MANAGEMENT OF CROSSBITE

Presented by;
House Surgeon Zaw Lin Naing,
Htet Myat Aung & Aung Zaw Moe

Date-2.4.2024

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 Crossbite
CONTENTS
 Introduction
 Definition
 Classification
 Anterior crossbite
definition
etiology
diagnosis
mangement
 Posterior crossbite
etiology
diagnosis
management
 Surgical correction
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 INTRODUCTION
In normal occlusion, there is overlap of maxillary teeth over
the mandibular teeth.
In the anterior segment, there is vertical as well as horizontal
overlap of maxillary teeth over mandibular teeth.
The vertical overlap is ‘overbite’ & horizontal overlap is
‘overjet’.
In posterior segment, the maxillary buccal cusp overlap over
mandibular buccal cusp. The mandibular buccal cusp
occlude in the central fossa of maxillary teeth.
Likewise, maxillary palatal cusp occlude with the central
fossa of the mandibular teeth.

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 DEFINITION

According to Graber, ‘Cross bite’ is a condition where one or

more may be malpositioned abnormally- buccally/ labially or
lingually with reference to opposing tooth or teeth.

Fig-Cross bite
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 Classification of Cross Bite
 Based on the Nature of position

• Anterior Cross Bite

• Posterior Cross Bite

Anterior Cross Bite

• Single Tooth Cross Bite
• Segmental Tooth Cross Bite
Posterior Cross Bite
 Unilateral
 Bilateral
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  Based on Etiology and Anatomic Location

Skeletal Cross Bite

Dental Cross Bite
Functional Cross Bite
 According to number of teeth involved
Single tooth crossbite
Segmental tooth crossbite
 According to existence on one/both sides of arch
Unilateral
Bilateral.

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 Skeletal Cross Bite

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 Dental Cross Bite

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 Functional Cross Bite

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 Anterior Cross Bite

Definition
Anterior Cross Bite is defined as malocclusion
resulting from the lingual position of one or more of
the maxillary anterior teeth in relationship with the
mandibular anterior teeth when the tooth are in centric
relation occlusion.

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 1.Anterior Skeletal Cross Bite
Retarded development of maxilla ie: Retarded
development of maxilla in sagittal as well as transverse
direction can cause Cross Bites in the anterior or
posterior region.
Etiology
genetic & developmental disorders such as
cleidocranial dysplasia,
Collapse of maxillary arch as seen in cleft of palate.
Over development of mandible→ Craniofacial
dysplasia
Hormonal disturbances→ Aromegaly & Gigantism.
Unilateral hypo or hypo-plastic growth of any of the
jaws
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 2. Anterior Dental Cross Bites
Etiology

Trauma to the deciduous dentition in which there is

displacement of permanent tooth buds.
Prolonged retained deciduous teeth
Arch length tooth material discrepancies
 Missing of permanent tooth especially the upper lateral
incisor

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 FEATURES

Skeletal Anterior Cross Bites are characterized by

concave
profile as seen in class III skeletal conditions.
Asymmetry of the face can be seen in unilateral cross
bites
Intra-oral Features:
 Reverse overjet
Loosening of teeth
Abnormal abrasion of teeth

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 Diagnosis
1. Routine clinical Examination
Careful examination of models and cephalmetric analysis
-To determine the nature of Cross Bite, whether skeletal,
dental or functional..
-Presence of occlusal interference & functional shifts.
2. Functional shift,

Whether a fuctional
shift exists between centric relation and centric
occlusion.
3. Presence of dental compensation
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 Management of Anterior Cross Bites
 Primary Dentition Stage:
Anterior Cross Bite when noticed can be resolved by removing
the interferences by occlusal grinding or by extracting the primary
incisor which are in cross bite relation.

 Mixed Dentition Period:

Maxillary lateral incisors bind to erupt lingually and may be
tapped if there is no enough space. In such cases, extracting the
primary canine prior to complete eruption of lateral incisor leads to
spontaneous correction of cross bite.
.

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  If sufficient space is available, a maxillary removable appliance
is the best mechanism to correct anterior cross bite that requires
tipping movement. Developing crossbite can be treated with
tongue blade therapy or Catalan’s applaince therapy.

• Permanent dentition period

Fixed applainces can be given to correct anterior crossbites if the
reverse overjet is not more than 1-2 mm.

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 Applainces and methods include
1.Tongue blade therapy
It is used in developing single tooth anterior cross bite
prior to complete eruption.
There should be sufficient space in the arch to
accommodate the tooth in cross bite after resolving the
crossbites.
One end of tongue blade is placed inside the mouth,
contacting the palatal aspect of the upper tooth that is
in cross bite. The blade is made to rest on the
mandibular tooth that is in cross bite which acts as a
fulcrum.
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 The patient is asked to bites firmly and maintaining the
pressure for 5 seconds , then interrupt and repeat for 25
times, 3 time a day.
Most of the developing cross bites if recognized at an early
stage by the dentist can be resolved by this simple tongue
blade therapy.

Fig-Tongue blade therapy

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 2.Catalan’s appliance or lower anterior inclined plane

Indications
 in case where adequate space exists in the arch for
alignment of the maxillary teeth that are in cross bite.
 in case of anterior crossbite which have resulted from
palatally displaced maxillary incisor but not due to that of
labially tipped mandibular anterior tooth.
 used to intercept the fully developed cross bite of single
tooth of the upper arch.

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 The inclined planes are usually made of acrylic but can also
be fabricated with cast metal.
They are concerned onto the lower anterior teeth.
The inclined plane is designed to have a 45°angulation to
the long axis of the lower anterior.
Whenever the maxillary tooth in cross bite touches the
inclined plane, a forward directed force moves the tooth to a
more labial position.

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 The steeper the angle ,the more the force generated.
The Catalan’s appliance should not be placed for more
than six weeks, otherwise it may lead to open bite.

Fig-Lower anterior inclined plane

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 3.Use of double cantilever spring(z spring)
A double cantilever spring can be used to push labial
one or two maxillary anterior teeth that are in crossbite.
 However there should be adequate space in the arch to
accommodate the corrected position of the teeth that
were in crossbite.
 A flapper spring can also be used to correct single tooth
crossbite.
A posterior bite plane is incorporated to relieve the
locking of the teeth that are in cross bite.

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 Fig-Double cantilever spring(z spring)

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 4.Acrylic Plates with Screws:
A split acrylic plate with screw incorporated can be
used to treat anterior crossbites.

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 5.Fixed corrective appliances for treatment of
anterior crossbite:
Dental anterior crossbite involving one or two teeth
can be treated with fixed appliances using multi-
looped arch wires.

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 Management of Anterior Skeletal Cross bites

1.Mixed Dentition Period:

Treatement of skeletal anterior crossbite during growth
period takes the advantage of growth modulation
procedures .
Cephalometric analysis should be carried out to locate
the skeletal problem.

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  Anterior cross bite that occurs as a result of a retropositioned maxilla
should be treated with protraction face-mask or reverse-pull
headgear.
 These facemasks help in protraction of the maxilla thereby
normalizing skeletal crossbite.

Fig-Protraction face-mask
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  Excessive mandibular growth leading to skeletal anterior crossbites
can be intercepted by use of chin cap.

Fig-chin cap
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 2.Permanent Dentition Period
The skeletal anterior crossbites can be treated by
camouflage by masking the skeletal effects.
3.Post Permanent Dentition
Comprehensive appliance therapy and/ or surgical
correction are required.

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 Othognathic surgery for correction of anterior
skeletal crossbites
1.Le fort osteotomy and advancement for maxillary
retrognathism
2.Orthognathic maxilla and mandible
3.Bilateral sagittal split osteotomy and set back for
correction of mandibular prognathism.

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 Posterior Crossbite
Defnition
Posterior Crossbite refers to an abnormal transverse
relationship between the maxillary and mandibular
posterior teeth.

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 Etiology
1.Skeletal cross bite
Narrow maxilla but occasionally from an excessively
wide mandible
Hemi-mandibular hypertrophy
Surgical treated cleft lip and palate

2.Dental cross bite

Prolonged retention of primary teeth
Premolar and molar erupted palatally or buccally due to
crowding or early loss of deciduous second molar
Prolonged thumb and finger sucking

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 3.Functional cross bite
Unilateral posterior cross bite

Due to occlusal interferences

Deviation of mandible during jaw closure

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 Diagnosis:
Carefull examination of models and cephalometric
analysis should localize the problem. Examination
should include the following:
Evaluation of facial proportion and symmetry
Evaluation of intra-arch malaignment and symmetry of
jaws
Presence of occlusal interferences and functional shifts
To determine the nature of the crossbite whether skeletal,
dental or functional
Evaluation of skeletal and dental relationship in the
transverse plane of space.

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 Management of posterior Dental Crossbite.
Primary dentition period:
Unilateral posterior crossbites with functional shift
should be treated in the primary dentition to prevent
asymmetric positioning of the condyles and asymmetric
growth.
 If the intermolar width is satisfactory, grinding of
primary canines is done to eliminate deflective contact.
If both molar and canine width are narrow, expansion of
the upper arch is indicated.

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 Mixed dentition period:
The three basic approaches to the treatment of posterior
dental crossbite in mixed dentition period are:
Equilibration of occlusion to eliminate mandibular
shift
Expansion of the constricted maxillary arch
Repositioning of individual teeth to deal with intra-
arch asymmetries

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 Permanent Dentition Period:
 Dental crossbites of single tooth can be effectively
corrected by crossbite elastics.
 Posterior dental crossbites of entire segment are
corrected by removable or fixed springs like coffin
spring, Quad helix, W-arch.
 Slow maxillary (palatal) expansion can be utilized to
correct the dental crossbites. Mild arch expansion in
the posterior segment can be obtained by corrective
fixed appliances.

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 Appliances and Methods used in Treatment
of Posterior Dental Crossbite

1.Crossbite Elastics:
 Single tooth crossbites that commonly involve the
molars can be treated using cross elastics.
These are stretched through the occlusal suface
between the palatal surface of maxillary tooth and
the buccal surface of mandibular tooth that are in
crossbite.

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  There should be sufficient space in the arch for their
alignment.
 The elastics are worn continuously day and night for
effective correction.
 The treatment should not be continued for more than six
weeks as the elastics can extrude the teeth.

Fig-Cross elastic
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 2.Coffin Spring
 It is a removable appliance capable of slow dento-alveolar
expansion.
 It is an ideal appliance to treat unilateral crossbites during
mixed dentition stage.
 Coffin spring is believed to bring about dento-alveolar
expansion.

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  However use of this appliance in younger patients is
believed to bring about some amount of skeletal expansion.
 It has an advantage over screw appliances in that
differential expansion can be obtained in the premolar and
molar regions.

Fig-Coffin Spring

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 3. W-arch Expansion Appliance (Porter’s Appliance):
 The Preferred appliances for the correction of bilateral
posterior crossbites in pre-adolescent child
 It brings about both dental and skeletal changes.
 It can be modified to be used as a removable appliance.
 Usually 2-3 months of active treatment followed by retention
for 2 months is required.

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 5. Removable Plates:
 Unilateral crossbites can be treated using removable
appliances.
 These appliances basically consist of an acrylic plate that is
split and connected by a jack screw similar to an expansion
plate.
 It is retained with the help of Adam’s clasps.
 A labial bow can also be incorporated into the appliance for
minor space closure and retraction.

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  The plate is bi-sectioned into a small segment and larger
segment. The two segments are connected by one or more
jack screws. The smaller segment lies proximal to the area
in crossbite whereas the larger segment is used for
anchorage.

Fig-Removable Plate with screw

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 Referance
1.Textbook of Orthodontics – S Gowri Shankar
2.Orthodontics –The art & science- Bhalaji

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