Volume 35 Issue 1 Article 1

April 2023

Transverse Malocclusions: Etiology, Development, Diagnosis and

Treatment
Ib Leth Nielsen
Department of Orofacial Sciences, Division of Orthodontics University of California, San Francisco, CA,
USA

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Recommended Citation
Nielsen, Ib Leth (2023) "Transverse Malocclusions: Etiology, Development, Diagnosis and Treatment,"
Taiwanese Journal of Orthodontics: Vol. 35: Iss. 1, Article 1.
https://doi.org/10.38209/2708-2636.1328
Available at: https://www.tjo.org.tw/tjo/vol35/iss1/1

This Review Article is brought to you for free and open access by Taiwanese Journal of Orthodontics. It has been
accepted for inclusion in Taiwanese Journal of Orthodontics by an authorized editor of Taiwanese Journal of
Orthodontics.
Transverse Malocclusions: Etiology, Development, Diagnosis and Treatment

Abstract
Malocclusions that involve the transverse dimension are very common in the orthodontic office. They can
be as simple as a crossbite of the posterior teeth or as severe as a Class III malocclusion with a
mandibular asymmetry. Transverse malocclusions can vary from being a simple dento-alveolar problem
to a more complex challenge as represented by a skeletal asymmetry that has developed after puberty
and causing temporomandibular disorder (TMD) problems. In this review we shall address the most
common types of transverse malocclusions and review their etiology and development. The most typical
etiology of transverse anomalies will be discussed, and we will suggest diagnostic criteria to differentiate
the individual malocclusions. We shall also introduce a frontal cephalometric analysis that relates to the
anterior part of the face helping to differentiate between dento-alveolar and skeletal transverse
malocclusions as well as determine the presence of dento-alveolar compensations. Furthermore, we shall
suggest possible treatment approaches and the best timing of treatment for the most common types of
transverse malocclusion. Finally, we shall present several cases with more unusual etiology including a
case with mandibular asymmetry due to an anterior disc displacement of temporomandibular joint. A
case with Class III malocclusion with mandibular overjet caused by maxillary stenosis will also be
presented. Furthermore, we will show an example of a late developing mandibular asymmetry which is
not an uncommon problem and document a case of excess mandibular growth with mandibular
asymmetry and Class III malocclusion combined with posterior crossbite. This review will also address
considerations that may affect the post treatment stability.

Keywords
Posterior lingual crossbite; Posterior buccal crossbite; Mandibular asymmetry; Lower midline deviation;
Asymmetric mandibular growth; Treatment timing.

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This review article is available in Taiwanese Journal of Orthodontics: https://www.tjo.org.tw/tjo/vol35/iss1/1

REVIEW ARTICLE

Transverse Malocclusions: Etiology, Development,

Diagnosis and Treatment

Ib Leth Nielsen*

Department of Orofacial Sciences, Division of Orthodontics University of California, San Francisco, CA, USA

ABSTRACT

Malocclusions that involve the transverse dimension are very common in the orthodontic office. They can be as simple
as a crossbite of the posterior teeth or as severe as a Class III malocclusion with a mandibular asymmetry. Transverse
malocclusions can vary from being a simple dento-alveolar problem to a more complex challenge as represented by a
skeletal asymmetry that has developed after puberty and causing temporomandibular disorder (TMD) problems. In this
review we shall address the most common types of transverse malocclusions and review their etiology and development.
The most typical etiology of transverse anomalies will be discussed, and we will suggest diagnostic criteria to differ-
entiate the individual malocclusions. We shall also introduce a frontal cephalometric analysis that relates to the anterior
part of the face helping to differentiate between dento-alveolar and skeletal transverse malocclusions as well as
determine the presence of dento-alveolar compensations. Furthermore, we shall suggest possible treatment approaches
and the best timing of treatment for the most common types of transverse malocclusion. Finally, we shall present several
cases with more unusual etiology including a case with mandibular asymmetry due to an anterior disc displacement of
temporomandibular joint. A case with Class III malocclusion with mandibular overjet caused by maxillary stenosis will
also be presented. Furthermore, we will show an example of a late developing mandibular asymmetry which is not an
uncommon problem and document a case of excess mandibular growth with mandibular asymmetry and Class III
malocclusion combined with posterior crossbite. This review will also address considerations that may affect the post
treatment stability. Taiwanese Journal of Orthodontics 2023;35(1):1e17

Keywords: Posterior lingual crossbite; Posterior buccal crossbite; Mandibular asymmetry; Lower midline deviation;
Asymmetric mandibular growth; Treatment timing

INTRODUCTION this type of malocclusion. In most patients,

transverse malocclusions do not exist as a sepa-

T ransverse malocclusions are frequently seen

in the orthodontic office and include both
malocclusions in the posterior and anterior region
of the dentition. In the anterior region they are
mostly present as midline deviations of the lower
or upper front teeth. When reviewing the litera-
ture on the topic, one finds that sagittal and ver-
tical malocclusions have received much more
attention as compared to transverse malocclu-
sions. Epidemiological studies, however, have
shown that transverse malocclusions are quite
common in nearly all populations.1e7 In this re-
view it is the intention to bring more attention to
rate entity but are nearly always present in com-
bination with additional problems in both the
sagittal and vertical dimension.
When it comes to treatment, it is often necessary
to correct the transverse problem before the sagittal
or vertical malocclusions can be corrected. Typi-
cally, in patients with a Class II, Div. 1 malocclusion
that the upper jaw should be expanded prior to
correcting the sagittal problem by widening the
dental arch. Timing of treatment of posterior
crossbite is an important issue as the posterior
crossbite left untreated until all teeth have erupted
often resulting in an underdeveloped maxilla. The
most desirable time to address this issue is in the
early mixed dentition.

Received 3 January 2023; revised 14 February 2023; accepted 28 February 2023.

Available online 30 March 2023

* Address correspondence to Emeritus Professor Ib Leth Nielsen: University of California, 60 Lambeth Sq., Moraga, CA, 94556, USA.
E-mail address: ibortho9@gmail.com.

https://doi.org/10.38209/2708-2636.1328
2708-2636/© 2023 Taiwan Association of Orthodontist. This is an open access article under the CC-BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
I.L. NIELSEN
TRANSVERSE MALOCCLUSIONS
Posterior crossbite is one of the most common
malocclusions seen in young children in the mixed
dentition. These crossbites can develop as the result
of a persistent finger sucking habit persistent finger
sucking habit, an inherited narrow maxilla, or from
a sleeping habit. The latter can cause a unilateral
posterior crossbite that often is associated with a
mandibular shift. This problem can, if not treated
early, lead to a more permanent asymmetry of the
mandible. Crossbite can exist in two forms namely
lingual crossbite which is by far the most common,
and buccal crossbite where the upper teeth are
outside of the lower arch. This latter malocclusion
has also been referred to as the Brodie syndrome
when the upper posterior teeth occlude outside of
the lower arch. The buccal crossbite is occasionally
seen in patients with Class II, Div. 2 malocclusion,
and the development of this malocclusion has been
explained previously by Nielsen.8
Etiology and development of transverse
malocclusion
Transverse malocclusions are in many cases a
combination of inherited and acquired changes. In
case of the posterior crossbites they are often asso-
ciated with airway problems, an inherited maxillary
deficiency, or the dental eruption. In some patients
the posterior crossbite is genetic and associated with
a narrow maxilla. In others, they are environmental
and developmental because of airway problems,
abnormal tooth eruption, early loss of teeth or
habits. On the other hand, facial asymmetries
mostly develop as a result of disordered craniofacial
development that happen after birth.9
Mandibular asymmetry commonly develops from
a variety of causes including inflammatory resorp-
tion of the condyle, and hyperplastic condylar
growth after trauma. Several studies have examined
the asymmetries of the facial skeleton, and most
have concluded that facial asymmetries are a com-
mon occurrence.10e12 In this review we shall focus
on transverse malocclusions that are within normal
range of facial development.
Diagnosis of transverse malocclusions
In the following we shall look at the possible
diagnostic criteria that separate the different trans-
verse malocclusions. The transverse malocclusions
can be divided into those that are primarily related
to the posterior teeth and those related to the
anterior teeth. An important difference between
transverse malocclusions and those in the vertical
and sagittal plane is that there is an additional
2
Taiwanese Journal of Orthodontics
2023;35(1):1e17
Table 1. Classification of transverse malocclusions.
Posterior occlusion Anterior occlusion
Lingual crossbite
Unilateral Maxillary midline deviation
▪ Skeletal Skeletal
▪ Dental Dental
▪ Postural Postural
Bilateral Mandibular midline deviation
▪ Skeletal Skeletal
▪ Dental Dental
▪ Postural Postural
Buccal crossbite
Bilateral
▪ Skeletal
▪ Dental
▪ Postural
Unilateral
▪ Skeletal
▪ Dental
▪ Postural
category in the group of transverse discrepancies,
namely the postural malocclusions. The possible
transverse malocclusions are listed in Table 1.
As seen in the Table 1, there are many possibilities
for transverse malocclusions, and they can be quite
complex. It is therefore important to diagnose these
precisely before making any treatment decisions. In
other words, it is in each case critical to know what
type of problem is associated with the occlusion.
The category labeled Postural refers to the situation
where a malocclusion is present that is the result of
the lower jaw being guided or forced into a forward
position. This is frequently the result of one or more
teeth interfering and is commonly observed in
young patients with anterior crossbite, an example
can be seen in Figure 1.
Another situation where a postural problem can
be present is related to a side shift manifesting itself
in a midline discrepancy caused by pointy decidu-
ous canines that guide the lower jaw into a postured
forward position or a side shift preventing the pa-
tient from biting correctly. This situation is impor-
tant to assess prior to treatment as it may affect both
the treatment plan and also the design of the
appliance and its use.
Cephalometric analysis of the postero-anterior (PA)
headfilm
The analysis of the skeletal and dental compo-
nents using a frontal x-ray has long proven to be
helpful in differentiating between the different types
of transverse malocclusions.13e16 Whereas the
lateral headfilm can be useful in determining the
sagittal and vertical relationships, a frontal or PA
cephalometric headfilm can be helpful in analyzing
Taiwanese Journal of Orthodontics
2023;35(1):1e17
Figure 1. Seven-year-old boy with anterior and posterior crossbite. When manipulating the mandible the patient can bite in an edge-to-edge
occlusion.
the anterior and posterior transverse relationships.
In this context assessing the extent of any midline
discrepancy and possible dento-alveolar compen-
sations is also an important part of the analysis. A
new analysis in this area has been introduced by
Svanholt et al. This analysis can help in locating the
midline discrepancies more precisely and assess if
any dental compensations are present and where
they are located.17
The Svanholt and Solow analysis, seen in Figure 2,
focuses on midline deviations in the anterior part of
the face. This analysis helps to determine if the
deviations are skeletal or dental and if there are
dento-alveolar compensations in cases with a skel-
etal deviation. Other analyses that were introduced
by Dahan, Grummons, Ricketts and Letzer have
addressed the posterior discrepancies in the trans-
verse plane.13e16 Among the PA analysis of poste-
rior discrepancies, the Grummons and Ricketts
analysis (1987) is undoubtedly the most detailed and
comprehensive as it goes into detail with respect to
the skeletal and dentoalveolar relationships.
The primary intention with the Svanholt and
Solow analysis is to locate midline discrepancies,
3
I.L. NIELSEN
TRANSVERSE MALOCCLUSIONS
and help to decide if they are in the maxilla,
mandible, or both.17 The reference lines consist of
the following. A vertical line (ORP), that represent
the facial midline, and is perpendicular to the
orbital line from (lo) left to (lo) right. This line di-
vides this distance and goes through the so-called
orbital midpoint (ORP). In the mandible a line
connecting the ante-gonial point left and right (ag)
that defines any inclinational differences between
the two sides. The maxillary and mandibular mid-
points are then located, and the lines are con-
structed to the respective dental midlines in
maxilla and mandible.
Possible dental compensations for any skeletal
discrepancies can then be assessed by the inclina-
tion of the jaw midlines. As seen in the illustration
below where there is a clear asymmetry of the
mandible the mandibular dentition that has
attempted to compensate for the discrepancy by
leaning towards the facial midline. Any jaw dis-
crepancies can also be assessed by measuring the
difference between the maxillary perpendicular line
(MXP) and the mandibular perpendicular midline
(MLP).
I.L. NIELSEN
TRANSVERSE MALOCCLUSIONS
Figure 2. P-A cephalometric analysis of skeletal and dental deviations. The Svanholt and Solow analysis also provides means of determining
dentoalveolar compensation.17.
TREATMENT TIMING AND METHODS OF
TRANSVERSE MALOCCLUSION
Treatment in the mixed dentition
Expansion of the midpalatal suture in growing
patients has been studied by Krebs and Skieller
ork.18e20
using metallic implants as developed by Bj€
The use of such radiographic markers or implants
allows for a more precise assessment of the
changes in the maxilla as it eliminates the influ-
ence of surface modeling of the bones.21 Krebs,
using rapid palatal expansion reported that the
dental arch is expanded in part by separation of
4
Taiwanese Journal of Orthodontics
2023;35(1):1e17
the two maxillary segments, in part by movement
of the teeth. He also pointed out that without the
implants it was hard to find fixed points of refer-
ence to make it possible to differentiate between
the skeletal and dental changes.18 Skieller using a
similar implant technique but slow expansion in
young patients was able to achieve results similar
to those undergoing rapid palatal expansion
except more dental changes were noted.19 In some
young children bilateral posterior crossbite in the
early mixed dentition may be combined with an
anterior crossbite where the front teeth erupt in an
upright position, or the patient habitually bites in a
Taiwanese Journal of Orthodontics
2023;35(1):1e17
forward position to get the teeth to meet. An
example of this type of malocclusion was previ-
ously shown in Figure 1.
Posterior crossbite in the early mixed dentition
can often be treated with a removable appliance and
slow expansion where the expansion screw is
turned twice weekly. Whereas unilateral posterior
crossbite should be corrected early in the mixed
dentition a bilateral posterior crossbite can often be
treated later in the mixed dentition or when all
permanent teeth have erupted. By delaying treat-
ment until this stage of dental development, it is
possible to get a more stable result as more teeth are
interdigitating. When examining the patient at the
initial visit, it is important to determine if a trans-
verse malocclusion is of a skeletal or primarily
dentoalveolar origin. It is also important to assess if
there is a postural tendency of the lower jaw in cases
with a midline deviation as this often should be
treated as early as possible to prevent a permanent
mandibular asymmetry.
The occlusal surfaces of the posterior teeth, in
most cases, do not need to be covered with acrylic
unless the deciduous canines interfere with the
lateral movement of the posterior teeth during
expansion. In cases where the deciduous canines do
present a problem, occlusal coverage with acrylic
resin may be needed. The expansion protocol is
similar but as the expansion progresses the acrylic
covering the posterior teeth can gradually be
reduced and eventually removed. In Figure 3A we
have shown a maxillary Hawley expansion appli-
ance with no occlusal coverage and a midline screw
to permit transverse expansion. Notice the over-
lapping finger springs behind the upper incisors
that allow for proclination of the front teeth if
needed. There has been some discussion in the past
whether slow expansion is less efficient than
rapid.18,19 Hicks studied the skeletal and dentoal-
veolar effects of slow expansion and concluded that
the slow expansion has less of a traumatic effect on
the palatal tissues than the rapid expansion.22,23
Another often used expansion appliance, the
Quad Helix, that is fixed to the teeth is shown in
Figure 3. A. Maxillary removable Hawley expansion appliances with midline screw and overlapping finger springs for proclination of the maxillary
incisors. B. Fixed Quad Helix appliance for transverse expansion of the maxillary arch.
5
I.L. NIELSEN
TRANSVERSE MALOCCLUSIONS
Figure 3B. The Quad Helix was introduced by
Ricketts, Bench, Chaconas and has been used in
cases where differentiated posterior expansion is
needed.24e26 The lingual arms allow for selective
expansion of either or both buccal segments. When
opening the distal loop of the Quad Helix it also
permits rotational movement of the first molars
when needed.
Treatment in the permanent dentition
In cases with crossbite in the permanent dentition
that need transverse expansion, a Hyrax appliance is
often useful Figure 4. Another somewhat similar
appliance called the Haas appliance has acrylic resin
attached to the palatal arms of the appliance for more
support against the palatal.27 Studies comparing the
clinical outcome between the two appliances have
shown little or no difference in their effectiveness on
the maxillary expansion. The indication for the use of
rapid palatal expansion is dictated by the status of
the maxillary midline skeletal suture. If this suture is
considered closed and it has been verified on an
upper occlusal radiograph, the expansion may need
to be surgically assisted. However, if the suture is still
deemed to be open the expansion should happen
with daily turns of the midline screw in some cases
even twice daily. Melsen studied the effect of rapid
palatal expansion on autopsy material and reported
on the changes of the midline suture over time.28 She
found that the midline suture's morphology changes
gradually during the growth period from being
straight at birth to being heavily interdigitated at age
13e15 when it on average closes. Melsen also re-
ported that rapid palatal expansion in the older in-
dividuals resulted in fractures of the heavily
interdigitated osseous surfaces because of the
complexity of the suture.
When using rapid palatal expansion, it is impor-
tant to observe the separation of the maxillary cen-
tral incisors as it is an indication that the expansion
is skeletal and not just dental. In these cases it is
critically important that no attempt is made to close
the diastema between the incisors as it closes by
I.L. NIELSEN Taiwanese Journal of Orthodontics
TRANSVERSE MALOCCLUSIONS 2023;35(1):1e17

Figure 4. Bonded Hyrax expansion appliance with occlusal coverage. The screw in this appliance was turned twice daily.

itself as the bone gradually fills in. The appliance
can be left in place for several months as it is
cemented to the teeth to stabilize the expansion in
most cases. It is important that prior to the expan-
sion the patient is well informed about that this
diastema will develop and that it will take time for it
to close. A typical example of a cemented Hyrax
appliance as used for rapid palatal expansion is
shown in Figure 5A.
Following removal of the Hyrax appliance a fixed
palatal arch with extension arms should always be
placed to maintain the expansion (Figure 5B). This
stabilizing arch can stay in for several months while
the suture fills in with bone and the bone matures.
An upper occlusal radiograph can help to monitor
the closure of the suture. Once the midline gap
between the incisors is closed, fixed appliances can
be placed and detailing of the occlusion can begin
(Figure 5C).
Class III malocclusion with bilateral posterior
crossbite, non-surgical treatment
In some patients a posterior crossbite does not
exist on its own but is combined with other occlusal
problems. An example is seen in the case seen in
Figure 6. The treatment was initiated with rapid
palatal expansion to both correct the crossbite and
gain sufficient space for the lateral incisors. Full
mouth fixed appliances were placed following
expansion and another 4 months of expander
retention. After 18 months of active treatment all
appliances were removed and upper and lower
Hawley retainers were inserted for retention
(Figure 7).
Treatment of this patient's malocclusion was
borderline for what can be successfully treated
without surgical intervention. The patient's parents,
however, were strongly opposed to any surgical
correction and accordingly she was treated non-
surgically. It is in these borderline cases especially
important to make sure that mandibular condylar
growth is fully completed. In this patient it was
further a positive finding that the lower dental arch
was well aligned with no crowding prior to treat-
ment and that the malocclusion primarily was
limited to the sagittal occlusion and the upper arch.
Initial transverse rapid palatal expansion was
possible in this patient as the midpalatal suture still
was open. Following expansion and several months

Figure 5. A. Cemented Hyrax appliance for rapid palatal expansion. The screw is turned twice daily until sufficient transverse correction has been
achieved. Notice the extension arms that ensure all posterior teeth are being moved at the same time. B. Cemented retention appliance support the
expansion. This appliance can remain in place until the dental arches are aligned and all fixed appliances can be removed. C. Final detailing of the
upper dental arch.

6
Taiwanese Journal of Orthodontics I.L. NIELSEN
2023;35(1):1e17 TRANSVERSE MALOCCLUSIONS

Figure 6. This 14-year-old girl has a bilateral posterior crossbite combined with anterior crossbite. Minimal lower arch anterior crowding and the fact
that her mandibular growth is almost complete made it possible to treat her with orthodontics only.

Figure 7. Post treatment records showing Class I canines and Class I occlusion on the left side and a slight Class III tendency on the right.

7
I.L. NIELSEN
TRANSVERSE MALOCCLUSIONS
of retention, fixed appliances were placed to com-
plete alignment of the arch and correct the sagittal
and vertical malocclusion.
Severe class III malocclusion with negative overjet
and bilateral posterior crossbite
An example of a severe Class III malocclusion
with mandibular overjet and bilateral posterior
crossbite is seen in Figure 8. The malocclusion is
primarily due to maxillary skeletal retrusion and
will require combined orthodontics and orthog-
nathic surgically correction to achieve the desired
result.
A Panorex™ taken prior to treatment shows all
third molars are present and the mandibular third
molars to be impacted (Figure 9A). To determine the
patient's stage of skeletal maturation, a hand wrist
radiograph was taken that showed closure of the
radius epiphysis indicating that limited mandibular
growth was remaining (Figure 9B).
Figure 8. 15 year 1 mos old girl with severe bilateral posterior crossbite, mandibular overjet and Class III occlusion.
8
Taiwanese Journal of Orthodontics
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Treatment was initiated by surgically assisted
rapid palatal expansion as the maxillary midline
suture was closed according to an occlusal radio-
graph. The treatment plan included two stage sur-
gical correction of which stage one was a surgically
assisted maxillary expansion (Figure 10). Notice the
median diastema that has now developed between
the maxillary central incisors.
The expansion of the maxilla and upper dental
arch was followed by alignment of the dental arches
after the midline diastema had closed. During this
treatment period a lateral open bite developed that
will be closed after orthognathic surgery (Figure 11).
Following maxillary surgical advancement further
detailing of the occlusions was continued to estab-
lish a solid Class I posterior occlusion with the
aligned midlines and normal overjet and overbite.
Immediately following surgery the patient still had a
minor bilateral open bite and a shallow overbite.
The facial photos show that some post-surgical
swelling of cheeks still remains (Figure 12).
Taiwanese Journal of Orthodontics
2023;35(1):1e17
Figure 9. A. The Panorex™ shows impacted the third molars and unusually long mandibular condyles. B. The hand wrist radiograph shows a closed
radius epiphysis (red arrow) indicating the mandibular growth is near completion.
The post-treatment records after removal of the
appliances show that the patient now has a Class I
occlusion with normal overjet and overbite
(Figure 13). The upper and lower dental midlines
are now well aligned and there is solid interdigita-
tion of the teeth. The patient is using a maxillary
Hawley appliance and a lower 3-3 fixed retainer to
maintain the alignment of the incisors after
debonding.
The post-treatment lateral headfilm shows a
normal jaw relationship resulting from the
advancement of the maxilla. Rigid fixation with
plates was used to ensure stability of the advance-
ment (Figure 14A). The Panorex™ seen in
Figure 14B shows normal root length on all teeth as
well as the rigid fixation of the osteotomized
maxilla. The upper third molars were removed at
Figure 10. Intraoral view of the front teeth after surgically assisted
maxillary expansion. The appliance used was a Hyrax that was placed
prior to the palatal surgical procedure.
9
I.L. NIELSEN
TRANSVERSE MALOCCLUSIONS
surgery but the lower third molars are still present
and will be removed later.
The decision to treat this Class III malocclusion by
advancing the maxilla rather than setting the
mandible back was based on the initial cephalo-
metric analysis that showed maxillary retrusion and
a normal mandibular protrusion. As previously
described treatment was initiated by placing a
Hyrax expansion appliance prior to a surgical
palatal split that included sectioning the zygomatic
processes to allow for transverse skeletal correction.
The patient turned the expansion screw twice daily
until sufficient width had been achieved. The
appliance was left in place for about 4 months until
the midline diastema had closed, and full fixed ap-
pliances could be placed. After removal of the Hyrax
appliance a transpalatal arch was placed between
the upper first molars to stabilize the expansion.
Active treatment was completed after 24 month and
the appliances were removed and upper and lower
Hawley retainers were placed to be worn full-time.
Late developing asymmetric Class III malocclusion
In some cases, a Class III malocclusion can
develop gradually after puberty. This change is
associated with asymmetric mandibular overgrowth
of one side that progresses until mandibular growth
is completed. In more unusual cases the Class III
malocclusion is the result of early completion of
maxillary sutural growth. In the case seen in
Figure 15A, we believe it is the combination of both
occurrences that resulted in the malocclusion. The
lateral headfilm supports this notion with and
I.L. NIELSEN Taiwanese Journal of Orthodontics
TRANSVERSE MALOCCLUSIONS 2023;35(1):1e17

Figure 11. Pre surgical alignment of the dental arches. The posterior occlusion is now Class I and the anterior occlusion is edge to edge. There is a
lateral open bite that will be closed following the surgical advancement of the maxilla.

Figure 12. Intra oral and facial photos immediate post-surgery. The posterior occlusion is now Class I and there is a normal overjet and overbite.
Notice the mild lateral open bite that will be closed during the detailing of the occlusion. The patient still shows some swelling of the cheeks.

10
Taiwanese Journal of Orthodontics I.L. NIELSEN
2023;35(1):1e17 TRANSVERSE MALOCCLUSIONS

Figure 13. Post-treatment records show Class I occlusion with normal overjet and overbite. The later open bite seen post surgically is now closed and
the midlines are coinciding.

unusual shape of the nasal floor. It suggests that in
this patient, the maxilla has undergone pronounced
modeling after early maxillary sutural stenosis
(Figure 15B). At the same time the mandible has
continued to grow and more on the right side than
on the left. The result of this development is a
pronounced Class III malocclusion with mandibular
overjet, a unilateral lingual crossbite on the right
side and lower midline deviation to the left by about
5e6 mm. There was good function of the temporo-
mandibular joint (TMJ) and no notable deviation on
opening and closing of the mouth.
This patient was monitored for possible continued
mandibular growth for one year by comparing serial
lateral headfilms. When no change in mandibular
prominence could be observed, presurgical

Figure 14. A and B. Lateral headfilm and Panorex™ post-treatment. Notice the improved jaw relationship and the rigid fixation of the maxilla.

11
I.L. NIELSEN Taiwanese Journal of Orthodontics
TRANSVERSE MALOCCLUSIONS 2023;35(1):1e17

Figure 15. A. 24-year-old man with Class III malocclusions and mandibular asymmetry. Notice the asymmetry remains unchanged during mouth
opening. B. Lateral headfilm showing pronounced mandibular prognathism and maxillary retrusion. The maxillary incisors are severely proclined to
compensate for the sagittal skeletal discrepancy. The lower incisors are in a normal inclination.

12
Taiwanese Journal of Orthodontics
2023;35(1):1e17
orthodontic treatment was initiated. Treatment
included alignment of the teeth in the individual
arches followed by surgical correction that included
asymmetric setback of the mandible and maxillary
advancement with rigid fixation to ensure stability
of the procedures.
The post treatment records seen in Figure 16 show
a Class I occlusion with normal overjet and overbite.
The midlines are now coinciding and there is a solid
interdigitation of the teeth. A possible rhinoplasty
was discussed with the patient, but he did not want
it done at this time.
Unilateral posterior crossbite with midline
deviation
The patient seen in Figure 17 is an example of a
unilateral posterior crossbite with a pronounced
midline deviation that resulted in a TMJ problem.
The initial clinical examination showed a midline
shift during opening and closing with normal
Figure 16. Post treatment facial and intraoral photos. Class I occlusion with normal overjet and overbite. The upper and lower midlines are coinciding
and the is normal range of jaw movement.
13
I.L. NIELSEN
TRANSVERSE MALOCCLUSIONS
translation of the right TM condyle. No translation
of the condyle in her left joint could be observed.
The disc displacement in the left joint prevented the
normal translation of the condyle upon opening and
closing. The patient had become aware of the
change in her bite recently and was concerned
about the clicking of the jaw.
The normal anatomy of the TMJ seen in
Figure 18A shows that the meniscus when the teeth
are in occlusions is positioned on top of the condyle.
During opening and closing of the mouth the disc
follows the mandibular condylar movement. In
cases where the disc is displaced, as exemplified in
Figure 18B, the disc can bunch up and be located in
front of the condyle preventing the normal trans-
lation of the condyle. In this example there is also a
perforation of the disc.
Treatment of the patient seen in Figure 17 was
initiated with an anterior repositioning splint that
was designed to hold the mandible in a forward
position and with the mandibular dental midline
I.L. NIELSEN Taiwanese Journal of Orthodontics
TRANSVERSE MALOCCLUSIONS 2023;35(1):1e17

Figure 17. 17 year 6 mos old female patient with unilateral posterior crossbite and pronounced midline deviation. The patient had noticed a change in
her bite that began a few months earlier and reported a clicking sound in her left TMJ joint on opening and closing. Notice the Class III occlusion on
the patient's right side.

Figure 18. A. Normal disc position in the TMJ. The disc is located on top of the condyle and moves with the opening and closing of the jaw. B. Anterior
displaced disc and perforated posterior ligament. The disc is unable to move with the jaw movements and locked in place.

coinciding with the maxillary midline. This splint
was used full-time and only removed during meals.
After 12 months of splint therapy the occlusion is
Class I and the midlines have improved. As a result
of using the splint full-time, there is now a lateral
open bite on the patient's left side to be closed with
fixed appliances (Figure 19).
During the beginning of the fixed appliance treat-
ment, the splint was still used to stabilize the occlu-
sion and maintain the forward postured position of
the mandible. The acrylic was gradually reduced to
permit tooth movement to close the lateral open bite.
As seen in Figure 20 the lateral open bite is now
greatly improved, but further detailing is needed.
The post-treatment records following appliance
removal show a Class I occlusion with normal
overjet and overbite. The midlines are now coin-
ciding and there is a normal range of jaw movement
(Figure 21). The patient was placed in retention with
upper and lower Hawley appliances that was to be
used full-time for the first year after which the wear
time was gradually reduced.

14
Taiwanese Journal of Orthodontics I.L. NIELSEN
2023;35(1):1e17 TRANSVERSE MALOCCLUSIONS

Figure 19. 12 months after splint therapy to reposition the TMJ disc the occlusion on her right side is now Class I and the midline has improved. On
the left side there is a lateral open bite that developed after splint therapy.

Figure 20. Occlusion following splint therapy and treatment with full fixed appliances. The lateral open bite is closed but some further detailing of the
occlusion remains.

Figure 21. Occlusion at the end of treatment. The click in her left joint has disappeared and there is normal range of motion of the lower jaw with no
deviation upon opening and closing.

The records taken one year post-treatment show The successful outcome of treatment in this pa-
that the occlusion has remained unchanged and tient can to a great extent be attributed to the pa-
there is still a normal range of jaw movement tient's excellent cooperation, especially during the
(Figure 22). period where she was asked to wear a splint full-

15
I.L. NIELSEN
TRANSVERSE MALOCCLUSIONS
Figure 22. One year post treatment. The occlusion has remained stable and there is a normal range of mandibular motion. The patient has no
symptoms of her previous TMJ problem.
time. When looking at the occlusion it is apparent
that the unilateral crossbite on the patients left side
must have developed over a period of time. It is
possible that this malocclusion has contributed to
the recent disc displacement. An additional factor
that undoubtedly made treatment of the anterior
disc displacement successful is the short interval of
only a few months between the displacement of the
disc and the placement of an anterior repositioning
splint to recapture the disc. In many cases, as
illustrated by the example in Figure 18B, the disc can
be so deformed that it cannot be recaptured and has
to be removed to regain normal condylar move-
ment. If too much time has passed since the event
that resulted in the displacement, this approach will
undoubtedly not be successful.
DISCUSSION
We have in this review article addressed some
of the most common challenges associated with
the diagnosis and treatment of transverse maloc-
clusions. It is important in all cases to have a clear
diagnosis and a detailed treatment plan. We have
presented a PA cephalometric analysis that focuses
on the anterior occlusion but have not provided an
analysis of the poster occlusions due to space con-
straints.17 Several previous studies have presented
transverse analyses of the posterior occlusion
including those introduced by Dahan, Ricketts,
Grummons.13e16 Transverse malocclusions are very
common in the orthodontic office and often seen in
young patients in the mixed dentition who present
with posterior crossbite. We have discussed both the
16
Taiwanese Journal of Orthodontics
2023;35(1):1e17
treatment timing and appliances that can help
alleviate the problems. In patients in the permanent
dentition the challenge is often more complex
especially if there is a skeletal asymmetry associated
with the malocclusion. Treatment in these patients
should often be delayed until completion of growth.
Expansion of the maxillary midline suture is not
possible when this suture closes which usually
happens around the age of 13e15 years.28 After this
age only a combination of surgical separation of the
midline suture and the zygomatic process can pro-
vide the ability to expand the maxilla. Lately the
procedure of rapid palatal expansion has changed
from the conventional Haas or Hyrax appliance to
miniscrew assisted expanders that reduce the un-
desired dental tipping during expansion. This
technique can also be used in cases where the su-
ture is closed or in combination with surgical
sectioning of the sagittal mid-palatal suture. Studies
using cone beam computed tomography have
shown that this approach prevents some of the
previous side effects including excessive tipping of
the teeth and alveolar bone in the expansion area.29
In patients where the posterior skeletal crossbite is
combined with a Class III malocclusion, two stage
surgical correction may be necessary in order to
achieve a stable result, as we have demonstrated.
Finally, we have shown a case with an unusual and
challenging unilateral disc displacement in the TMJ
that required initial splint treatment followed by
conventional orthodontic treatment. In all these
patients an extended retention period following
treatment is necessary to ensure long-term stability
of the treatment.
Taiwanese Journal of Orthodontics
2023;35(1):1e17
FUNDING
The author declares that the study has received no
financial support.
ETHICAL APPROVAL
Not required.
PATIENT CONSENT
The historical photographs of patients that shown
in this review article were the treatment records of
the author in his private and university practice
decades ago.
CONFLICT OF INTEREST STATEMENT
The author declares no conflicts of interest.
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