Crossbite is a form of malocclusion where a tooth (or teeth) has a more buccal or lingual position (that is, the tooth is either closer to the cheek or to the tongue) than its corresponding antagonist tooth in the upper or lower dental arch.

CROSSBITE MANAGEMENT

1. CROSSBITE Presented by: Dr. Priya Kawana Department Of Orthodontics & Dentofacial Orthopedics

2. CONTENTS Introduction Definition Prevalence Classification Anterior crossbite Posterior crossbite Skeletal crossbite Functional crossbite Etiology

3. Diagnosis Management of anterior crossbite Management of posterior crossbite References

4. INTRODUCTION Cross bites are term used to describe abnormal occlusion in the transverse plane. The term is also used to describe reverse overjet of one or more anterior teeth. Crossbite  is a form of malocclusion where a tooth (or teeth) has a more buccal or lingual position (that is, the tooth is either closer to the cheek or to the tongue) than its corresponding antagonist tooth in the upper or lower dental arch. .

5. Crossbite occurs when there is an imbalance between upper and lower jaw members. Crossbite may be due to localized problems of tooth position or alveolar growth, or to gross disharmony between maxilla and mandible. It may include one or more teeth and it may be unilateral or bilateral. Proffit WR, Fields HW, Larson BE, Sarver DM. Contemporary Orthodontics. Philadelphia, PA: Elsevier; 2019.

6. Varies significantly from one ethnic group to another. Prevalence of posterior crossbite in Asians or Africans < Caucasians. Anterior crossbite 10% of Japanese population 3% of US population Prevalence Proffit WR, Fields HW, Moray LJ . Prevalence of orthodontic treatment need in the United States: Estimates for the NHANES-III survey. Int J Orthod Orthogn Surg . 1998;13:97-106

7. A retrospective study was conducted in patients with crossbite. The final sample size was 934 after reviewing 41190 case sheets. The data was collected from the hospital digital database by reviewing the patients records and analysing them. The data was entered in an excel sheet and imported to SPSS software version 23 and the results were calculated using Chi square test. It was observed that the prevalence of crossbite in male population was 60.06% and in the female population was 39.9%. Crossbite in Class I malocclusion was more common among the male patients (47.64%) followed by class III malocclusion (8.57%). However, it is not significant statistically (P value>0.05). Within the limits of the study, it was observed that crossbite was more prevalent in the male population and crossbite in class I malocclusion was more common among the patients. Prevalence and Gender Distribution of Dental Crossbite and its Association with Malocclusion: An Institution Based Study Preetha Parthasarathy, Aravind kumar and Sreedevi Dharman

8. DEFINITION According to Graber ,C ross bite is defined as a condition where one or more teeth may be abnormally malposed buccally or lingually or labially with reference to opposing tooth or teeth. According to Moyers, crossbite is the term used to indicate an abnormal buccolingual (labiolingual) relationship of the teeth.  

9. CLASSIFICATION 1)Based on their location as: Anterior : i ) single tooth ii) segmental Posterior: According to no of teeth involved: i ) Single tooth ii) Segmental

10. b) According to side involved: i ) Unilateral ii) Bilateral 2)Based on the nature of the cross bites Skeletal Dental Functional

11. ANTERIOR CROSSBITE Simple anterior crossbites are dental malocclusions resulting from abnormal axial inclinations of maxillary anterior teeth . The simple anterior crossbite has many other names (e.g., "in-locked" incisors). The use of the word "simple" implies that some anterior crossbites are more complicated, and indeed they are, particularly those which accompany a Class III malocclusion or are part of a skeletal deep bite.

12. The dental crossbite involves only tipping of teeth buccally or lingually. The condition is localized in the alveolar process and does not affect the size or shape of basal bone. In this group the upper and lower midlines will coincide when the jaws are apart, and diverge as teeth come into occlusion. Some of the teeth in crossbite will not be centered buccolingually in the alveolar process; therefore, the most important diagnostic point is to localize asymmetry of the dentoalveolar arch.

13. POSTERIOR CROSSBITE According to Bjork (1964) Posterior cross bite is defined as a malocclusion in canine, premolar and molar regions, characterized by buccal cusps of maxillary teeth occluding lingual to buccal cusps of the corresponding mandibular teeth. This refers to an abnormal transverse relationship between the upper and lower posterior teeth. In this condition, instead of mandibular cusps occluding in the central fossae of maxillary posterior teeth they occlude buccal to maxillary cusps. .

14. It can be : Unilateral crossbite Bilateral crossbite Buccal non occlusion Lingual non occlusion

15. BUCCAL NON-OCCLUSION: This is a form of posterior crossbite where maxillary posteriors occlude entirely on the buccal aspect of the mandibular posteriors. This condition is also called as scissor bite. LINGUAL NON-OCCLUSION: This is a form of posterior crossbite where maxillary posteriors occlude entirely on the lingual aspect of the mandibular posteriors.

16. SKELETAL CROSSBITE This involves both a dental and skeletal discrepancy. The dental and skeletal midlines do not coincide both at rest and in occlusions. This condition could be due to a basal skeletal deformity. There may be asymmetrical growth of the maxilla or mandible or a lack of agreement of their widths. Robert E Moyers, Handbook Of Orthodontics,4 th Edition:418-423 .  

17. Skeletal dysplasia might be due to maxillary constriction or mandibular constriction or may be due to mandibular asymmetry. It can be due to: 1)M idface deficiency 2)M andibular prognathism 3)C ombination of the two.

18. Anterior crossbite due to maxillary retrognathism . Anterior crossbite due to mandibular prognathism . Anterior crossbite due to maxillary retrognathism and Mandibular prognathism .

19. Midface Deficiency: Patients with Class III midface deficiency display a Class III max­illo-mandibular relationship, a diminished cranial base-maxilla value, and normal cranial base-mandibular values. The profile analysis usually shows shortened maxillary skeletal unit and max­illary dentoalveolar unit distances. The mandibular skeletal unit distance is near normal, but the mandibular dentoalveolar unit distance may be slightly above normal.

20. Mandibular Prognathism: Patients with mandibular prognathism show a Class III maxillo-mandibular relationship, an excessive cranial base-mandible dimension both horizontally and vertically, and may show a diminished cranial base angle. In severe case, the maxillary dentoalveolar unit distance may also be excessive as the maxillary teeth tip labially to obtain function with mandibular incisors which have been carried forward by the excessive mandibular length. Anterior face height is usually excessive when compared with posterior face height, and lower face height is abnormal anteriorly.

21. Mandibular prognathism is sometimes seen without excessive anterior face height (i.e., the mandibular border is not steeply positioned). Midface Deficiency and Mandibular Prognathism: Patients show a combination of mild midface deficiency a mandibular prognathism . The prognosis usually is not as poor as for the serious mandibular prognathism.

22. FUNCTIONAL/MUSCULAR CROSSBITE Functional/Muscular: This type involves muscular adjustment to tooth interference. According to Moyer this muscular type is similar to the dental type of crossbite except that the teeth are not tipped within the alveolus. Both dental and skeletal crossbites require occlusal and muscular adjustments to complete their correction.

23. Moyer concludes that lack of harmony between maxillary and mandibular widths usually is due to bilaterally contracted maxilla, in which case the muscles shift the mandible to one side to acquire sufficient occlusal contact for mastication and comfort. If deviation occurs just before the teeth make contact it might be that tooth interference was the original etiologic factor. If deviation increases throughout opening, the primary fault is likely to be asymmetry of bony growth. Robert E Moyers, Handbook Of Orthodontics,4 th Edition:418- 423 .

24. ETIOLOGY OF CROSSBITE Crossbites could be caused due to skeletal disturbances, dental disturbances, or combination of both. I) Skeletal growth disturbances 1. Defects in embryologic Development 2. Muscle Dysfunctions 3. Fetal Molding and Birth Injuries 4. Childhood fractures of the Jaw Robert E Moyers, Handbook Of Orthodontics,4 th Edition:418- 423.

25. 5. Abnormal pressure Habits 6. Endocrine imbalance 7. Functional shifts 8. Others

26. II) Dental disturbances Dental factors include discrepancies of tooth to tooth relationships where the jaws or bony bases are relatively harmonious in size, shape and symmetry. Significant disturbances include: Congenitally Missing Teeth. Malformed and Supernumerary Teeth. Interference with Eruption. Ectopic Eruption. Early Loss of Primary Teeth. Traumatic Displacement of Teeth.

27. History Digit-sucking problem: its frequency intensity duration persistence. Narrowing of the maxilla may or may not create an apparent dental crossbite . DIAGNOSIS Brook PH, Shaw WC. The development of an index for orthodontic treatment priority. Eur J Orthod . 1989;11:309-332

28. 2. Clinical examination A functional examination of the mandible’s closing pathway from maximum opening to first contact and then final, maximum intercuspation must be performed to determine if a lateral or anterior-posterior mandible shift occurs following first contact. The amount and direction of any mandible shifting between first contact and maximum intercuspation should be noted. . 2004;26:266-272

29. 3. Diagnostic records It is necessary to prepare adequate study models and radiographs that depict both the teeth present in the oral cavity and those developing in the alveolar processes. For the latter, panoramic radiographs are required. A posterior-anterior cephalometric radiograph is useful in: measuring the transverse dimensions of the maxilla and mandible to calculate if a transverse discrepancy exists. assessing the position of the dental midlines in relation to their respective skeletal midlines. Cross D, McDonald JP . Effect of rapid maxillary expansion on skeletal, dental and nasal structure: A postero -anterior cephalometric study. Eur J Orthod . 2000;22:519-528

30. CBCT More accurate for: congenitally missing teeth formation stages of the permanent teeth’s developing roots and the resorption of their primary precursors measuring the transverse dimensions

31. MANAGEMENT OF ANTERIOR CROSSBITE

32. Management of anterior crossbite In 4 stages: 1)In primary dentition 2) In mixed dentition 3) In permanent dentition 4) In post permanent dentition

33. IN PRIMARY DENTITION : Elimination of the factors that may lead to anterior crossbite. Eg : Removal of occlusal prematurities Extraction of supernumerary tooth before they cause displacement of other tooth. Habit breaking appliance.

34. Developing anterior cross bites can be treated by extracting adjacent primary teeth if space is not available for the erupting permanent teeth. Extraction should be bilateral to prevent midline shift.

35. IN MIXED DENTITION : In pre-adolescent age group Anterior crossbite should be treated at an early stage If crossbite is present in the deciduous dentition, it may manifest in the mixed and permanent dentition as well. If simple anterior crossbite is not treated in early stage it may progress into skeletal malocclusion that later need complicated orthodontic treatment or surgical treatment.

36. Tongue blade therapy Indicated when there is sufficient space for the tooth to erupt. Flat wooden stick resembling ice cream stick. Blade is made to contact the palatal aspect of the tooth in crossbite which rests on the mandibular tooth in cross bite which acts as a fulcrum and patient is asked to rotate the oral part of the blade upward and forward. 1-2 hours for 2 weeks

37. Drawbacks: 1) Only effective till the clinical crown not completely erupted in the oral cavity. 2) Used only if sufficient space is available for correction. 3) Patient cooperation is required.

38. Catlans Appliance It is lower anterior inclined plane used to treat maxillary teeth in crossbite. It has 45 degree angulation which forces the maxillary teeth in crossbite in to more labial position. Prerequisities for use of inclined plane Enough space in maxillary arch to align the teeth/tooth. Mandibular incisors should be well aligned to allow appliance fabrication.

39. Advantages: 1)Ease of fabrication. 2)Lack of soreness or looseness of teeth during treatment. 3) Rarity of relapse Disadvantages: Difficulty in speech and chewing. Appliance cannot be given if mandibular incisors are periodontally compromised.

40. 3)Prolonged use can lead to anterior open bite. 4)Possibility of appliance becoming loose and requiring recementation because of strong occlusal stresses on it.

41. Prakash P, Durgesh BH. Anterior crossbite correction in early mixed dentition period using Catlan’s appliance: A case report. ISRN Dentistry. 2011;2011:1–5.

42. Reversed stainless steel crowns Anterior stainless steel crowns cemented backwards on the maxillary teeth. Stainless steel crown needs to open the bite 2 to 3 mm and establish at least a 25 percent overbite for successful treatment. Robert Staley and Neil Reske . Essentials of orthodonitics - Diagnosis and treatment planning, Wiley Blackwell publications, 2011

43. Two disadvantages of using reverse stainless steel crowns are the unsightly silver appearance of the crown form, and the limitations of working with an inclined slope that is already formed. Both problems can be avoided by using a bonded resin-based composite custom formed inclined slope Croll TP : Anterior tooth crossbite correction using bonded resin-composite slopes. Quintessence International 27: 7-10, 1996

44. Composite slopes The composite slope is designed to elongate the incisor such that some overbite is created in centric occlusion. The posterior teeth typically do not contact after slope placement, but normal posterior occlusion is re-established as soon as the maxillary incisor is displaced labially. Croll TP : Anterior tooth crossbite correction using bonded resin-composite slopes.Quintessence International 27: 7-10, 1996

45. Case report : An 8-year-old boy visited the pediatric dental clinic for routine control. Intraoral examination revealed a maxillary left central incisor in crossbite . A composite slope was bonded to the mandibular left central and lateral incisors and remained in place for 1 week. Treatment of Anterior Dental Crossbite Using Bonded Resin-Composite Slopes: Case Reports European Journal of Dentistry 2(4):303-6

46. Face mask Facemask is an extraoral traction appliance used to correct skeletal class 3 malocclusion In cases of anterior crossbite due to an actual skeletal deficiency of maxilla it is possible to mesialize the maxilla using a protraction face mask If the maxilla is narrow a rapid maxillary expansion screw can be employed simultaneously. Force: 300-500 grams per side. Duration: 12-14 hours per day

47. Chin cup A chin cup can be used to redirect the growth of mandible to prevent or correct the anterior crossbite due to a prominent mandible. Chin cup tends to rotate the mandible downward and backward. Retardation or even sometimes restriction of mandibular growth is supported by some authors ( Proffit 2000, Bishara 2001) Orthopedic force:300-500 grams per side (Proffit-450 grams per side) Patients are instructed to wear appliance for 14 hours/day.

48. In adolescent and adults; Double Cantilever Spring/Z spring Anterior crossbite involving one or two teeth can be treated using double cantilever spring provided that there is adequate space. It consist of two coils and resembles the shape of alphabet “Z” when activated hence it is also called as Z spring. Consists of double helix between two parallel arms and the inferior arm extends as retentive component.

49. Activation: To activate the spring open the coil about 2 to 3 mms. Open the palatal limb alone and adjust the free end so that it is perpendicular to the direction of tooth movement .

50. Fixed appliance Light arch wire combined with maxillary lingual arch with auxillary springs Indicated for a very young child or preadolescent with whom patient compliance is a concern Treats severely displaced incisors Should be over-corrected by at least 1-2 mm Distortion and breakage of the appliance and poor oral hygiene Robert Staley and Neil Reske . Essentials of orthodonitics - Diagnosis and treatment planning, Wiley Blackwell publications, 2011

51. Edgewise fixed appliances using nickel titanium arch wires can rapidly correct an anterior cross- bite in conjunction with either a lower posterior acrylic bite plate or glass ionomer cement on the occlusal surfaces of the lower molars to open the bite sufficiently to easily move the upper incisor out of crossbite ( Skeggs and Sandler 2002 ) Robert Staley and Neil Reske . Essentials of orthodonitics - Diagnosis and treatment planning, Wiley Blackwell publications, 2011

52. REFERENCES 1 ) Proffit WR, Fields HW, Larson BE, Sarver DM. Contemporary Orthodontics. Philadelphia, PA: Elsevier; 2019. 2) Robert E Moyers, Handbook Of Orthodontics,4 th Edition:418-423. 3) Graber L, L. V. Orthodontics current principles and Techniques. 7 th ed. Philadelphia: Elsevier - Health Sciences Division; 2023:313-316. 4) Björk A, Krebs Aa, Solow B. A method for epidemiological registration of Malocculusion . Acta Odontologica Scandinavica. 1964;22(1):27–41. 5) Prakash P, Durgesh BH. Anterior crossbite correction in early mixed dentition period using Catlan’s appliance: A case report. ISRN Dentistry. 2011;2011:1–5. 6)Robert Staley and Neil Reske . Essentials of orthodonitics - Diagnosis and treatment planning, Wiley Blackwell publications, 2011 7) Croll TP: Anterior tooth crossbite correction using bonded resin-composite slopes.Quintessence International 27: 7-10, 1996

53. THANK YOU

54. CROSSBITE(PART 2) Presented by: Dr. Priya Kawana Department Of Orthodontics & Dentofacial Orthopedics

55. MANAGEMENT OF POSTERIOR CROSSBITE

56. Selective grinding of teeth 􏰀 Elastics Palatal expansion􏰁 Surgery Treatment of posterior crossbites Robert Staley and Neil Reske . Essentials of orthodonitics - Diagnosis and treatment planning, Wiley Blackwell publications, 2011

57. Selective grinding for slight maxillary constriction due to primary canine interferences Functional shift of the mandible eliminated and the mandible allowed to assume its natural position Robert Staley and Neil Reske . Essentials of orthodonitics - Diagnosis and treatment planning, Wiley Blackwell publications, 2011 Primary dentition

58. Removable appliances are used. The maxillary arch should be over expanded and then held passively in this over expanded position for approximately 3 months before it is removed. Premature use of fixed rapid palatal expansion appliances has been known to create an increase in nasal width. Proffit WR. Contemporary Orthodontics. 3rd ed. St. Louis: Mosby, Inc ; 2000 Early mixed dentition period

59. When only few posterior teeth in crossbite and crossbite is caused by a mere tipping 􏰀Use cross elastics if both arches contribute to the crossbite problem 􏰀Overcorrect and leave the bands in place right after active treatment 􏰀In case of relapse, reinsert the elastics The major problem - patient cooperation Elastics

60. Dental crossbite : W-ARCH ,Quad Helix & Jack screw appliance are used They deliver less than 2 pounds of force Management in late mixed dentition period

61. Skeletal cross bite correction in late mixed dentition Corrected by opening the mid palatal suture. Growth at this suture continues in most children until late teens & then ceases. Robert Staley and Neil Reske . Essentials of orthodonitics - Diagnosis and treatment planning, Wiley Blackwell publications, 2011

62. CORRECTION OF POSTERIOR CROSSBITE 1.Coffin Spring This is an omega shaped wire (0.9 mm ) in a removable appliance used for expansion to correct the posterior cross bite The expansion produced is slow and bilaterally symmetrical If used in mixed dentition stage the appliance is capable of producing skeletal changes

63. 2.T Spring T spring can be used for buccal movement of premolars It is made of 0.5 mm hard round stainless steel wire Spring consist of t shaped arm whose ends are embedded in acrylic Spring is activated by pulling the free end of T towards the intended direction of tooth movement

64. 3.Jack screw A jack screw can used in the removable plate to carry out expansion to correct the posterior cross bite The patient should cooperative to maintain the appliance and activate the screw or atleast get it activated at regular intervals

65. 4.Quad helix It is a fixed appliance soldered to the molar bands cemented generally on the first permanent maxillary molars It can be reactivated using the three pong plier without having to be removed from the oral cavity It is a versatile appliance and can be used with usual fixed appliance therapy It can produce skeletal effects if given in preadolescent

66. 5.Rapid maxillary expansion Bilateral skeletal cross bite with a deep palate and narrow maxilla can be treated by RME where the mid palatal suture is split It incorporates a screw which is activated 0.5 – 1 mm/day The force level can build upto 10 to 20 pounds as the screw is turned at this rate