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19/2/2015

Crossbite

Classification:
Crossbite can be classified according to its
location in the arch as anterior crossbite and
Posterior crossbite.

rossbite is abnormal relationship of a tooth

or teeth to the opposing teeth, in which
normal buccolingual or labiolingual relationships
are reversed. Under normal circumstances, the
maxillary arch overlaps the mandibular arch both
labially and buccally (Fig. 1), i.e. the buccal
cusps of the maxillary teeth are in contact with
the central fossae of the mandibular teeth.
Nevertheless, when the mandibular teeth, single
tooth or a segment of teeth, overlap the opposing
maxillary teeth labially or buccally, depending
upon their location in the arch, a cross bite is
said to exist.

Anterior crossbite is an occlusal disorder where

one or more of the upper incisors are in linguoocclusion (i.e. in reverse Overjet) relative to the
lower arch (Fig.2). The anterior crossbite may
associate with anterior mandibular displacement
and if so, it is known as false anterior crossbite
(i.e. pseudo CL.III).

Fig. 2: upper central incisor in

crossbite.

Posterior crossbite can be classified into:

Buccal Crossbite: in which the buccal cusp of a
lower tooth occlude buccal to the buccal cusp of
an opposing upper tooth. It is most common
type.
Lingual Crossbite (Scissor bite): in which the
buccal cusp of a lower tooth occlude lingual to
the palatal cusp of an opposing upper tooth. It is
less likely type (Fig.3).

Fig. 1: normal overlap of upper to lower

teeth.

Crossbite refers commonly to a discrepancy in

transverse relationship in contrast to the overbite,
which refers to vertical discrepancy. It could be
associated with mandibular displacement that
means the deflection of the mandible, on closing
from the rest position into maximum
interdigitation due to presence of deflecting
contact(s), into the left or right side (lateral
displacement) or to the anterior (anterior
displacement).

Fig.3: lingual crossbite (scissors bite).

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Orthodontics...........................................Crossbite
Unilateral posterior crossbite without lateral
mandibular displacement is less frequent and
usually come from underlying skeletal
asymmetry, is called Stable (True) crossbite.
It is mostly seen in adults.

Posterior crossbite may be further classified

according to the existence of the crossbite on one
or both sides of the arch as Bilateral and
Unilateral crossbite.
Bilateral posterior crossbites are more likely
associated with skeletal discrepancy either in the
anteroposterior or transverse dimensions, or in
both.
Unilateral posterior crossbite is frequently
present with lateral mandibular displacement and
the common cause is the slight narrowing of
maxillary arch. If it so, it is called Unstable
(False) and is frequently seen in primary and
mixed dentition period. It is characterized by a
midline shift of lower arch relative to the upper
arch (Fig.4).

Both anterior and posterior crossbite can be

further classified according to the number of
teeth involved as Single tooth crossbite,
named instanding tooth, or Segmental
crossbite which includes group of teeth.
Based on the etiologic factors the crossbite
can be classified as:
Dental crossbites: are generally single tooth
or sometimes-segmental cross bites. These
usually result from arch length discrepancy or
an abnormal path of eruption. The problems
arising due to such crossbites are periodontal
or esthetic in nature.
Skeletal crossbites: These include those
crossbites, which are primarily due to malpositioning or malformation of the jaws. This
can be inherited (crossbite seen in patients
with Class III skeletal pattern), congenital (e.g.
cleft lip and palate cases) or arising due to
trauma at the time of birth (e.g. unilateral
ankylosis of the TMJ) or later in life. They are
capable of causing appreciable damage to a

Fig.4: displacement on closure into crossbite

with midline shfit

Crossbite

Number of Teeth

Location

Anterior

Buccal

Stable
(True)

Single
Tooth

Posterior

Unstable
(False)

(Scissor)

Bilateral

Unilateral

Stable

Unstable

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Group Of
Teeth

Etiology

Dental

Skeletal

Orthodontics...........................................Crossbite
person's health and personality as the
appearance may be compromised largely.

Skeletal Causes:
Generally the greater the number of teeth in
crossbite, the greater is the skeletal
component of the aetiology. A crossbite of the
buccal segments may be due purely to:

Aetiology:
A variety of factors acting either singly or in
combination can lead to the development of a
crossbite. A good knowledge of the basic
factors that cause crossbite will facilitate the
diagnosis, in turn the choosing of favorable
treatment approach.

Local Causes:
The most common local cause is lack of space
(crowding) where one or two teeth are
displaced from the arch. Lack of space can
come from large teeth and/or small arch, or
supernumerary teeth.
For example, a
crossbite of an upper lateral incisor often
arises owing to lack of Space between the
upper central incisor and the deciduous
canine, which forces the lateral incisor to
erupt palatally and in linguo-occlusion to the
opposite teeth (Fig. 5). Posteriorly, early loss
of a second deciduous molar in a crowded
mouth may result in forward movement of the
first permanent molar forcing the second
premolar erupt palatally. In addition,
retention of primary tooth can deflect the
eruption of the permanent successor leading
to crossbite.

Size discrepancy: a mismatch in the

relative
width
of
maxillary
and
mandibular jaws.
Position discrepancy: an anteroposterior
discrepancy, which results in a wider part
of one jaw occluding with a narrow part of
the opposing jaw.

For this reason buccal crossbite of an entire

buccal segment are most commonly
associated with Class III skeletal pattern
(Fig.6), and the lingual (scissor) crossbite are
associated with Class II skeletal pattern.
Anterior crossbite is associated with Class III
skeletal pattern. Crossbite can also be
associated with true skeletal asymmetry.

Fig.6: anterior and bilateral posterior crossbite in

skeletal CL.III malocclusion.

Soft Tissue and Habits:

As tongue drop down to the floor of the
mouth in bad oral habits cases (mouth
breathing, adaptive swallowing, or thumb
sucking), a negative pressure is generated
intra-orally.
The reduced intra-oral pressure, possibly
combined with the activity of the buccal
musculature could produce a slight narrowing
of the dental arch and production of buccal
crossbite, usually unilateral crossbite (Fig. 7).

Fig.5: upper laterals in crossbite due to lack

of enough space.

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Orthodontics...........................................Crossbite
This slight narrowing of the dental arch leads
to adopting of the lower jaw, a translocated
path of closure (i.e. displacement), and in turn
development of unstable type of posterior
crossbite.

intercuspation must be performed to

determine if a lateral or anterior-posterior
mandible shift occurs following first contact.
It is important to know, how can we
differentiate between skeletal and dental
crossbite, and between the stable (true) and
unstable (false) crossbites. There are several
guidelines can be considered:

If the crossbite is anterior and posterior

and bilateral so this means that it is
skeletal (as in Sk. Cl. III Malocclusion).

Fig.7: lowering the tongue lead to

imbalance with buccal muscularture.

Rare Causes:
They include any other factors that influence
the growth of the jaws by inhibition, changing
or increasing the growth rate. For example:
Cleft lip and palate, where the growth in
width of the upper jaw is restricted by the
scar tissue of the cleft repair (Fig.8).
Trauma to, or pathology of, TMG can lead
to restriction of growth of the mandible on
one side leading to asymmetry.

Fig.9: all the upper teeth are in crossbite.

If the roots of molars are flared buccally

with adequate palatal width, it is of dental
origin. In other words, the inter-molar
distance (CD) is roughly equal or less than
the palatal width (AB).

If the palatal vault narrow and deep with

teeth tilted outward more than normal, so
both palatal width (AB) and inter-molar
distance (CD) are less than normal and
(CD) is considerably larger than (AB), it is
mostly skeletal one.

Fig.8: collapsed maxilla associated

with cleft lip & palate.

Diagnosis
Clinically:
A functional examination of the mandibles
closing pathway from maximum opening to
first contact and then final maximum

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Orthodontics...........................................Crossbite
through the labial supporting tissues,
resulting in gingival recession.

Bilateral
buccal
crossbite
without
displacement is probably as efficient for
chewing as that the normal buccolingual
relationship of teeth. However, the same
cannot be said for lingual crossbite where the
cusps of affected teeth do not meet together at
all.

If crossbite associated with either lateral

or anterior displacement (functional shift),
it is more likely to be of dental origin.
If the unilateral posterior crossbite
associated with the lower midline shifting
toward the side of crossbite, it is of
unstable type.
The number of teeth involved in crossbite
is a guide to the severity of the problem
with fewer involved teeth usually
associated with dental type.

An accurate diagnosis and treatment planning

must be accomplished with the patient in
centric relation to detect the presence or
absence
of
displacing
contact.
An
overcorrection expansion protocol should be
applied in order to improve the treatment
stability.
Treatment Approaches:

Management:

Occlusal adjustment (equilibration)

In a few cases, mostly observed in the primary
or early mixed dentition, a shift into posterior
crossbite will be due solely to occlusal
interference caused by the primary canines or
(less frequently) primary molars. These
patients can be diagnosed by carefully
positioning the mandible in centric occlusion
then it can be seen that the width of the
maxilla is adequate and that there would be
no crossbite without the shift. In this case, a
child requires only limited equilibration of the
primary teeth (often, just reduction of the
primary canines) to eliminate the interference
and the resulting lateral shift into crossbite.

Rationale for early treatment:

Crossbite associated with a displacement is
considered as a functional indication for early
orthodontic treatment:
There is some evidence that displacing
contacts may predispose towards TMG
dysfunction syndrome in a susceptible
individuals.
Spontaneous correction in crossbite cases
is unusual even when eliminating the
etiologic factors.
If crossbite not treated early, it may result
in skeletal changes, demanding a more
complex approach.
Regarding the problems that affect the
maxilla-mandibular complex, the arch
width stands out because of its limited
growth, as the first dimension to stop
growing.
Regarding the anterior crossbite with
mandibular displacement, it can lead to
movement of a lower incisor labially

Removable appliances
Anterior crossbite:
Anterior crossbite due to palatally tilted
maxillary incisors so that they are trapped
into reversed relation with lower incisors; the
forward tipping will be the choice for its
correction. When the anterior crossbite
presented with a sufficient overbite, the

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Orthodontics...........................................Crossbite
treatment can be accomplished more readily
with a removable appliance incorporating
palatal springs, like Z. spring if one incisor in
in crossbite and R.Z. spring or anterior
segmental screw for two or more maxillary
incisors to achieve facial movement.
Sometimes lower removable appliance with
an active labial bow is used for lingual
movement of mandibular incisors. The
appliance should have multiple clasps for
good retention. A removable appliance of this
type requires nearly full -time wear to be
effective and efficient.

Posterior crossbite:
Upper removable appliance with a midpalatal
jackscrew and buccal capping can be used in
the treatment of posterior crossbite involving
all or segment of posterior teeth, which are
being tilted palatally (Fig.11). It mostly used
in the treatment of posterior crossbites of
small magnitude in children and young
adolescents.
This type of appliances relies on patient
compliance and the treatment time is usually
long. A simple removable appliance with a Tspring can correct posterior crossbite of
single tooth like the premolars.

Posterior biteplate to reduce the overbite

while the crossbite is being corrected usually
is unnecessary unless the overbite is
exceptionally deep. Whenever Posterior
biteplate is used, it should be adjusted to
provide just enough overbite clearance for the
forward movement of the maxillary incisors
(Fig.10). At the end of treatment, adequate
overbite eliminate the need for a retainer.

Fig.11: removable jackscrew

Fixed appliances:
The Cross-elastic: is a simple fixed appliance
useful in the correction of unilateral posterior
crossbites consists of two banded or bonded
attachments on upper and lower teeth in
crossbite. Latex elastics are worn full-time
between these attachments. This appliance is
most effective when the teeth in both arches
contribute to the problem and the correction
requires movement of opposing teeth in
opposite direction. The vertical force from the
elastics may extrude the teeth, causing an
opening of the bite.

Fig. 10: removable appliance with

posterior bitleplate to provide
anterior overbite clearance.

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Orthodontics...........................................Crossbite
Slow expansion is done at the rate of 1
mm/week, so opens the suture at a rate that is
close to the maximum speed of bone
formation. No midline diastema appears, but
both skeletal and dental changes occur. The
activation of screw done by one turn every
other day, i.e. four turns per week.

Fig.12: short cross-elastic is placed

between upper and lower 1st molars.

Rapid expansion typically is done with two

turns for screw daily (0.5 mm/day), so large
force generated in order to open the midline
suture and expand the maxilla by skeletal
expansion. A diastema usually appears
between the central incisors as the bones
separate in this area.

Adjustable lingual arches (W-arch & quad

helix) are Fixed appliances that expand the
maxilla
bilaterally
particularly
at
preadolescent age, producing a mix of skeletal
and dental changes. These appliances
generally deliver a few hundred grams of
force and provide slow expansion, usually are
used to correct crossbites of moderate
magnitude. Fixed appliances such as these
require little cooperation by the patient. For
reactivation, the W-spring or quad helix
appliances are removed from the banded
teeth, are widened, and then are recemented
on the teeth to complete the expansion.

Fig.13: banded hyrax screw.

It is important to realize that heavy force and

rapid expansion could be used in late mixed
and early permanent dentition in order to
create microfractures of interdigitating bone
spicules and moving the halves of the maxilla
apart. On the other hands, slow expansion is
preferred approach to maxillary constriction
in young children in primary and early mixed
dentition, because the rapid expansion has the
risk of producing undesirable changes in the
nose at that age.
A bonded expander that covers the occlusal
surface of the posterior teeth may be a better
choice for a child with a long face tendency by
producing less backward mandibular rotation
than a banded type.

Fixed maxillary expander, Hyrax screw, is

indicated for treatment of skeletal maxillary
constriction, through opening the midpalatal
suture, up to age 15 yrs. It can be banded or
bonded. The rates of expansion could be
either rapid or slow.

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Orthodontics...........................................Crossbite

Fig.14: bonded hyrax screw.

There are several disadvantages in using of

fixed Hyrax screw, as it is more bulky than
expansion lingual arches and more difficult to
place and remove. The patient inevitably has
problems in cleaning it, and the patient or his
parent must activate the appliance.

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