European Journal of Orthodontics, 2016, 638–651

doi:10.1093/ejo/cjw003
Advance Access publication 28 January 2016

Systematic review

Association between posterior crossbite,

skeletal, and muscle asymmetry: a systematic
review

Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022

Giorgio Iodice1, Gianluca Danzi1, Roberta Cimino1, Sergio Paduano2 and
Ambra Michelotti1
1
Department of Dental and Maxillofacial Sciences, Section of Orthodontics and Gnathology, University of Naples
Federico II, Italy and 2Department of Orthodontics, University of Catanzaro Magna Graecia, Italy

Correspondence to: Dr Giorgio Iodice, School of Dentistry, Department of Dental and Maxillofacial Sciences, University of
Naples Federico II, Via Pansini, 5. I-80131, Naples, Italy. E-mail: iodicegiorgio@gmail.com

Summary
Background: Of the various malocclusions, unilateral posterior crossbite has often been associated
to skeletal and muscular asymmetrical growth and function.
Objective: To assess, by systematically reviewing the literature, the association between unilateral
posterior crossbite (UPCB) and morphological and/or functional asymmetries (i.e. skeletal,
masticatory muscle electromyographic (EMG) performance, bite force, muscle thickness, and
chewing cycle asymmetries).
Materials and Methods: A literature survey covering the period from January 1965 to June 2015
was performed. Two reviewers extracted the data independently and assessed the quality of the
studies.
Results: The search strategy resulted in 2184 citations, of which 45 met the inclusion criteria.
The scientific and methodological quality of these studies was medium–low, irrespective of
the association reported. In several studies, posterior crossbite is reported to be associated to
asymmetries in mandibular skeletal growth, EMG activity, and the chewing cycle. Fewer data are
available on bite force and masticatory muscle thickness.
Conclusions: The relationship between unilateral posterior crossbite and skeletal asymmetry is
still unresolved. To date, most of the studies available report a skeletal asymmetric growth. EMG
activity of masticatory muscles is different between crossbite and non-crossbite sides. Subjects
with UPCB show smaller bite force than non-crossbite subjects. There is no consistency of studies
reporting masticatory muscle thickness asymmetry in UPCB subjects. UPCB is associated to an
increase in the reverse chewing cycle. The literature available on the subject is of medium–low
scientific and methodological quality, irrespective of the association reported. Further investigations
with higher sample size, well-defined diagnostic criteria, rigorous scientific methodologies, and
long-term control are needed.

Introduction more opposing teeth in centric occlusion (1). Its prevalence in the primary
and early mixed dentition is reported to occur in 8–22% of orthodontic
Posterior crossbite is defined as the presence of one or more teeth of the
patients (2–4) and in 5–15% of the general population (5–9). Dental, skel-
posterior group (from canine to second molar) in an irregular (at least
etal, and neuromuscular factors can be recognized as possible etiological
one cusp wide) bucco-lingual or bucco-palatal relationship, with one or

© The Author 2016. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
638
For permissions, please email: journals.permissions@oup.com
G. Iodice et al.
factors, but the most frequent cause is reduction in width of the maxillary
arch. Even if spontaneous correction can occur (10–13), posterior cross-
bite, and especially unilateral posterior crossbite, can result in mandibular
shift and postural alterations, with a possible asymmetrical growth and
function of the skeletal and muscle structures (14, 15).
It has been suggested that an altered morphological relationship
between the upper and lower dentition is associated to right-to-left-side
differences in the condyle–fossa relationship (16). The asymmetrical func-
tion in posterior crossbite patients was reported to be associated to dif-
ferent development of the right and left sides of the mandible over time
(17–20), asymmetric contraction of the masticatory muscles (21–25),
reduced thickness of the ipsilateral masseter muscle (26), and a differ-
ent chewing pattern (27–29). However, others reported different findings
(30–33) with a consequent inconsistency retrieved from the literature.
Therefore, the aim of our study was to perform a systematic
review in order to investigate the association between posterior
crossbite and morphological and/or functional asymmetries, i.e. skel-
etal, masticatory muscle electromyographic (EMG) performance,
bite force, muscle thickness, and in chewing cycle asymmetries.
Materials and Methods
A literature survey was performed through the Medline database
(Entrez PubMed, http://www.ncbi.nim.nih.gov) in order to inves-
tigate the correlations between posterior crossbite and different
asymmetric conditions of the stomatognathic system. The research
process analyzed studies published between 1 January 1966 and 27
June 2015, using the medical subject heading term: ‘crossbite’, which
was crossed with the keywords ‘masticatory cycle’, ‘chewing cycle’,
‘asymmetry’, ‘bite force’, ‘EMG’, and ‘muscle thickness’.
Three researchers (GI, GD, and RC) selected the studies by read-
ing the titles, and the abstracts, using specific inclusion and exclusion
criteria. Inclusion criteria were human studies, posterior crossbite, lat-
eral crossbite, retrospective studies with and without controls or refer-
ence group, and prospective studies. Instead, we excluded all articles
not written in English, case reports and case series, reviews, studies
Figure 1. Flow chart of the search strategy.
639
with unclear diagnosis or poorly defined samples, treatment strategies
and appliances, craniofacial syndrome diagnosis possibly influencing
the prevalence of temporo mandibular disorders (TMD), those with
full-text versions not available, and experimental animal studies. The
researchers excluded all the studies not pertinent to the aim of the
review (i.e. not investigating the relationship between posterior cross-
bite and skeletal asymmetries or asymmetric function of the stoma-
tognathic system) and the studies analyzing the anterior crossbite.
Moreover, when studies were retrieved several times by using different
keywords, they were counted only once. Finally, the full-text version
of all included studies was analyzed independently by two researchers
(GI and RC), and the studies were catalogued on the basis of the asso-
ciations between crossbite and ‘skeletal asymmetry’, ‘EMG activity’,
‘bite force’, ‘masticatory muscle thickness’, and ‘chewing cycle’.
If the full-text version of the study was not directly available,
Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022
a request of the manuscript was sent by email to the correspond-
ing author. Some studies investigating more than one item were
reported in two or more groups of associations. The scientific
and methodological quality of each study was then independently
evaluated by two researchers (GI and RC) using a previously pub-
lished quality score (9, 31). Each study was categorized as low (0–5
points), medium (6–8 points), or high (9 or 10 points). The data were
extracted from each article; the authors in question were not blinded
to the examiners. In the event of conflict, intra-examiner consensus
was gained by discussion of each article.
Pearson product-moment correlation supplemented by linear
regression and unpaired Student’s two-tailed t-test was used for sta-
tistical analysis. Statistical significance was set at P < 0.05. All the
statistical procedures were performed with the Statistical Package
for the Social Sciences (SPSS 20.0, SPSS Inc., Chicago, Illinois, USA).
Results
The flow chart of the search strategy is presented in Figure 1. The
initial search yielded 2184 citations. After a selection according to
the inclusion and exclusion criteria, 45 articles were analyzed.
640
Crossbite and Skeletal Asymmetry
Nineteen articles focused specifically on the relationship between
crossbite and skeletal asymmetry. The quality was high in 0 stud-
ies, medium in 16 (84.2%), and low in 3 (15.8%; Table 1 and
Supplementary Table 1, available online).
Twelve studies (63.2%) reported a significant association between
posterior crossbite and skeletal asymmetry (‘association’) with a
mean score of 6.7: 11 (91.7%) with a medium score and 1 (8.3%)
with a low score. Seven studies (36.8%) did not find any significant
association between posterior crossbite and skeletal asymmetry (‘no
association’) with a mean score of 6.2: five (71.4%) with a medium
score and two (28.6%) with a low score. Mean years of publication
for the articles were, respectively, 7.1 years for the ‘association’ and
9 years for the ‘no association’ articles. Neither quality assessment
nor study years of publication differed between groups (P = 0.29
and P = 0.41, respectively). Fourteen studies included adolescents (8
reporting ‘association’; 6 reporting ‘no association’), and five studies
adults (4 reporting ‘association’; 1 reporting ‘no association’).
Crossbite and EMG Activity
Eleven articles focused specifically on the relationship between cross-
bite and EMG activity. The quality was high in two studies (18.2%),
medium in seven (63.6%), and low in two (18.2%; Table 2 and
Supplementary Table 2, available online).
All studies (100%) reported a significant association between
posterior crossbite and EMG activity (‘association’) with a mean
score of 6.4. Mean years of publication for the articles were 9.9 years.
Eight studies included adolescents, and three studies adults.
Crossbite and Bite Force
Four articles focused specifically on the relationship between cross-
bite and bite force. The quality was assessed as high in one study
(25%), medium in two (50%), and low in one (25%; Table 3 and
Supplementary Table 3, available online).
A significant association between posterior crossbite and bite
force (‘association’) was reported in three studies (75%), with a
mean score of 7.6. One study (25%) did not find any significant
association between posterior crossbite and bite force (‘no associa-
tion’) with a score of 4. Mean years of publication for the articles
were, respectively, 9 years for the ‘association’ and 12 years for the
‘no association’ article. Quality assessment was significantly differ-
ent (P = 0.07). No significant difference, instead, was found accord-
ing to years of publication (P = 0.63). All studies included children/
adolescents, ranging from 3.5 years (56–58) to 13 years old (55).
Crossbite and Masticatory Muscle Thickness
Four articles focused specifically on the relationship between
crossbite and masticatory muscle thickness. All studies presented
a medium quality score assessment (Table 4 and Supplementary
Table 4, available online).
A significant association between posterior crossbite and masti-
catory muscle thickness (‘association’) was reported in two studies
(50%), with a mean score of 7.5. Two studies (50%) did not find any
significant association between posterior crossbite and masticatory
muscle thickness (‘no association’), both reporting a medium score
of 7. Mean years of publication for the articles were, respectively,
8 years for the ‘association’ and 5.5 years for the ‘no association’
articles. Quality assessment did not differ between groups (P = 0.42).
By contrast, the years of studies publication differed between groups
(P = 0.04). The studies included children/adolescents (2 reporting
‘association’; 2 reporting ‘no association’).
European Journal of Orthodontics, 2016, Vol. 38, No. 6
Crossbite and Chewing Cycle
Seven articles focused specifically on the relationship between
crossbite and the chewing cycle. The quality was assessed as high
in one study (14.3%) and medium in six (85.7%; Table 5 and
Supplementary Table 5, available online).
A significant association between posterior crossbite and chew-
ing cycle (‘association’) was reported in five studies (71.4%), with
a medium score (mean 7.4). Two studies (28.6%) did not find any
significant association between posterior crossbite and chewing cycle
(‘no association’) with a mean score of 7.5: one with a high score
and one with a medium score. Mean years of publication for the
articles were, respectively, 7 years for the ‘association’ and 10 years
for the ‘no association’ articles. Neither quality assessment nor study
years of publication differed between groups (P = 0.76 and P = 0.40,
respectively). Three studies included children/adolescents (2 report-
Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022
ing ‘association’; 2 reporting ‘no association’), two studies adults
(both reporting ‘association’), and one study included both adoles-
cents and adults (reporting ‘association’).
Discussion
This systematic review aimed to select all prospective and retrospec-
tive observational studies with or without control groups, analyz-
ing the association between posterior crossbite, skeletal, and muscle
asymmetries. Forty-five studies were retrieved, some being included
in more than one group of association. After scientific and methodo-
logical assessment, the quality of most studies was adjudged to be
medium–low, deeply influencing the import and reliability of their
relative results.
A previous systematic review of the association between unilat-
eral posterior crossbite (UPCB) and functional changes (31) did not
investigate skeletal asymmetries, muscle thickness, or the chewing
cycle. The authors analyzed only two studies on EMG evaluation,
whereas the present updated review included nine more recent stud-
ies. Another systematic review (62) analyzed the association between
posterior unilateral crossbite and skeletal asymmetry. The authors
included also treatment studies, did not consider muscular and
functional fields, and did not include several studies reported in our
review.
The problems found in all the studies analyzed in this review
are the following. First, most of the samples were selected among
orthodontic patients, dental students, or staff members, thus not
representative of the general population with a consequent selection
bias leading to unreliable results (63). Second, many studies included
scantily described samples (15, 41, 48, 58), small sample size (14,23,
41, 42, 44, 57), features poorly represented in the sample (i.e. only
3 of 45 patients presented crossbite in 51), and rarely reported pre-
determined sample sizes (25). Third, the age of the sample differed
greatly among studies including children or adults, with non-com-
parable results (64). Fourth, even though the harmful/detrimental
effects of unilateral versus bilateral crossbite on specific muscle and/
or skeletal asymmetries could be of particular interest, it was ana-
lyzed in very few studies. Finally, no study on the topic reported
long-term data.
Crossbite and Skeletal Asymmetry
The existing relationship between posterior crossbite and skeletal asym-
metries is still unresolved, with contrasting findings (20, 40, 43, 47).
Indeed, a positive association between unilateral posterior crossbite
and skeletal asymmetries was supported by 63% of the 19 analyzed
studies. It has been hypothesized that the altered dental transversal
Table 1. Crossbite and skeletal asymmetry.

Methods/
Author Year Study design Crossbite Sample Selected from Age Measurements Results Association Score

1 Abad-Santama- 2014 Cross-sectional with UPCB 20 (14F, 6M) 60 sbj: 20 sbj Dental Clinic UPCB: 9.1 ± 2.2 Panoramic Condylar asymmetry was observed No 6
G. Iodice et al.

ría (34) control group UCLP; 20 sbj ys; control radiographs in all three groups. No statistically
control group group: 10.6 ± 2 significant differences were found
ys among the three study groups for
any of the asymmetry indexes.
2 Castelo (14) 2010b Cross-sectional with DecC: 19 (9F, 72 sbj DecN: Dep. Pediatric DecC: 59.4 ± 7 Clinical Children with functional posterior Yes 6
control group 10M); MixC: 16 19 (4F, 15M); dent. m; MixC: examination crossbite presented greater facial
(11F, 5M) MixN: 27 (9F, 73.2 ± 7 m; and frontal asymmetry than those with normal
18M) DecN: 58.4 ± 8 photo occlusion.
m; MixN:
65.7 ± 10 m
3 Cohlmia (35) 1996 Observational study Not reported 232 sbj (137F, Preorthodontic 9.4–42.6 ys; Not Lateral Ceph RX There was no significant difference No 5
95M) subjects reported for PCB in condylar position between indi-
patients viduals with/without crossbites.
4 Ferro (36) 2011 Observational study 94 UPCB (60F, 94 sbj; (no Orthodontic 7–9.8 ys range Postero-anterior The expanded maxillary arch Yes 5
34M) control group) patients and panoramic was statistically associated with
radiograph potential mandibular skeletal
asymmetry.
5 Halicioglu (37) 2014 Cross-sectional with 30 UPCB (15F, 95 sbj (57F, Dentistry UPCB: 14.5 ± 1.9 CBCT There was no statistically signifi- No 8
control group 15M) 38M); 29 BPCB patients ys; BPCB: cant difference in condylar height,
(17F, 12M); 14.6 ± 1.8 ramal height, and condylar-
36 sbj control ys; Controls: plus-ramal height measurements
group (25F, 14.2 ± 2.4 ys between the right and left sides
11M) of the UPCB group and control
group.
6 Kasimoglu (38) 2015 Cross-sectional with 30 UPCB (15F, 120 sbj (60F, Patients Clinics Total Panoramic Patients with UPCB have asymmet- Yes 8
control group 15M) 60M); 30 CL of Pedodontics sample: 11–16 ys X-Rays ric condylar heights. These patients
I (15F, 15M); (13.6 ± 1.6) might be at risk for developing
30 CL II (15F, skeletal mandibular asymmetries in
15M); 30 CL III the future.
(15F, 15M)
7 Kiki (39) 2007 Cross-sectional with 75 BPCB 150 (114F, Department of Total sample: Panoramic The patients with posterior Yes 7
control group 36M); 75 Orthodontics 11–17 ys; BPCB: radiographs crossbite had more asymmetrical
control group 14.2 ± 1.9; Ctr: condyles than controls.
14.7 ± 2.3
8 Kilic (40) 2008 Cross-sectional with UPCB: 81 (64F, 156 sbj (121F, School Total sample: Panoramic Condylar ramus and ramus height Yes 8
control group 17M) 35M); 75 con- 11–17 ys; UPCB: radiographs on crossbite side were significantly
trol group (57F, 14.3 ± 29.2 ys; smaller than those of non-crossbite
18M) Ctr: 14.7 ± 2.3 ys side. Condylar, ramal and total
asymmetry indexes were higher
in the crossbite group than in the
control group
641

Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022

Table 1. Continued
642

Methods/
Author Year Study design Crossbite Sample Selected from Age Measurements Results Association Score

9 Kusayama (41) 2003 Cross-sectional with PCB: not reported. 44 sbj; 19 con- Orthognatic Total sample: Frontal A significantly high correlation Yes 6
control group trol group (8F, Surgical mean age 21.1 ys cephalometric between transverse dental anomalies
11M) patients and 3D dental and skeletal asymmetry was found.
model
10 Langberg (42) 2005 Cross-sectional with UPCB 15 (7F, 8M) 30 sbj; 15 con- Orthod UPCB: mean age Postero-anterior Adult patients with UPCB had statis- Yes 7
control group trol group (12F, patients 26.2 ys; control radiographs tically significantly more transverse
3M) group 30.6 ys mandibular dental asymmetry.
11 O’Byrn (43) 1995 Cross-sectional with UPCB 30 (20F, 60 sbj; 30 con- Orthod UPCB: 28 ± 3 ys; Submental vertex No statistically significant dif- No 8
control group 10M) trol group (21F, patients Control: 27 ± 9 radiographs ference was found in condylar
9M) ys position within the two groups.
Skeletally, the mandible showed
no asymmetry.
12 Pellizoni (44) 2006 Cross-sectional with UPCB: 15 (9F, 6M) 31 sbj (19F, Not reported 6–12.9 ys; Clinical exami- These findings suggest that tem- No 6
control group 12M); 16 con- UPCB: 9.3 ± 2.1 nation and MRI poromandibular joint derange-
trol group (10F, ys; Control: ments and functional UPCB are
6M) 9.6 ± 2.1ys independent occurrences.
13 Pirttiniemi (45) 1991 Observational study PCB: 13 sbj (not 49 sbj (34F, Patients and Total sample: Computed Significant asymmetry in condyle Yes 6
reported gender) 15M); 36 students 15–33 ys; tomography path in cases of lateral crossbites,
normal lateral 24.2 ± 3.8 ys which is connected with asym-
occlusion metry in craniofacial skeleton and
midline deviation.
14 Primozic (46) 2013 Prospective observa- UPCB 78 (42F, 234 sbj (115F, Department of Total sample: Three- Children with unilateral functional Yes 7
tional study 36M) 119M); 156 Orthodontics 3.9–11.9 ys dimensional laser CB exhibited a greater facial asym-
control group scanning device metry than children without this
(73F, 83M) malocclusion in all the dentition
phases herein investigated.
15 Primozic (47) 2009 Prospective observa- UPCB 30 (17F, 58 sbj (30M, Department of UPCB: 3.6–6.6 Three- The crossbite children had a sta- Yes 7
tional study 13M) 28F); 28 control Paedodontics ys, 4.9 ± 1 ys; dimensional laser tistically greater asymmetry of the
group (11F, Control: 4.8–6.1 scanning device face especially the lower third and
17M) ys, 5.3 ± 0.4 ys a significant lower smaller palatal
volume than normal occlusion
group at baseline.

16 Takada (16) 2015 Cross-sectional with UPCB 15 (9F, 6M) 30 sbj (12M, Subjects seeking UPCB: 23.5 ± 7.6 Computed Facially asymmetric adult subjects Yes 7
control group 18F); 15 control or treatment ys; Control: axiography, with malocclusions associated with
group: (9F, 6M) 22.8 ± 5.8 ys postero-anterior, UPCB exhibit not only mandibular
submentovertex asymmetry but also remodelling of
the condylar head and glenoid fossa
that accompanies the three-dimen-
sional shifting of the MHA.
European Journal of Orthodontics, 2016, Vol. 38, No. 6

Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022

 G. Iodice et al. 643

relationship results in alteration of the glenoid fossa–disc–condyle rela-

Association Score

Crossbite = number of subjects in the sample presenting crossbite; PCB = posterior crossbite; UPCB = unilateral posterior crossbite; Sbj =subjects; Ctr = control group; UCLP = unilateral cleft lip palate; DecC = deciduous-
tionship, which in turn could be responsible for skeletal asymmetric

6
growth (40). An animal study on rats (65) supported this hypothesis,
showing that an experimentally induced UPCB leads to an increase in
cartilage thickness on the contralateral side and a decrease in the lateral

Yes
No

No
region on the ipsilateral side, these alterations being normalized to the
values of the control group after the removal of the artificial UPCB.
measurements were not statistically

between the observers, also in the

different among the normal occlu-
Condylar asymmetry index, ramal

There were no significant differ-

An important confounding factor, which could account for the

deviation in the crossbite group

asymmetry index, and condylar-

Skeletal components of mandi-

between crossbites and control

ences in the assessment of chin

ble have significant asymmetry

sion and the crossbite groups.
conflicting results, could be ascribed to the lack of validity of the
plus-ramal asymmetry index

methods used to assess skeletal asymmetry. Indeed, four studies (20,

36, 39, 40) used panoramic radiographs that have the major limi-

non-crossbite group.

crossbite; MixC = mixed-crossbite; DecN = deciduous-normal occlusion; MixN = mixed-normal occlusion; ys = Years; m = months; CL = Angle Class; MHA = mandibular hinge axis.
tation of unequal magnification of right–left sides in the horizontal
dimension if the mid-sagittal plane of the patient’s head is not posi-
tioned in the rotational midline of the machine (66). This limit may
lead to inaccurate interpretation of the TMJ, the condyle structure and
Results

group.

Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022

the rami. Three studies (35, 41, 42) used postero-anterior X-rays to
investigate skeletal asymmetry. Even though this technique provides
the most direct assessment of transverse skeletal asymmetry compared
Measurements

UPCB: 14.5 ± 3.7 Facial Photos

to other methods, rotations of the head during exposure by 5 degrees

radiographs
Panoramic

in the vertical axis can produce error in the degree and side of asym-
Methods/

CBCT

metry and superimposition of various anatomic structures (62, 67,

68). O’Byrn et al. (43) used submentovertex radiographies to evaluate
structural, positional, and dentoalveolar asymmetry of the mandible
UPCB: 13 ± 3.5

UPCB: 13.5 ± 2

in patients with UPCB. Submentovertex radiographs are superior to

12.7 ± 3.2 ys

13.4 ± 1.5 ys
ys; Control:

frontal radiographs as they are not influenced by rotation of the head

14.4 ± 3 ys
ys; BPCB:

ys; BPCB:
13.3 ± 2.1
Control:

and can delineate the source of asymmetry as being structural, posi-

tional, and dentoalveolar (62, 69). Two studies (48); Castelo et al. (14)
Age

ys

used facial photos as investigation tool, which are influenced by face

Oral and Maxil-

group (7F, 8M) ogy Department

rotation. It is important to consider that the diagnostic value of all

23F); 15 control lofacial Radiol-
Archives of the

Preorthodontic
Department of
Selected from

Orthodontics

of Faculty of

these instruments is limited by the fact that they are 2D representa-

Dentistry

tions of 3D structures. Primozic et al. (46, 47) evaluated the asymme-

children

try by means of a 3D facial scanner. Nevertheless, this tool allowed the

authors to investigate only the facial asymmetries and not the skeletal
ones. The possible influence of the soft tissues as confounding fac-
matched for age
control group

control group

tors in this case has to be considered. Veli et al. (15) used cone beam
45 sbj (22M,
126 sbj (75F,

(24F, 16M);

144 sbj; 72

and gender

computed tomography (CBCT) to assess linear and volumetric man-

51M); 40
Sample

dibular asymmetry on crossbite and non-crossbite sides. However, the

authors merged structural, positional, condylar, and dentoalveolar
asymmetries in a single group. Similarly, Pirttiniemi et al. (45) used a
15 UPCB (9F, 6M);
15 BPCB (7F, 8M)

CBCT technique but assessed mandibular asymmetries by means of

19M); BPCB 40
UPCB 46 (27F,

UPCB 72 (42F,

2D landmarks and measurements.

Finally, it has to be underlined that among the studies based on
(24F, 16M)
Crossbite

adolescent samples 8 out of 14 (57%) reported a significant associa-

30M)

tion, whereas, among the studies based on adult samples, 4 out of 5

(80%) reported a significant association between posterior crossbite
and mandibular asymmetry. The higher association between cross-
bite and skeletal asymmetry in adults than in adolescents could be
Cross-sectional with

Cross-sectional with

Cross-sectional with

speculatively explained by the fact that adolescents are still growing

and the potential alteration due to posterior crossbite did not yet
control group

control group

control group
Study design

occur. This consideration justified the suggestion of making an early

orthodontic correction of a posterior crossbite in order to reduce
the adaptation demands of the stomatognathic system (39, 40, 46,
47, 64, 70). Albeit supported by a very recent systematic review (71)
2009

2004

2011

analyzing the oral functional asymmetry (not including the skeletal

Year

asymmetry), to date this chain of events represents only an unde-

Table 1. Continued

monstrated hypothesis because long-term controlled studies are still

18 van Keulen (48)

lacking, and the cause/effect is merely speculative.

17 Uysal (20)

19 Veli (15)
Author

Crossbite and EMG Activity

Eleven articles evaluated the association between posterior cross-
bite and EMG activity, all reporting a positive association. Hence,
Table 2. Crossbite and EMG activity.
644

Methods/
Author Year Study design Crossbite Sample Selected from Age Measurements Results Association Score

1 Alarcon (25) 2009 Cross-sectional with UPCB: 30 sbj (15F, 60 sbj (30 M, 30F); 30 Pediatric Clinic UPCB: 10–12 ys; Bilateral sEMG During clenching, activity of Yes 9
control group 15M) control group (15F, Control group: activity the crossbite side masseter area
15M) 10–12 ys was significantly lower in cases
versus controls.
2 Alarcon (24) 2000 Cross-sectional with UPCB: 30 (17F, 13M) 60 sbj (33F, 27M); 30 Department of UPCB: mean 12.2 Eight-channel elec- The posterior temporalis of Yes 9
control group control group (16F, Odontology ys; control group: tromyography the non-crossbite side was
14M) mean 12.5 ys more active than that of the
same side in subjects with
crossbite at rest position
and during swallowing. In
addition, the activity of both
anterior digastrics was higher
in the crossbite subjects during
swallowing. During chewing,
the masseter muscle on the
crossbite side was less active in
the crossbite patients than in
normocclusive subjects.
3 Andrade (49) 2010 Cross-sectional with UPCB: 17 (not 37 sbj; 20 control Department Total sample: EMG System Balanced EMG activity of Yes 6
control group reported gender) group (not reported of Pediatric 7–10 ys; UPCB: masseter and anterior tem-
gender) Dentistry 8.6 ± 1.2 ys control poralis muscles was observed
group: 8.6 ± 1.1 ys only in the control group.
These results indicate that in
children, UPCB can alter the
co-ordination of masticatory
muscles during mastication.
4 Andrade (31) 2009 Cross-sectional with UPCB: 20 (8F, 12M) 36 sbj (14F, 22M); Department UPCB: 8.8 ± 1 ys; EMG system The masseter of the crossbite Yes 7
control group 16 control group (6F, of Pediatric control group: side was more active than that
10M) Dentistry 8.9 ± 1 ys of the non-crossbite side in
UPCB group during maximal
clenching.
5 Ciavarella (50) 2012 Cross-sectional with UPCB 15 sbj (9F, 6M) 30 sbj (14M, 16 F); Orthod UPCB: mean 11.5 sEMG The mean electric activity Yes 6
control group 15 control group (7F, Department ys; control group: for masseter and temporal
8M) mean 12 ys muscles at clench was lower
in the UPCB group than in the
control group. Mean muscle
activity at rest showed how the
UPCB group presented lower
activation of masseters than
the control group.
European Journal of Orthodontics, 2016, Vol. 38, No. 6

Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022

Table 2. Continued

Methods/
Author Year Study design Crossbite Sample Selected from Age Measurements Results Association Score
G. Iodice et al.

6 Ferrario (23) 1999 Cross-sectional with UPCB 10 sbj (6F, 4M) 30 sbj (14M, 16F); 20 Not reported Total sample: Four-channel EMG In the crossbite subjects, the Yes 6
control group control group (10F, 16–18ys; UPCB: recorder four analyzed muscles ap-
10M) 17.3 ± 0.8 ys; peared to contract with altered
control group: and asymmetric patterns. The
17.4 ± 0.6 ys altered occlusal relationship
influenced the co-ordination of
the masticatory muscles during
chewing on both sides.
7 Ingervall (22) 1975 Observational study 16 UPCB with man- 19 sbj (11F, 8M) with Not reported Mandibular shift Three-channel Compared with children Yes 1
dibular shift mandibular shift; 3 group: 8–12 ys, sEMG with normal occlusion the
sbj with mandibular mean 9.7 ys; con- entire group of children with
shift without UPCB; trol group with forced bite (19 sbj) showed a
52 control group (27F, corresponding age significant greater activity of
25M) the anterior temporal muscle
on the side of forced bite,
while that in the posterior
temporalis on the non-forced
bite side in children with large
lateral deviation was lower.
Compared with children with
normal occlusion, the children
with a forced bite had lower
amplitude in the anterior and
posterior temporalis on the
non-forced bite side during
chewing.
8 Moreno (51) 2008 Observational study 7% (3) of the sample 45 sbj (33F, 12M) University Total sample: 8 channels sEMG Despite the low frequency of Yes 4
(not reported gender) Students 22–29 ys, mean: recordings a PCB in this sample. It has
24ys demonstrated an important
effect upon the activity of ip-
silateral masseter in maximum
clenching. The major force is
produced by the anterior tem-
poralis muscle, while masseter
remains nearly inactive.
645

Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022

Table 2. Continued
646

Methods/
Author Year Study design Crossbite Sample Selected from Age Measurements Results Association Score

9 Piancino (52) 2009 Cross-sectional with UPCB: 82 (not re- 94 sbj; 12 control Orthod De- UPCB: 8.6 ± 1.3ys; Multichannel elec- Muscle activity during mas- Yes 7
control group ported gender) group partment control group: tromyography tication on the non-affected
8.9 ± 0.6 ys side is normal, whereas on the
crossbite side muscle activity
during mastication is altered
both in reverse and non-
reverse cycles. The masseter
of the non-affected side is, in
general, more loaded than in
healthy controls, whereas the
masseter of the crossbite side is
less active.
10 Tecco (53) 2010 Cross-sectional with 75 PCB (30F, 45M): 100 sbj (36F, 64M); Patients and UPCB: 19.9 ± 4.4 sEMG In the mandibular rest Yes 8
control group 50 UPCB; 25 BPCB 25 control group (6F, dentistry ys (mean M/F); position, patients with UPCB
19M) students. BPCB: 20.4 ± 4.3 showed a significant difference
ys; control group: in sEMG activity of the ante-
22.5 ± 5.8 ys rior temporal muscle. During
maximum voluntary clenching,
control subjects showed signif-
icantly lower sEMG activity in
both the sternocleidomastoid
and the posterior cervical mus-
cles compared with patients
demonstrating both unilateral
and bilateral crossbites.
11 Woźniak (54) 2015 Cross-sectional with UPCB and ssTMD: 50 150 sbj (74M, 76F); Patients UPCB and sEMG The results confirmed the Yes 7
control group (22F, 28M) 100 malocclusion pz TMDss: 20.8 ± 1.1 influence of unilateral poste-
(54F, 46M) ys; Malocclusion rior crossbite on variations in
pz: 21.42 ± 1ys spontaneous muscle activity
in the mandibular rest posi-
tion and maximum voluntary
contraction. In addition, there
was a significant increase in
the Asymmetry Index and
Torque Coefficient, responsible
for a laterodeviating effect on
the mandible caused by unbal-
anced right and left masseter
and temporal muscles.

Crossbite = number of subjects in the sample presenting crossbite; PCB = posterior crossbite; UPCB = unilateral posterior crossbite; BPCB = bilateral posterior crossbite; Sbj = subjects; Ctr = control group; sEMG = surface
electromyography; Ys = years; ssTMD = subjective symptoms of temporomandibular dysfunction.
European Journal of Orthodontics, 2016, Vol. 38, No. 6

Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022

Table 3. Crossbite and bite force.

Methods/
Author Year Study design Crossbite Sample Selected from Age Measurements Results Association Score

1 Sonnesen (55) 2001 Cross-sectional UPCB 26 (13F, 52 sbj (26F, 26M); Dental health UPCB: 7–13 ys Pressure Differences in the muscle function associated with Yes 9
G. Iodice et al.

with control group 13M) 26 control group service (9.35 mean); c transducer unilateral crossbite lead to a significantly smaller
(13F, 13M) ontrol group: bite force in the crossbite group compared with
corresponding age controls and this difference did not diminish with
age and development.
2 Castelo (56) 2007 Cross-sectional 21 UPCB (12F, 9M,); 49 sbj (26M, 23F); Department of Aged 3.5–7 ys; PCB Pressure A statistical difference in bite force was observed Yes 7
with control group PCB 10 (4F, 6M); PNO: (5F, 10M); Pediatric (60.5 ms); MCB transducer between the MNO and MCB groups, with greater
MCB 11 (8F, 3M) MNO (7F, 6M) Dentistry (71.9 ms); PNO values for the MNO subjects.
(58.7 ms); MNO
(72.8 ms)
3 Castelo (57) 2010a Cross-sectional 35 sbj (15M, 20F); 67 sbj (36M, 31F); Department of Aged 3.5–7 ys; PCB Pressure The MCB group presented bite force values Yes 7
with control group PCB 19 (9F, 10M); PNO 19 (5F, 14M); Pediatric (59.5 ms); MCB transducer significantly smaller than group MNO.
MCB 16 (11F, 5M) MNO 13 (6F, 7M) Dentistry (73.2 ms); PNO
(58.4 ms); MNO
(72.7 ms)
4 Rentes (58) 2002 Cross-sectional Number not 30 sbj Dental school 3.5–5 ys range Pressure There were no significant statistical differences No 4
with control group reported transducer among crossbite group and control group.

Crossbite = number of subjects in the sample presenting crossbite; UPCB = unilateral posterior crossbite; Sbj = subjects; Ctr = control group; PCB = primary crossbite; MCB = mixed-crossbite; PNO = primary normal oc-
clusion; MNO = mixed-normal occlusion; Ms = months; ys = years.

Table 4. Crossbite and masticatory muscle thickness.

Methods/
Author Year Study design Crossbite Sample Selected from Age Measurements Results Association Score

1 Andrade (31) 2009 Cross-sectional UPCB 20 (8F, 12M) 36 sbj (22M, 14F); 16 Dental patients Total sample: Ultrasonography The ultrasonographic evaluation (thick- No 7
with control NOccl group (6F, 10M) 7–10ys; UPCB: at rest and during ness of the masseter and anterior tempo-
group 8.8 ± 1.1 ys; NOccl: maximal clenching ralis) did not show statistically significant
8.8 ± 1.1 ys differences between groups nor between
sides in the PCB and NOccl groups.
2 Castelo (14) 2010b Cross-sectional 35 UPCB (15M, 20F); 81 sbj; 19 PNO Department Total sample: Ultrasonography The results showed that muscle thickness No 7
with control 19 PCB (9F, 10M); 16 (4F, 15M); 27 MNO of Pediatric 64.7 ± 7 m at rest and during did not differ significantly between the
group MCB (11F, 5M) (9F, 18M) Dentistry maximal clenching sides of the dental arches in all groups.
3 Castelo (56) 2007 Cross-sectional 21 UPCB (12F, 9M,); 49 sbj (26M, 23F); Department Aged 3.5–7 ys; PCB Ultrasonography The anterior temporalis thickness at rest Yes 7
with control PCB 10 (4F, 6M); PNO: (5F, 10M); MNO of Pediatric (60.5 ms); MCB at rest and during was statistically thicker for the crossbite
group MCB 11 (8Fxgs, 3M) (7F, 6M) Dentistry (71.9 ms); PNO maximal clenching side than the normal side in the MCB
(58.7 ms); MNO group.
(72.8 ms)
4 Kiliaridis (26) 2007 Cross-sectional 38 UPCB (17M, 21F) 282 sbj; 16 BPCB; 224 Department of UPCB: 11.9 ys Ultrasonography In the UPCB group, the thickness of the Yes 8
with control control group (112F, Orthodontics mean (8.1–17.8 ys); at rest and during masseter muscle on the crossbite side was
group 112M) Control group: 12 ys maximal clenching statistically significantly thinner than the
mean (7.2–18.2 ys) one on the normal side.

Crossbite = number of subjects in the sample presenting crossbite; PCB = posterior crossbite; UPCB = unilateral posterior crossbite; BPCB = bilateral posterior crossbite; Sbj = subjects; Ctr = control group; NOccl = normal
occlusion; PCB = primary crossbite; MCB = mixed- crossbite; PNO = primary normal occlusion; MNO = mixed-normal occlusion; ms = months; ys = years.
647

Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022

Table 5. Crossbite and chewing cycle.

Methods/
648

Author Year Study design Crossbite Sample Selected from Age Measurements Results Association Score

1 Andrade (49) 2010 Cross-sectional with 17 UPCB (not 37 sbj; 20 control Dental patients Total sample: 7–10 Visual spot- Children with and without UPCB No 6
control group reported gender; group (not re- ys; UPCB: 8.6 ± 1.2 checking presented a bilateral masticatory
5 on the R, 12 on ported gender) ys; Control group: method pattern with similar chewing rate
the L) 8.6 ± 1.1 ys and cycle duration.
2 Martín (59) 2000 Cross-sectional with 30 right PCB (17F, 60 sbj (33F, 27M); Department of Total sample: 10–14 Kinesiograph No differences were found in the No 9
control group 13M; all on the R) 30 control group Odontology ys; UPCB: 12.2 parameters of the masticatory
(16F, 14M) ys mean; Control cycle between groups. There was
group: 12.5 ys mean. no relationship between the side of
the crossbite and the masticatory
preference side.
3 Miyawaki (60) 2004 Cross-sectional with 12 UPCB (6F, 6M); 24 sbj (12F, 12M); Orthod Total sample: 18–30 Optoelectronic The lateral and medial poles of Yes 7
control group 12 control group: Department ys; UPCB: 23.8 jaw-tracking the condyle on the crossbite side
(6F, 6M) ys mean; Control system moved more in the medial direc-
group: 22.9 ys mean tion and less in the lateral direction
during mastication in the crossbite
patients than the condyle in the
normal subjects.
4 Nie (27) 2010 Cross-sectional with 16 PCB (Not re- 128 sbj (43M, Orthod CB: 12–35 ys range; Kinesiograph In the crossbite groups, normal Yes 8
control group ported gender; Not 85F); 106 CB Department Control group: chewing occurred much less often
reported side) (36M, 70F); 22 16–30 ys range than in subjects with normal occlu-
control group (15F, sion. In the crossbite or shift side,
7M) reverse type and reverse-crossing
type occurred more often than in
contralateral side.
5 Piancino (52) 2009 Cross-sectional with 82 UPCB (not 94 sbj; 12 control Orthod UPCB: 8.6 ± 1.3 Kinesiograph The reverse cycles on the crossbite Yes 8
control group reported gender; group Department ys; Control group: side were narrower with respect to
50 on the R, 32 on 8.9 ± 0.6 ys the cycles on the non-affected side.
the L)
6 Rilo (61) 2007 Cross-sectional with 25 UPCB (21F, 4M; 50 sbj (40F, 10M); University UPCB: 17–26 ys Gnathograph Patients with UPCB showed a Yes 8
control group 12 on the R, 13 on 25 control group students range; 19.6 ys mean; higher proportion of reverse-se-
the L) (19F, 6M) Control group: quencing patterns during chewing
20–26 ys range on the crossbite side compared
with that on the non-crossbite side
and that for the control group. Ab-
normal cycles on the crossbite side
were more frequent when two or
more teeth are involved than when
only one tooth was involved.
7 Sever (28) 2010 Cross-sectional with 20 UPCB (14F, 6M; 30 sbj (19F, 11M); Pedodontic UPCB: 5 ± 1.2 ys; Sirognatho- Children with a UPCB produced Yes 6
control group 11 on the R, 9 on 10 control group Clinic Control group: graph (COSIG chewing cycles with a shorter rest
the L) (5F, 5M) 5.3 ± 1.3 ys II). position and more frequently in a
reverse direction when chewing on
the UPCB side in comparison with
children with a normal occlusion
and with the non-UPXB side.
European Journal of Orthodontics, 2016, Vol. 38, No. 6

Crossbite = number of subjects in the sample presenting crossbite; CB = anterior and/or posterior crossbite; PCB = posterior crossbite; UPCB = unilateral posterior crossbite; BPCB =
bilateral posterior crossbite; Sbj = subjects; Ctr = control group; R = right side; L = left side; ys = years.

Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022

G. Iodice et al.
according to the currently available scientific data, UPCB is associ-
ated to masticatory muscle EMG asymmetric activity. In particular,
Alarcon et al. (24) found that in posterior crossbite subjects, the con-
tralateral posterior temporalis showed higher EMG activity than the
ipsilateral one, possibly as a consequence of functional mandibular
shift in order to reach an occlusal stability (24, 31). Nevertheless,
it must be stressed that asymmetric EMG activity does not mean
pathology. Indeed, the same authors found that the right anterior
temporal demonstrated a higher EMG activity than the left ante-
rior temporal in the normocclusive group, suggesting that muscu-
lar asymmetry could be considered physiological and compatible
with normal function (9, 24, 31). Furthermore, the lack of consist-
ency also in the studies reporting an association between posterior
crossbite and EMG asymmetry has to be stressed. Indeed, Alarcon
et al. (24) even reporting the crossbite side to be less active than
in normocclusive subjects, did not find any difference between the
crossbite side and non-crossbite side. Instead, Andrade et al. (31)
found that the masseter of the crossbite side was more active than
that of the non-crossbite side in the UPCB group during maximal
clenching. Conversely, Piancino et al. (52) reported a reduced mas-
seter activity on the crossbite side and unaltered or increased on the
non-crossbite side.
All the analyzed studies used surface EMG measurements to
evaluate muscle activity. Some studies reported good reproducibility
and sufficient accuracy in young subjects (72, 73). Nevertheless, sev-
eral authors reported very large standard deviations in EMG activity,
both in subjects with and without crossbite (23, 25, 74). This wide
inter-individual variability should be taken into account when inter-
preting the results. Finally, surface EMG does not allow the activity
of a single muscle to be recorded due to the so-called cross-talking of
the neighbouring muscles (25).
Crossbite and Bite Force
Four articles evaluated the association between posterior crossbite
and bite force. A positive association is supported by 75% of the
analyzed studies. It must be stressed that three out of four studies
were published by the same research group, with samples of similar
age, but opposite results (56–58). Interestingly, the only study report-
ing ‘no association’ (58) is older than the others and of low scientific
and methodological quality.
All studies analyzed children/adolescents, ranging from 3.5 to
13 years, using a pressure transducer to record bite force. No infor-
mation is available on adults on this topic.
According to these data, UPCB might lead to a significantly
smaller bite force compared with non-crossbite subjects, and
this difference does not decrease with age and development (55).
Nevertheless, no definitive conclusion can be drawn on this topic, as
a consequence of the insufficient evidence available.
Crossbite and Masticatory Muscle Thickness
Four studies analyzed the association between UPCB and mastica-
tory muscle thickness, half of them reporting a significant association
and half of them not. Indeed, Kiliaridis et al. (26) reported that in
UPCB subjects the thickness of the masseter muscle was significantly
thinner on the crossbite side, with no significant differences in the
non-crossbite group. On the other hand, Andrade et al. (31) found
no differences either between sides or between UPCB and no-UPCB
groups. Interestingly, the opposite findings were reported by the same
authors in different studies in a three-year time lapse. This could be
ascribed to the different sample size of the studies. Hence, no conclu-
sions can currently be drawn on UPCB and muscle thickness.
649
All the analyzed studies used similar methods, i.e. ultrasonogra-
phy investigation. Nevertheless, 3 selected children ranging from 4
to 6 years old, whereas Kiliaridis et al. (26) used a sample of adoles-
cents ranging from 8 to 18 years old.
Crossbite and Chewing Cycle
Seven articles evaluated the association between posterior crossbite
and chewing cycle. According to most of the studies (27, 28, 52, 60,
61), subjects with UPCB present different kinematics of the mandible
during mastication when chewing on the affected side, compared with
no-UPCB subjects. Indeed, during chewing, the mandible deviates lat-
erally towards the bolus side and then medially during closure (52).
Sometimes, the mandible can first deviate medially and then later-
ally, thus ensuring overlap of opposing dental occlusal surfaces. This
is called a ‘reverse chewing cycle’. Reverse chewing cycles show an
Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022
abnormal, narrow pattern characterized by smaller lateral displace-
ment and slower velocity of the mandible in comparison with normal
chewing. In a patient with unilateral crossbite, reverse cycles occur
mainly on the crossbite side, although not all cycles are reverse when
chewing from the crossbite side (52). Nevertheless, the reverse chew-
ing cycle is very common in children with a normal occlusion (33),
who present a smaller lateral component during opening and closing
than adults. According to the authors, the reverse cycle is not abnor-
mal because normal children with primary dentition have a smaller
lateral component and difficulty in controlling asymmetric muscle
activity. Hence, reverse chewing cycles cannot be considered patho-
logic but could be a physiologic and common feature of the chewing
cycle in children.
A limit of the present review is that, in order to enhance the
methodological rigor of the studies examined and the conclusion
drawn, only articles in peer-reviewed journals and in English were
included. Nevertheless, according to this strategy, publications in
other languages and/or publications reported in different databases
may have been unjustly excluded in our review.
Conclusions
1. Most studies currently available report a skeletal asymmetric
growth in UPCB subjects; EMG activity of masticatory muscles
has been reported to be different between the crossbite side and
non-crossbite sides; UPCB might lead to a significantly smaller
bite force compared with non-crossbite subjects; there is no evi-
dence of masticatory muscle thickness asymmetry; and UPCB is
reported to be associated to an increase in the reverse chewing
cycle.
2. No definitive conclusion can be drawn on the relationship between
posterior crossbite and skeletal asymmetry. The overwhelming
majority of the studies analyzed, both reporting and not report-
ing association, are of medium–low scientific and methodologi-
cal quality. The possible association should be addressed by future
research, with rigorous scientific methodology (see Strobe State-
ment checklist).
3. Very few studies on the topic report long-term data, limiting the
evidence on the topic and making it impossible to understand
whether the posterior crossbite is a cause, an effect, or unrelated to
skeletal and muscular asymmetries. Future surveys with long-term
control are needed, especially in adolescent samples.
4. Finally, it is very important to stress that, even if a significant
association between UPCB, skeletal, and functional asymmetries
has been reported elsewhere, a certain amount of asymmetry has
to be considered physiologic and present in all subjects.
650
Supplementary material
Supplementary material is available at European Journal of Orthodontics
online.
References
1. Daskalogiannakis, J. (2000) Glossary of Orthodontic Terms. Quintessence
Publishing, Chicago, IL, pp. 79.
2. Sonnesen, L., Bakke, M. and Solow, B. (1998) Malocclusion traits and
symptoms and signs of temporomandibular disorders in children with
severe malocclusion. European Journal of Orthodontics, 20, 543–559.
3. Melink, S., Vagner, M.V., Hocevar-Boltezar, I. and Ovsenik, M. (2010) Pos-
terior crossbite in the deciduous dentition period, its relation with sucking
habits, irregular orofacial functions, and otolaryngological findings. Ameri-
can Journal of Orthodontics and Dentofacial Orthopedics, 138, 32–40.
4. de Sousa, R.V., Ribeiro, G.L., Firmino, R.T., Martins, C.C., Granville-Gar-
cia, A.F. and Paiva, S.M. (2014) Prevalence and associated factors for the
development of anterior open bite and posterior crossbite in the primary
dentition. Brazilian Dental Journal, 25, 336–342.
5. Thilander, B. and Myrberg, N. (1973) The prevalence of malocclusion in
Swedish schoolchildren. Scandinavian Journal of Dental Research, 81,
12–21.
6. Helm, S. and Prydsö, U. (1979) Prevalence of malocclusion in medieval
and modern Danes contrasted. Scandinavian Journal of Dental Research,
87, 91–97.
7. Ciuffolo, F., Manzoli, L., D’Attilio, M., Tecco, S., Muratore, F., Festa, F.
and Romano, F. (2005) Prevalence and distribution by gender of occlusal
characteristics in a sample of Italian secondary school students: a cross-
sectional study. European Journal of Orthodontics, 27, 601–606.
8. Farella, M., Michelotti, A., Iodice, G., Milani, S. and Martina, R. (2007)
Unilateral posterior crossbite is not associated with TMJ clicking in young
adolescents. Journal of Dental Research, 86, 137–141.
9. Iodice, G., Danzi, G., Cimino, R., Paduano, S. and Michelotti, A. (2013) Asso-
ciation between posterior crossbite, masticatory muscle pain, and disc displace-
ment: a systematic review. European Journal of Orthodontics, 35, 737–744.
10. Thilander, B., Wahlund, S. and Lennartsson, B. (1984) The effect of early
interceptive treatment in children with posterior cross-bite. European
Journal of Orthodontics, 6, 25–34.
11. Lindner, A. (1989) Longitudinal study on the effect of early interceptive
treatment in 4-year-old children with unilateral cross-bite. Scandinavian
Journal of Dental Research, 97, 432–438.
12. Macena, M.C., Katz, C.R. and Rosenblatt, A. (2009) Prevalence of a poste-
rior crossbite and sucking habits in Brazilian children aged 18-59 months.
European Journal of Orthodontics, 31, 357–361.
13. Dimberg, L., Lennartsson, B., Arnrup, K. and Bondemark, L. (2015) Preva-
lence and change of malocclusions from primary to early permanent denti-
tion: a longitudinal study. The Angle Orthodontist, 85, 728–734.
14. Castelo, P.M., Pereira, L.J., Andrade, A.S., Marquezin, M.C. and Gavião,
M.B. (2010b) Evaluation of facial asymmetry and masticatory muscle
thickness in children with normal occlusion and functional posterior
crossbite. Minerva Stomatologica, 59, 423–430.
15. Veli, I., Uysal, T., Ozer, T., Ucar, F.I. and Eruz, M. (2011) Mandibular
asymmetry in unilateral and bilateral posterior crossbite patients using
cone-beam computed tomography. The Angle Orthodontist, 81, 966–974.
16. Takada, J., Miyamoto, J.J., Yokota, T., Ono, T. and Moriyama, K. (2015)
Comparison of the mandibular hinge axis in adult patients with facial
asymmetry with and without posterior unilateral crossbite. European
Journal of Orthodontics, 37, 22–27.
17. Hesse, K.L., Artun, J., Joondeph, D.R., Kennedy, D.B. (1997) Changes in
condylar postition and occlusion associated with maxillary expansion for
correction of functional unilateral posterior crossbite. American Journal of
Orthodontics and Dentofacial Orthopedics, 111, 410–418.
18. Nerder, P.H., Bakke, M. and Solow, B. (1999) The functional shift of the
mandible in unilateral posterior crossbite and the adaptation of the tem-
poromandibular joints: a pilot study. European Journal of Orthodontics,
21, 155–166.
European Journal of Orthodontics, 2016, Vol. 38, No. 6
19. Pinto, A.S., Buschang, P.H., Throckmorton, G.S. and Chen, P. (2001) Mor-
phological and positional asymmetries of young children with functional
unilateral posterior crossbite. American Journal of Orthodontics and
Dentofacial Orthopedics, 120, 513–520.
20. Uysal, T., Sisman, Y., Kurt, G. and Ramoglu, S.I. (2009) Condylar and
ramal vertical asymmetry in unilateral and bilateral posterior crossbite
patients and a normal occlusion sample. American Journal of Orthodon-
tics and Dentofacial Orthopedics, 136, 37–43.
21. Troelstrup, B. and Moller, E. (1970) Electromyography of the temporalis
and masseter muscles in children with unilateral cross-bite. Scandinavian
Journal of Dental Research, 78, 425–430.
22. Ingervall, B. and Thilander, B. (1975) Activity of temporal and masseter
muscles in children with a lateral forced bite. The Angle Orthodontist, 45,
249–258.
23. Ferrario, V.F., Sforza, C. and Serrao, G. (1999) The influence of crossbite
on the coordinated electromyographic activity of human masticatory mus-
cles during mastication. Journal of Oral Rehabilitation, 26, 575–581.
Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022
24. Alarcon, J.A., Martin, C. and Palma, J.C. (2000) Effect of unilateral pos-
terior crossbite on the electromyographic activity of human masticatory
muscles. American Journal of Orthodontics and Dentofacial Orthopedics,
118, 328–334.
25. Alarcon, J.A., Martín, C., Palma, J.C. and Menéndez-Núñez, M. (2009)
Activity of jaw muscles in unilateral cross-bite without mandibular shift.
Archives of Oral Biology, 54, 108–114.
26. Kiliaridis, S., Mahboubi, P.H., Raadsheer, M.C. and Katsaros, C. (2007)
Ultrasonographic thickness of the masseter muscle in growing individuals
with unilateral crossbite. The Angle Orthodontist, 77, 607–611.
27. Nie, Q., Kanno, Z., Xu, T., Lin, J. and Soma, K. (2010) Clinical study
of frontal chewing patterns in various crossbite malocclusions. American
Journal of Orthodontics and Dentofacial Orthopedics, 138, 323–329.
28. Sever, E., Marion, L. and Ovsenik, M. (2010) Relationship between mas-
ticatory cycle and unilateral crossbite in the primary dentition. European
Journal of Orthodontics, 33, 620–627.
29. Piancino, M.G., Comino, E., Talpone, F., Vallelonga, T., Frongia, G. and
Bracco, P. (2012) Reverse-sequencing chewing patterns evaluation in ante-
rior versus posterior unilateral crossbite patients. European Journal of
Orthodontics, 34, 536–541.
30. Sonnesen, L. and Bakke, M. (2007) Bite force in children with unilateral
crossbite before and after orthodontic treatment. A prospective longitudi-
nal study. European Journal of Orthodontics, 29, 310–313.
31. Andrade Ada, S., Gameiro, G.H., Derossi, M. and Gavião M B. (2009)
Posterior crossbite and functional changes. A systematic review. The Angle
Orthodontist, 79, 380–386.
32. Throckmorton, G.S., Buschang, P.H., Hayasaki, H. and Pinto, A.S. (2001)
Changes in the masticatory cycle following treatment of posterior unilat-
eral crossbite in children. American Journal of Orthodontics and Dentofa-
cial Orthopedics, 120, 521–529.
33. Saitoh, I., Yamada, C., Hayasaki, H., Maruyama, T., Iwase, Y and Yama-
saki, Y. (2010) Is the reverse cycle during chewing abnormal in children
with primary dentition? Journal of Oral Rehabilitation, 37, 26–33.
34. Abad-Santamaría, L., López-de-Andrés, A., Jiménez-Trujillo, I., Ruíz, C.
and Romero, M. (2014) Effect of unilateral posterior crossbite and unilat-
eral cleft lip and palate on vertical mandibular asymmetry. Irish Journal of
Medical Science, 183, 357–362.
35. Cohlmia, J.T., Ghosh, J., Sinha, P.K., Nanda, R.S. and Currier, G.F. (1996)
Tomographic assessment of temporomandibular joints in patients with
malocclusion. The Angle Orthodontist, 66, 27–35.
36. Ferro, F., Spinella, P. and Lama, N. (2011) Transverse maxillary arch form
and mandibular asymmetry in patients with posterior unilateral crossbite.
American Journal of Orthodontics and Dentofacial Orthopedics, 140,
828–838.
37. Halicioglu, K., Celikoglu, M., Yavuz, I., Sekerci, A.E. and Buyuk, S.K.
(2014) An evaluation of condylar and ramal vertical asymmetry in adoles-
cents with unilateral and bilateral posterior crossbite using cone beam com-
puted tomography (CBCT). Australian Orthodontic Journal, 30, 11–18.
38. Kasimoglu, Y., Tuna, E.B., Rahimi, B., Marsan, G. and Gencay, K. (2015)
Condylar asymmetry in different malocclusion types. Cranio, 33, 10–14.
G. Iodice et al.
39. Kiki, A., Kiliç, N. and Oktay, H. (2007) Condylar asymmetry in bilateral
posterior crossbite patients. The Angle Orthodontist, 77, 77–81.
40. Kilic, N., Kiki, A. and Oktay, H. (2008) Condylar asymmetry in unilat-
eral posterior crossbite patients. American Journal of Orthodontics and
Dentofacial Orthopedics, 133, 382–387.
41. Kusayama, M., Motohashi, N. and Kuroda, T. (2003) Relationship
between transverse dental anomalies and skeletal asymmetry. American
Journal of Orthodontics and Dentofacial Orthopedics, 123, 329–337.
42. Langberg, B.J., Arai, K. and Miner, R.M. (2005) Transverse skeletal and
dental asymmetry in adults with unilateral lingual posterior crossbite.
American Journal of Orthodontics and Dentofacial Orthopedics, 127,
6–15.
43. O’Bryn, B.L., Sadowsky, C., Schneider, B. and BeGole, E.A. (1995) An
evaluation of mandibular asymmetry in adults with unilateral posterior
crossbite. American Journal of Orthodontics and Dentofacial Orthope-
dics, 107, 394–400.
44. Pellizoni, S.E., Salioni, M.A., Juliano, Y., Guimarães, A.S. and Alonso, L.G.
(2006) Temporomandibular joint disc position and configuration in chil-
dren with functional unilateral posterior crossbite: a magnetic resonance
imaging evaluation. American Journal of Orthodontics and Dentofacial
Orthopedics, 129, 785–793.
45. Pirttiniemi, P., Raustia, A., Kantomaa, T. and Pyhtinen, J. (1991) Relation-
ships of bicondylar position to occlusal asymmetry. European Journal of
Orthodontics, 13, 441–445.
46. Primozic, J., Perinetti, G., Richmond, S. and Ovsenik, M. (2013) Three-
dimensional evaluation of facial asymmetry in association with unilateral
functional crossbite in the primary, early, and late mixed dentition phases.
The Angle Orthodontist, 83, 253–258.
47. Primozic, J., Ovsenik, M., Richmond, S., Kau, C.H. and Zhurov, A. (2009)
Early crossbite correction: a three-dimensional evaluation. European Jour-
nal of Orthodontics, 31, 352–356.
48. van Keulen, C., Martens, G. and Dermaut, L. (2004) Unilateral posterior
crossbite and chin deviation: is there a correlation? European Journal of
Orthodontics, 26, 283–288.
49. Andrade Ada, S., Gavião, M.B., Gameiro, G.H. and De Rossi, M. (2010)
Characteristics of masticatory muscles in children with unilateral poste-
rior crossbite. Brazilian Oral Research, 24, 204–210.
50. Ciavarella, D., Monsurrò, A., Padricelli, G., Battista, G., Laino, L. and Per-
illo, L. (2012) Unilateral posterior crossbite in adolescents: surface elec-
tromyographic evaluation. European Journal of Paediatric Dentistry, 13,
25–28.
51. Moreno, I., Sánchez, T., Ardizone, I., Aneiros, F. and Celemin, A. (2008)
Electromyographic comparisons between clenching, swallowing and
chewing in jaw muscles with varying occlusal parameters. Medicina oral,
patología oral y cirugía bucal, 13, E207–E213.
52. Piancino, M.G., Farina, D., Talpone, F., Merlo, A. and Bracco, P. (2009)
Muscular activation during reverse and non-reverse chewing cycles in
unilateral posterior crossbite. European Journal of Oral Sciences, 117,
122–128.
53. Tecco, S., Tetè, S. and Festa, F. (2010) Electromyographic evaluation of
masticatory, neck, and trunk muscle activity in patients with posterior
crossbites. European Journal of Orthodontics, 32, 747–752.
54. Woźniak, K., Szyszka-Sommerfeld, L. and Lichota, D. (2015) The electrical
activity of the temporal and masseter muscles in patients with TMD and
unilateral posterior crossbite. BioMed Research International, 2015, 1–7.
55. Sonnesen, L., Bakke, M. and Solow, B. (2001) Bite force in pre-orthodontic
children with unilateral crossbite. European Journal of Orthodontics, 23,
741–749.
56. Castelo, P.M., Gavião, M.B., Pereira, L.J. and Bonjardim, L.R. (2007)
Masticatory muscle thickness, bite force, and occlusal contacts in young
651
children with unilateral posterior crossbite. European Journal of Ortho-
dontics, 29, 149–156.
57. Castelo, P.M., Gavião, M.B., Pereira, L.J. and Bonjardim, L.R. (2010a)
Maximal bite force, facial morphology and sucking habits in young chil-
dren with functional posterior crossbite. Journal of Applied Oral Science,
18, 143–148.
58. Rentes, A.M., Gavião, M.B. and Amaral, J.R. (2002) Bite force determina-
tion in children with primary dentition. Journal of Oral Rehabilitation, 29,
1174–1180.
59. Martín, C., Alarcón, J.A. and Palma, J.C. (2000) Kinesiographic study of
the mandible in young patients with unilateral posterior crossbite. Ameri-
can Journal of Orthodontics and Dentofacial Orthopedics, 118, 541–548.
60. Miyawaki, S., Tanimoto, Y., Araki, Y., Katayama, A., Kuboki, T. and
Takano-Yamamoto, T. (2004) Movement of the lateral and medial poles
of the working condyle during mastication in patients with unilateral
posterior crossbite. American Journal of Orthodontics and Dentofacial
Orthopedics, 126, 549–554.
Downloaded from https://academic.oup.com/ejo/article/38/6/638/2739003 by guest on 07 December 2022
61. Rilo, B., da Silva, J.L., Mora, M.J., Cadarso-Suárez, C and Santana, U.
(2007) Unilateral posterior crossbite and mastication. Archives of Oral
Biology, 52, 474–478.
62. Talapaneni, A.K. and Nuvvula, S. (2012) The association between poste-
rior unilateral crossbite and craniomandibular asymmetry: a systematic
review. Journal of Orthodontics, 39, 279–291
63. Palla, S. and Farella, M. (2009) External validity: a forgotten issue? Jour-
nal of Orofacial Pain, 23, 297–298.
64. Thilander, B. and Bjerklin, K. (2012) Posterior crossbite and temporo-
mandibular disorders (TMDs): need for orthodontic treatment? European
Journal of Orthodontics, 34, 667–673.
65. Sato, C., Muramoto, T. and Soma, K (2006) Functional lateral deviation
of the mandible and its positional recovery on the rat condylar cartilage
during the growth period. The Angle Orthodontist 76, 591–597
66. White, S.C. and Pharoah, M.J. (2004) Oral Radiology. Mosby, St. Louis,
MO, 5th edn, pp. 197–198.
67. Major, P.W., Johnson, D.E., Hesse, K.L. and Glover, K.E. (1994) Landmark
identification error in posterior anterior cephalometrics. The Angle Ortho-
dontist, 64, 447–454.
68. Major, P.W., Johnson, D.E., Hesse, K.L. and Glover, K.E. (1996) Effect of
head orientation on posterior anterior cephalometric landmark identifica-
tion. The Angle Orthodontist, 66, 51–60.
69. Forsberg, C., Burstone, C. and Hanley, K. (1984) Diagnosis and treatment
planning of skeletal asymmetry with submental-vertex radiographs. Amer-
ican Journal of Orthodontics and Dentofacial Orthopedics, 85, 224–237.
70. Lippold, C., Stamm, T., Meyer, U., Végh, A., Moiseenko, T. and Danesh, G.
(2013) Early treatment of posterior crossbite--a randomised clinical trial.
Trials, 22, 14–20.
71. Tsanidis, N., Antonarakis, G.S. and Kiliaridis, S. (2016) Functional changes
after early treatment of unilateral posterior cross-bite associated with man-
dibular shift: a systematic review. Journal of Oral Rehabilitation, 43, 59–68.
72. Ferrario, V.F., Sforza, C., D’Addona, A. and Miani, A., Jr. (1991) Repro-
ducibility of electromyographic measures: a statistical analysis. Journal of
Oral Rehabilitation, 18, 513–521.
73. Bakke, M. (1993) Mandibular elevator muscles: physiology, action, and effect
of dental occlusion. Scandinavian Journal of Dental Research, 101, 314–331.
74. Ferrario, V.F., Sforza, C., Miani, A., Jr, D’Addona, A. and Barbini, E.
(1993) Electromyographic activity of human masticatory muscles in nor-
mal young people. Statistical evaluation of reference values for clinical
applications. Journal of Oral Rehabilitation, 20, 271–280.
75. Andrade, A.S., Gavião, M.B., Derossi, M. and Gameiro, G.H. (2009b)
Electromyographic activity and thickness of masticatory muscles in chil-
dren with unilateral posterior crossbite. Clinical Anatomy, 22, 200–206.