed dentition periods
Over the years, dental practitioners have been
hesitant about correcting crossbites in primary
dentition, probably because of lack of substantial
clinical data on the stability of the early corrections
in the permanent dentition or may be due to the
behavioral considerations in young patients.
Clifford (1971)4 strongly advocated early
correction of crossbites, especially the pseudo Class
III malocclusions. He stated that at early age, these
deviations involve only dentoalveolar structures
in deciduous dentition and if left untreated, could
lead to severe structural deformities in permanent
dentition affecting the deeper skeletal structures
of the maxilla and mandible. If a crossbite is
corrected early, normal function is restored
thereby facilitating normal development. He also
highlighted the favorable personality changes
that could occur if the child’s facial appearance is
corrected at an early age. He strongly put forth that
any advice against early correction of crossbites is
not just incorrect but is a gross neglect of a patient
in need of orthodontic treatment.
Vadiakas G (1992)3 also opinioned that anterior
crossbites usually have a strong skeletal component
and majority of pseudo Class III in early years
grow through time into Class III malocclusions.
Many other reports favoring the early correction
RGUHS Journal of Dental Sciences, July 2019 / Vol-11 / Issue-2
of primary crossbites can be found in literature.
Breitner’s (1940)5 experimental findings in young
rhesus monkeys where the primary teeth were
moved using orthodontic appliances, showed
that uneruptedsuccedaneous teeth tend to move
along with their predecessors. These findings
were applied to humans by Mathews (1969)6.
He published a case report providing additional
evidence for the orthodontic movement of
unerupted permanent teeth along with primary
teeth.Kutin and Hawes (1969)7 advocated early
correction of posterior crossbites as they observed
that posterior crossbites do not improve with the
eruption of permanent teeth.
Several authors1,3 have suggested various reasons
for early correction of anterior crossbites which
includes: establishing proper muscle balance
and preventing adverse growth before the
dentoskeletal changes becomes well established;
improving facial appearance thereby favoring
positive personality changes; preventing abnormal,
excessive wear of incisors in crossbite and avoiding
risk of periodontal diseases due to abnormal forces
exerted on teeth in crossbite.
However, some authors believe that
self-correction might occur in some patients
during the transition from primary to permanent
dentition.8-10 It was also mentioned that patients’
may develop crossbite again during the transition
dentition, even if crossbites in primary dentition
has been corrected orthodontically, thus requiring
further treatment.11
Nagahara K (1997)10 examined 44 deciduous
anterior crossbite patients on a regular 3-month
intervals between the primary and the transitional
dentition. The subjects were divided into three
groups: Group N where the crossbite involved
all the primary incisors that corrected on its own
when the permanent incisors erupted; Group R1,
where the range of crossbite was same as Group
N but crossbite persisted after the eruption of
permanent incisors; Group R2 where the range of
crossbite was beyond the two groups and persisted
55
following eruption of permanent incisors. They
observed that the skeletal characteristics of each
group differed from each other and measurements
that were statistically significant were identified
and were used to develop an equation known
as ‘Deciduous Indicator (DI)’. They observed
that lower the DI value (negative), higher is the
probability of the crossbite to self-correct at the
transitional phase. Whereas, a positive or high
score indicates the necessity for crossbite correction
in primary dentition stage.11
YuanShu Ge (2011)12 applied Deciduous indicator
by Nagahara K (2001)11 to evaluate the necessity of
early treatment for primary crossbites. They used
posterior bite raising and 2X4 appliance therapy
and found it to be effective interceptive treatment of
primary anterior crossbites which were predicted
to persist during transitional period according
to DI. Few of the corrected cases relapsed in the
transitional stagesbut authors opinioned that out
of 44 subjects predicted to have persistentcrossbite
according to DI, only 11 of them had negative
overjet or edge to edge incisor relation at the end
of 6 years, while all the patients achieved positive
overjet during the treatment.
They observed that the expected treatment
objectives of primary anterior crossbite should be
preventing the existing problem from deteriorating,
providing a more favorable environment for
normal growth and improving facial esthetics for
more psychosocial development. They identified
the relapse group to be associated with a severe
Class III pattern than stable group at the end of
treatment.
Ghiz MA (2005)13 reported that the relapse patients
had a more forward position of mandible relative
to the cranial base, a longer mandible, shorter
ramus and an increased gonial angle.
Various appliances reported in the literature for
the early correction of anterior crossbite
Various appliances have been advised for early
interceptive treatment of crossbites. Vadiakas G
56
(1992)3 has differentiated these into three categories.
First category includes the ones that deliver heavy-
intermittent forces such as inclined plane, reversed
stainless steel crowns, strip crowns, Planas’ Direct
Tracks. The force exerted by these appliances is
dependent on chewing action by the patient and
therefore is unpredictable. Heavy forces exerted by
these appliances can traumatize deciduous teeth.
The second category includes the appliances that
deliver light continuous forces such as removable
appliances with auxiliary springs, screws and fixed
light arch wire appliances like 2X4 appliance. The
light continuous forces delivered are more biologic
and effective in achieving the required correction
without discomfort especially in young children.
The last category includes the appliances for
correction of skeletal problems such as chin cups,
reverse headgears and various other functional
appliances.
Removable appliances
Simple acrylic appliance with expansion
screw with or without posterior bite plane is the
most common removable appliance reported in
the literature for the correction of anterior crossbite
(Figure 1). This forms an easy, safe and esthetically
acceptable method with reduced chairside time
as the appliance is fabricated in the laboratory.
Reports of correction of crossbite in few weeks
to few months can be found in the literature.14,15
However, compliance is always a concern in this
mode of treatment.
Clifford FO (1971)4 reported a case of crossbite
correction in deciduous dentition period in a
41/2-year-oldchild using a small, removable
black rubber positioner. The rubber positioner
was constructed on ‘corrected’ plaster casts, after
removing the maxillary anterior teeth on the casts
and repositioned in normal alignment with lower
arch. Author reported the correction of crossbite
within 6 weeks with the patient being very
cooperative even though only 41/2 years old.
Cemented appliances
Several case reports16 on use of reversed stainless
RGUHS Journal of Dental Sciences, July 2019 / Vol-11 / Issue-2
steel crowns for the correction of anterior crossbite
can be found in the literature. However, this
method was not well accepted due to the difficulty
in adapting the crown to fit a tooth in crossbite and
especially the unaesthetic appearance associated
with use of stainless steel crowns in the anterior
segment. Later, esthetic crowns such as preformed
strip crowns were used both for patients with and
without caries in the maxillary anterior teeth. This
technique involves the tipping of the long axis of
the maxillary anterior crowns buccally, thereby
positioning the mandible backwards. Reports of
crossbitecorrection in deciduous dentition in 1 or
2 weeks were published in literature using this
method.17,18 (Figure 2)
Based on similar principle, technique involving
usage of Planas’ Direct Tracks (PDTs) has been
reported to treat both anterior and posterior
crossbites in primary dentition.19 This involves
built up of composite on deciduous molars, guiding
the mandible backwards and permitting the
tongue to deliver optimal force on upper incisors.
However, good patient cooperation is necessary to
build and adjust the PDTs on deciduous molars.
Other cemented appliances include lower acrylic
bite planes20 and bonded resin composite slopes21
on lower incisors.
Functional appliances
Functional appliances such as Bionator III, 22
Bruckl appliance, 23 protraction head gear,
24 chincup therapy25 has been reported in
the literature. These appliances are used to
correct the skeletal crossbites in the growing
periods. Bruckl appliance is a simple, removable
functional appliance which consists of a fixed,
lower inclined plane which stimulates the forward
movement of maxillary incisors in crossbite and a
mandibular Hawley’s for retraction of mandibular
incisors. Muscle forces causes movement of
maxillary incisors while the labial bow exerts
retrusive forces on mandibular incisors leading to
correction of anterior crossbite.
RGUHS Journal of Dental Sciences, July 2019 / Vol-11 / Issue-2
Fixed appliances
Fixed appliances are advantageous over
removable ones in terms of compliance especially
when it comes to young children. Several fixed
appliances are reported in the literature for the
early correction of anterior crossbite. Frey CJ
(1988)26 reported use of W appliance and labial
arch wire for the correction of both anterior and
posterior crossbite in primary dentition. Total
treatment time for correction of both anterior and
posterior crossbites was reported as 6 months.
Few investigators reported correction of anterior
crossbite using rapid palatal expanders anchored
on deciduous teeth in the early mixed dentition
period. Rosa M et al (2012)27 reported a study
involving 50 patients (mean age 8y, 5m) conducted
to evaluate the effectiveness of HAAS Rapid Palatal
Expander, for inducing spontaneous correction
of crossbite involving permanent incisors. The
patients were treated with HAAS Rapid Palatal
Expander anchored on second deciduous molars
and bonded on primary canines without application
of any direct forces on permanent teeth. They
observed spontaneous correction of permanent
incisor crossbite within 6 weeks of treatment in
all cases and opinioned early maxillary expansion
by rapid palatal expander anchored on deciduous
teeth to be an effective and efficient procedure for
inducing self-correctionofanteriorcrossbitein early
mixed dentition period without involvement of
permanent teeth and with no compliance.
Another popular fixed appliance is the 2X4
appliance, comprising of bands on the first
permanent maxillary molars, brackets on maxillary
incisors and wire with advancing loops (Figure
3).Hagg U et al (2004)28 investigated the long-
termoutcome of simple fixed 2X4 appliance in 27
young patients with pseudo Class III malocclusions
in early mixed dentition period. They observed
that the first phase of treatment resulted in positive
overjet, which was maintained in the long-term
with only minority of patients requiring fixed
appliance therapy in the second phase.
57
CONCLUSION
Early correction of crossbite can help in restoring
normal function, thereby leading to normal
development. It may prevent need for further
orthodontic treatment in the future. At the least,
the severity of the malocclusion and the treatment
timing can be reduced with the early correction.
However, the compliance of the patients at this
young age is always of concern. With many
treatment options available, clinicians should
beprudent in making appropriate choice for each
patient for successful management of the anterior
crossbites involving primary teeth.
FIGURES
Figure 1: Correction of anterior crossbite using
removable appliance with Jack screw
Figure 2: Correction of anterior crossbite using
aesthetic anterior strip crowns
(Pic Courtesy –Sugandh M, Vivek DK,
Madhavika P, Suma GD. Anterior
crossbite in primary dentition treatment
with strip crowns: A case report.17)
58
Figure 3: 2X4 appliance
REFERENCES
1. Borrie F, Bearn D. Early correction of
anterior crossbites: a systematic review. J
Orthod2011;38:175-184.
2. Valentine F, Howitt JW. Implications of early
anterior crossbite correction. ASDC J Dent
Child 1970;37:420-427.
3. Vadiakas G, Viazis AD. Anterior crossbite
correction in the early deciduous dentition. Am
JOrthodDentofacOrthop 1992;102(2):160-162.
4. Clifford FO. Crossbite correction in the
deciduous dentition: Principles and procedures.
Am J Orthod 1971;59(4):343-349.
5. Breitner C. The influence of moving deciduous
teeth on the permanent successors. Am J
Orthod Oral Surg1940;26:1152-1177.
6. Mathews R. Translational movement of first
deciduous molars into second molar positions.
Am J Orthod1969;55:276-285.
7. Kutin G, Hawes RR. Posterior crossbites
in deciduous and mixed dentitions. Am J
Orthod1969;56:491-504.
8. Susami R. A cephalometric study of dentofacial
growth in mandibular prognathism. J
JpnOrthodSoc1989;67:439-446.
9. Nagahara K. A study of longitudinal changes in
the dentition of the deciduous reversed bite using
plaster casts. JpnOrthodSoc1989;48:275-303.
RGUHS Journal of Dental Sciences, July 2019 / Vol-11 / Issue-2
10. Nagahara K, Suzuki T, Nakamura S.
Longitudinal changes in the skeletal pattern
of deciduous anterior crossbite. Angle
Orthod1997;67:439-446.
11. Nagahara K, Murata S, Nakamura S, Tsuchiya
T. Prediction of the permanent dentition in
deciduous anterior crossbite. Angle Orthod
2001;71(5):390-395.
12. Ge Y, Liu J, Guo X, Han J. A follow-up study of
early interceptive treatment of primary anterior
crossbites. Eur J Orthod. 2011;33(5):551-557.
13. Ghiz MA, Ngan P, Gunel P. Cephalometric
variables to predict future success of
early orthopedic Class III treatment. Am J
OrthodDentofacOrthop 2005;127(3):301-306.
14. Ulusoy AT, Bodrumlu EH. Management of
anterior dental crossbite with removable
appliances. ContempClin Dent 2013;4(2):223-
226.
15. Prajapati D, Nayak R, Kappadi D, Nayak
A. Complete maxilla in crossbite in primary
dentition – a rare case report. Asian Pac J Health
Sci 2014;1(2):57-60.
16. Sexton T, Croll TP. Anterior crossbite correction
in the primary dentition using reversed
stainless steel crowns.ASDC J Dent Child.
1983;50(2):117-120.
17. Sugandh M, Vivek DK, Madhavika P, Suma
GD. Anterior crossbite in primary dentition
treatment with strip crowns: A case report.
International Journal of Innovative Research
and Development 2014;10(3):201-204.
18. Ramirez-Yanez G. Treatment of anterior
crossbite in the primary dentition with esthetic
crowns: Report of 3 cases. Pediatr Dent
2011;33(4):339-342.
19. Ramirez-Yanez G. Planas’ Direct Tracks as a
RGUHS Journal of Dental Sciences, July 2019 / Vol-11 / Issue-2
useful method to correct crossbite in an early
age: description of the technique and a case
report. J ClinOrthod 2003;37:294-298.
20. Nouri MR, Kennedy DB. Combined orthodontic
and restorative care of early childhood caries
and anterior crossbite: a case report. Pediatr
Dent 2001;23(3):238-240.
21. Bayrak S, Tunc ES. Treatment of anterior dental
crossbite using bonded resin-composite slopes:
Case reports. Eur J Dent 2008;2:303-306.
22. Giancotti A, Maselli A, Mampieri G, Spano E.
Pseudo Class III malocclusion treatment with
Balter’sBionator. J Orthod 2003;30:203-215.
23. Jirgensone I, Liepa A, Abeltins A. Anterior
crossbite correction in primary and mixed
dentition with removable inclined plane (Bruckl
appliance). Stomatologija. 2008;10(4):140-144.
24. Gu Y, Rabie ABM, Hagg U. Treatment effects
of simple fixed appliance and reverse headgear
in correction of anterior crossbites. Am J
OrthodDentofacOrthop 2000;117:691-699.
25. Major PW, Glover K. Treatment of anterior
crossbite in early mixed dentition. J Can Dent
Assoc 1992;58:574-579.
26. Frey CJ, Full CA. Correction of combined
anterior and posterior crossbites in the primary
dentition with fixed appliances: case report.
Pediatr Dent 1988;10(2):105-107.
27. Rosa M, Lucchi P, Mariani L, Caprioglio A.
Spontaneous correction of anterior crossbite
by RPE anchored on deciduous teeth in the
early mixed dentition. Eur J Pediatr Dent
2012;13(3):176-180.
28. Hagg U, Tse A, Bendeus M, Rabie ABM. A
follow up of early treatment of pseudo class
III malocclusion. Angle Orthod 2004;74(4):465-
472.
59