Hexa Helix: Modified Quad Helix Appliance

to Correct Anterior and Posterior Crossbites

in Mixed Dentition.

Syed Mohammed Yaseen and Ravindranath Acharya. Case Reports in

Dentistry. Volume 2012, Article ID 860385, 5 pages
• Crossbite is a term used to describe abnormal
occlusion in the transverse plane.

• Graber- “condition where one or more teeth may be

abnormally malposed buccally or lingually or labially
with reference to the opposing tooth or teeth”
 CLASSIFICATION OF CROSS-BITE
BASED ON LOCATION
• ANTERIOR

• POSTERIOR
• Buccal non-occlusion/scissor bite

• Lingual non-occlusion
BASED ON THE NATURE OF CROSS-BITE

• SKELETAL
• DENTAL
• FUNCTIONAL
SKELETAL CROSS-BITE

Etiology:
• Hereditary
• Congenital (Cleft lip & palate)
• Trauma at birth (forceps delivery)
• Trauma during growth (ankylosis of TMJ)
• Trauma after completion of growth (malunion of fracture segments)
• Habits (if not corrected during growth)
DENTAL CROSS-BITE

Etiology:
• Prolonged retention of deciduous teeth
• Presence of supernumerary teeth
• Premature loss of deciduous teeth
• Trauma to deciduous teeth displacement of permanent tooth bud.
• Abnormal eruptive path.
ANTERIOR CROSS-BITE: ETIOLOGY

• A palatal eruption path of the maxillary anterior incisors.

• Trauma to the primary incisor resulting in lingual displacement of the permanent tooth
germ.
• Supernumerary anterior teeth
• An over-retained necrotic or pulpless deciduous tooth or root.
• Odontomas;
• Crowding in the incisor region.
• Inadequate arch length
• A habit of biting the upper lip

Sule Bayrak, Emine Sen Tunc. Treatment of Anterior Dental Crossbite

Using Bonded Resin-Composite Slopes: Case Reports. Eur J Dent2008;2:303-
307
POSTERIOR CROSS-BITE:ETIOLOGY

• Genetics, environmental factors, and habits.

• Transverse maxillary deficiency - asymmetric growth of mandible or
maxilla, discrepant width of maxilla or mandible
• Crowding
• Premature loss or prolonged retention of primary teeth
• Impaired nasal breathing
• Digit sucking
• Abnormal swallowing habits
• Temperomandibular disorders
FUNCTIONAL CROSS-BITE

• Presence of occlusal interferences.

• Habitual forward positioning of mandible (pseudo class III).

• Acquired muscular reflex pattern during closure of the

mandible.
 TREATMENT FOR ANTERIOR CROSS-BITE

1. TONGUE BLADE THERAPY

1-2 hours for about 2 weeks.

Early Interception Of Anterior Crossbite In Mixed Dentition Period: Two Case
Reports. Neeraj Mahajan.,Samriti Bansal, Pratibha Garg. Indian Journal of
Dental Sciences. October 2013.Issue:4, Vol.:5

• Patient was asked to bite firmly for five seconds followed

by rest. This is repeated for 25 times for three times a day.
2. CATLANS APPLIANCE/LOWER ANTERIOR INCLINED PLANE
• Acrylic or cast metal.
• 45º angulation
• To be used only in those cases where the cross-bite is due to a palatally
displaced maxillary incisor.
Disadvantages:
1. Problems in speech
2. Dietary restrictions
3. If used >2 weeks, anterior open bite
4. Tooth more prone to avulsion
5. Appliance may need frequent
recementation.
6. The appliance cannot be given if the
mandibular incisors are periodontally
compromised.
7. The appliance cannot be fabricated if the
mandibular incisors are maligned.
• Anterior crossbite correction in primary and mixed dentition with
removable inclined plane (Bruckl appliance). Irena Jirgensone, Andra
Liepa, Andris Abeltins. Stomatologija, Baltic Dental and Maxillofacial
Journal, 10:140-144, 2008

Bruckl appliance.
• It is used when there is anterior crossbite involving several teeth.
• Vertical overbite approximately 1/2-2/3 or more.
• Not recommended in cases with crowded maxillary incisors.
• Mandibular Hawley retainer with inclined plane added.

• Labial bow for retraction of lower incisors.

• When labial bow is activated, acrylic is cut away on the lingual surface of
mandibular incisors.

• The labial bow exerts a retrusive force to upright lower incisors, close
spaces and correct anterior crossbite.
3. DOUBLE CANTILEVER SPRING
4. RESIN-BONDED COMPOSITE SLOPES

• Correction in 1-2 weeks.

Sule Bayrak, Emine Sen Tunc. Treatment of Anterior Dental Crossbite
Using Bonded Resin-Composite Slopes: Case Reports. Eur J Dent2008;2:303-
307
5. SCREW APPLIANCES
• Micro-screw- most comfortable for the patient; can be used on
individual teeth. Multiple micro-screws can be used to correct
individual teeth in a segmental cross bite.

• Mini-screws-capable of moving up to two teeth.

• Medium screws- capable of moving 4-6 teeth in a segment.
(Segmental expansion)
6. FACE MASK & CHIN CAP
7. FRANKEL III APPLIANCE
• In class III cases characterised by maxillary skeletal retrusion.
 TREATMENT FOR POSTERIOR CROSS-BITE

1. CROSS-BITE ELASTICS
• Single tooth crossbite involving molars
• Elastics between maxillary palatal surface & mandibular
buccal surface.
• Not >6 weeks.
2. COFFIN SPRING
• Walter Coffin
• 1.25mm diameter omega-shaped wire
• Dento-alveolar epansion.
3. QUAD HELIX
• Dento-alveolar expansion
• Skeletal expansion when used in young patients.
• 4 helices- increase flexibility & range of activation.
• Buccal tipping & skeletal expansion in a ratio of 6:1in pre-pubertal children.

Maxillary expansion. Anirudh Agarwal, Rinku Mathur. Int J Clin Ped Dent, Sept-Dec
2010; 3(3):39-146
• Boysen and colleagues (1992) reported that a small percentage of
expansion was caused by skeletal separation. The greatest percentage was
caused by expansion of the teeth and tipping.

• Sandikcioglu and Hazar (1997)- similar findings; Expansion with a quad-

helix appliance was primarily dentoalveolar, with more tipping of teeth.

• Malagola and coleagues (1988)- similar results

Skeletal and dental changes with fixed slow maxillary expansion treatment. A
systematic review. Manuel o. Lagravere, Carlos Flores-mir. JADA, Vol. 136,
February 2005
• Chaconas and Caputo (1982)- effects produced by a quad-helix appliance
are dependent on the patient’s age.

• When midfacial sutures are patent, as seen in children seven to nine years
old, activation of the quad-helix appliance meets with little resistance,
meaning that more skeletal expansion can be obtained than for older
patients.

• Conversely, during treatment of adults, the intermaxillary and surrounding

sutures are less patent and, in some cases, fused, which makes orthopedic
results difficult to obtain.

• Skeletal and dental changes with fixed slow maxillary expansion treatment. A
systematic review. Manuel O. Lagravere, Carlos Flores-mir. JADA, Vol. 136,
February 2005
• Frank (1997) observed orthopedic changes- 0.92mm mean increase in
maxillary width.

• Müge Sandikçioglu (1997)- concluded that in mixed dentition, equal

skeletal and dental results were obtained at the end of treatment with the
quad-helix appliance.

• The most remarkable dental and skeletal effects were seen in the transversal
plane, less in the vertical plane, and none in the sagittal plane

Slow Expansion In Cleft Patient With Quad- Helix. Amit Prakash1, Arundhati
P. Tandur, Sonali Rai. Indian J Dent Adv 2012; 4(1): 772-775
4. W-ARCH APPLIANCE
• Activated by opening the apices of W-arch
• Can be easily adjusted to provide more anterior than posterior
expansion or vice-versa.
5. SPRING JET
• Telescopic unit placed 5mm from the centre of the molar tube
• Activation by moving the lock-screw horizontally along the
telescopic tube
6. NiTi EXPANDER
• Generates optimal, constant expansion forces.
• Central component made of thermally activated Niti alloy, rest with SS.
• Shape memory and transition temp effects.

Maxillary expansion. Anirudh Agarwal, Rinku Mathur. Int J Clin Ped Dent, Sept-Dec
2010; 3(3):39-146
 RAPID MAXILLARY EXPANSION
• Bilateral skeletal cross-bite with a deep palate, nasal
obstruction & narrow maxilla.
• Mid-palatal suture is split.
• TOOTH & TISSUE BORNE- Haas, Derichsweiler
• TOOTH BORNE- Hyrax, Issacson
• RME is usually defined as 2 turns per day (0.5mm expansion) and has a cumulative
force of approximately 100 N across the midpalatal suture.

• SME is defined as 1 turn (0.25 mm of expansion) every second day for a Haas or
hyrax appliance, or 1 molar width activation for a quad-helix, with 5 to 20 N of
force.

Treatment response and stability of slow maxillary expansion using Haas, hyrax,
And quad-helix appliances: A retrospective study. Thuylinh Huynh, David B.
Kennedy, Donald R. Joondeph, and Anne-Marie Bollen. Am J Orthod Dentofacial
Orthop 2009;136:331-9
 CASE REPORT
• 8 year old girl.

• Balanced face with pleasant profile.

• Maxillary dental midline coincident with facial midline.

• No deviation of chin from facial midline.

INTRA-ORAL FEATURES
• Entire maxillary right & left posterior segments tipped palatally.
• Mixed dentition
• Class I molar relation on left side & class II on right side.
• Anterior crossbite involving all the maxillary anterior teeth except
permanent left lateral incisor, and bilateral posterior crossbite.
• The fixed appliance planned was hexa helix; a modification of quad helix in which
both anterior and posterior crossbites can get corrected simultaneously.

• The traditional quad helix consists of a pair of anterior helices and posterior
helices.

• The free wire ends adjacent to the posterior helices are called outer arms. They rest
against the lingual surface of the posterior teeth and are soldered on to the lingual
aspect of the molar bands.

• An additional helix was incorporated to the traditional design on either side of the
outer arm. This additional helix was utilized to correct the anterior crossbite.
Clinical Management.
• The appliance was activated prior to insertion and then
cemented.
• The helices were activated with a three prong plier once every
3 weeks.
• A posterior bite plane using GIC was placed on the occlusal
surfaces of mandibular posterior teeth.
• Within a period of 6 weeks almost all the anterior teeth were corrected out
of crossbite except maxillary permanent right lateral incisor as there was
not enough sufficient space.

• Hence selective grinding was done on maxillary right primary canine to

make room for lateral incisor.

• Following this lateral incisor moved labially uneventfully.

• There was a transverse expansion of 5mm achieved- took approximately
15 weeks.
• 3 months retention.
• Post treatment exhibited class I molar relation.
• Two years post treatment patient has a functional occlusion without cross-
bite.
 DISCUSSION
• Both anterior and posterior crossbites require early correction for
functional reasons and the correction of an anterior crossbite is also
required for aesthetic reasons.
• Fixed appliance treatment- minimal discomfort, reduces need for patient
cooperation, better control of tooth movements, and cost effectiveness.

• Removable appliances- need for patient cooperation, difficulty in

speech/eating, decalcification, caries, palatal hyperplasia, fungal infections,
and incorrect activation leading to unhelpful results.
 Why quad helix??
• Can deliver sufficient forces to promote skeletal changes on maxillary
bone in younger patients (during deciduous and mixed dentitions phases).

• A very versatile appliance, with applications such as: molar rotation

control, torque, and tipping control.

• Can produce advancement in the incisor region and create greater anterior
expansion, resulting in an improved arch form (taking advantage of the
anterior arms that deliver a “sweeping action”).

• No need of patient’s or parent’s cooperation to reach the set

objectives.
• Hicks (1978) reported substantial skeletal changes with slow expansion,
especially in younger children.

• Additionally, slow expansion is related to a more physiological

reorganization of the maxilla in the three planes of the space, providing
more stability and less relapse possibilities than RMEs.

• Quad helix has significantly lower direct and indirect costs, with fewer
failures requiring retreatment when compared to other expansion plates,
thus is the preferred method for correcting posterior crossbite in the mixed
dentition.
• The correction of posterior crossbite in primary and mixed dentition aims
to

(i) profit from the bioelastic features of the bone;

(ii) redirect permanent tooth germs;
(iii) promote better skeletal interactions between the apical base;
(iv) correct inappropriate temporomandibular joint patterns;
(v) support normal mandible closing course; and
(vi) contribute to the better self-esteem of the child patient.

Slow Expansion In Cleft Patient With Quad- Helix. Amit Prakash, Arundhati P
Tandur, Sonali Rai. Indian J Dent Adv 2012; 4(1): 772-775
 CONCLUSION
• The rate of self-correction of crossbites is too low to justify without intervention.
• Posterior crossbites in the deciduous dentition showed self-correction of between
0% and 9%.
• Kutin and Hawes (1969) reported a spontaneous correction rate of only 8% in
their sample of 515 children, 5 to 9 years of age.

• Early cross-bite corrections lead to a stable and normal occlusion pattern and
contribute to symmetrical condyle growth, harmonious TMJ, and overall growth
in the mandible.

• It is very important to correct crossbites at an early age, reducing the need for long
term orthodontic therapy in the future.
Thank You