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Orthodontics, Posterior Crossbite

William Gossman; Aparna Palla; Dilip K. N.

Author Information

Last Update: July 11, 2019.

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Introduction

A crossbite is a discrepancy in the buccolingual relationship of the upper and lower teeth. Crossbite can
be seen commonly in orthodontic practice. It can be clinically identified, when the lower teeth are in a
buccal or labial position regarding the upper teeth, in a unilateral, bilateral, anterior and/or posterior
manner.[1][2][3]

In the transverse dimension, normal occlusion is when the palatine cusps of the upper molars and
premolars occlude in the fossa of lower molars and premolars. In the anteroposterior plane, the upper
incisors occlude on the labial aspects of lower incisors.

The term buccal crossbite refers to the buccal cusps of the lower teeth occlude buccal to the buccal
cusps of the upper teeth. Scissor bite refers to the condition when the buccal cusps of the lower teeth
occlude lingual to the lingual cusps of the upper teeth.

Crossbite malocclusion can have a skeletal or dental component or combination of both.

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Etiology

The etiology of a cross-bite deformity includes:

Hereditary influence

Inadequate dental arch length

Over retained deciduous teeth

Supernumerary teeth

Habits like digit sucking

Skeletal-anteroposterior discrepancy of arches

Cleft lip and palate

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Epidemiology
Bell and Kiebach in 2014 observed posterior crossbite as a common condition in deciduous and mixed
dentition, with a prevalence of 5% to 8% in age group of 3 to 12 years. They also noted a high prevalence
of 90% of functional crossbite associated with transverse discrepancies.

A study conducted in Turkish population by Gungor et al. in 2016 evaluated a high prevalence of
bilateral crossbite (51%) and unilateral crossbite on the right side (47.3%) and left side (53.6%) in
permanent dentition.[4][5]

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History and Physical

Types of Crossbite

Anterior crossbite: Anterior crossbite is present when one or more of the upper incisors are in linguo-
occlusal

Posterior crossbite: Posterior crossbite is present when buccal cusps of upper molars and premolars,
such that the lower teeth surpass buccally the upper teeth during occlusion.

Unilateral buccal crossbite with displacement

Unilateral buccal crossbite with no displacement

Bilateral buccal crossbite

Unilateral lingual crossbite

Bilateral lingual crossbite-scissor bite

Anterior crossbite can occur in primary, and mixed dentition due to a disharmony between the skeletal,
functional and dental components of the child. This is characterized by one or more anterosuperior teeth
occlude behind the lingual aspect of anteroinferior teeth.
In dental anterior crossbite, one or more teeth are involved. The profile is straight in centric occlusion
and centric relation. Class I molar and canine relation can be seen. SNA, SNB, and ANB angles are within
normal limits. It can be due to abnormal axial dental inclination.

Pseudo Class III or functional anterior crossbite can be caused by mandibular hyper propulsion, which
provokes a lower tongue position and a premature canine contact that entraps the upper maxilla. The
mandible is advanced mesially occasionally to obtain maximum intercuspation. The patient can reach an
edge to edge incisal relation in centric relation. There is a Class III molar relation in centric occlusion and
a Class I relation in centric relation. The facial profile is straight in centric relation and concave in
maximum intercuspation.

Skeletal anterior crossbite is characterized by molar and canine Class III relation in centric occlusion and
centric relation. An edge to edge incisor relation cannot be obtained in centric relation. The etiology of
the malocclusion and the inclination of the affected teeth should be evaluated. The upper arch
expansion is more likely to be stable if teeth to be moved are initially tilted palatally. The appliances used
for expansion are Coffin spring, Quad helix appliance, surgically assisted rapid maxillary expansion, Ni Ti
palatal expander.on. The patient has a concave profile and a retrusive upper lip, predominant chin and
ANB angle is negative.

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Evaluation

The difference between a skeletal and dental crossbite includes:

Dental Evaluation: When the incisors are in edge to edge relation, and the lower incisors are retroclined,
compensated Class III malocclusion must be considered. A clinical evaluation of under jet in association
with Class III molar relation should be done, along with functional evaluation.

Functional Evaluation: An assessment of the relation between the mandible and maxilla to determine
any discrepancy in centric relation (CR) or centric occlusion (CO)

Profile evaluation: An examination of the facial proportions, chin and face positions.

Cephalometric evaluation: Determine the position of the maxilla and the mandible.

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Treatment / Management
Management if Anterior Crossbite

The presence or absence of anterior displacement from centric relation to centric occlusion during
mandibular closure must be established as a part of the diagnosis. The distinction between true class III
and pseudo class III malocclusions have an impact on treatment plan, prognosis, and stability.[6]

Factors to be considered for treatment:

What type of movement is required

Overbite at the end of treatment

Extraction/non-extraction

If the movement of opposing tooth required

The type of movement required for correction is assessed. Removable appliances can be considered for
tipping movement; the fixed appliance is indicated for bodily tooth movement. The appliance should
incorporate these features, good anterior retention to counteract the displaying effect of the active
element. To free the occlusion with the opposing arch, a bite plane could be used or an active
component to move the teeth. Fixed appliances can be indicated when there is insufficient overbite to
retain the corrected incisors. Open coils springs can be used in straight wire mechanics, to create enough
arch length to position the teeth. A negative root torque is sometimes required for a palatally placed
upper incisors. An adequate overbite and a normal inclination of the long axis of the tooth to be treated
is important for the stability of retention.

Correction of Anterior Crossbite in Preadolescent Age Group

Use of tongue blade: This method can be used to correct a developing crossbite. A tongue blade
resembles a flat ice cream stick, which is placed inside the mouth contacting the erupting tooth in
crossbite on its palatal side. During the slight closure of jaws, the opposing side of the tooth comes in
contact with the labial aspect of the opposing mandibular tooth. Light forces generated during this
period might help the tooth to attain the better position.

Catalan’s appliance or lower inclined plane: The lower inclined plane is constructed at an angle of 45 to
the maxillary occlusal plane and can be cemented on lower incisors.
Face masks and Rapid maxillary expansion: This method can be used when a skeletal-transverse
deficiency occurs in the maxilla

Frankel III appliance: Can be used for correction of a developing Class III skeletal malocclusion.

Chin cup appliance: It can be used to redirect the growth of a prognathic mandible.

Correction of Anterior Crossbite in Adolescents and Adults

Fixed appliances can be used to correct single or multiple tooth crossbite.

Use of TADs

Management if Posterior Crossbite

Coffin spring is an omega-shaped wire appliance used in correcting crossbite in young developing
dentition. The expansion produced is slow and bilaterally symmetrical.

Quad helix is a fixed appliance, soldered to molar bands cemented to first permanent molars. It can
produce slow expansion and can be used along with fixed appliance. Forces generated by appliance can
be controlled depending on the amount of activation. Reactivation is done using the three-prong pliers.

The rapid maxillary expansion involves a hyrax screw type of appliance capable of splitting the mid-
palatine suture and bring about skeletal changes in a short interval. The RME screw can be incorporated
into 2 types of appliances, the banded RME and bonded RME.

NiTi Expanders: These are nickel-titanium wire shapes which can be attached to lingual sheath that is
welded to molar bands cemented to the maxillary first permanent molars. Various sizes are available
and need to be selected depending upon the amount of expansion desired and the pretreatment width
of the palate.

Fixed orthodontic appliances can be used for correction of posterior crossbite, as they provide 3-
dimensional control over the tooth. The arches can be kept slightly expanded or constricted depending
upon the movement required. Cross-elastics of 3/16-inch diameter is exerting a force of 2.5 to 4.5 oz can
be used to bring about correction of individual tooth crossbites in the posterior segment.

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Questions

To access free multiple choice questions on this topic, click here.

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References

1.

Sollenius O, Petrén S, Bondemark L. An RCT on clinical effectiveness and cost analysis of correction of
unilateral posterior crossbite with functional shift in specialist and general dentistry. Eur J Orthod. 2019
Apr 11; [PubMed]

2.

Asiry MA, AlShahrani I. Prevalence of malocclusion among school children of Southern Saudi Arabia. J
Orthod Sci. 2019;8:2. [PMC free article] [PubMed]

3.

Yu X, Zhang H, Sun L, Pan J, Liu Y, Chen L. Prevalence of malocclusion and occlusal traits in the early
mixed dentition in Shanghai, China. PeerJ. 2019;7:e6630. [PMC free article] [PubMed]

4.

Perrotta S, Bucci R, Simeon V, Martina S, Michelotti A, Valletta R. Prevalence of malocclusion, oral

parafunctions and temporomandibular disorder-pain in Italian schoolchildren: An epidemiological study.
J Oral Rehabil. 2019 Jul;46(7):611-616. [PubMed]

5.

Doriguêtto PVT, Carrada CF, Scalioni FAR, Abreu LG, Devito KL, Paiva SM, Ribeiro RA. Malocclusion in
children and adolescents with Down syndrome: A systematic review and meta-analysis. Int J Paediatr
Dent. 2019 Jul;29(4):524-541. [PubMed]

6.

Khayat NAR, Shpack N, Emodi Perelman A, Friedman-Rubin P, Yaghmour R, Winocur E. Association

between posterior crossbite and/or deep bite and temporomandibular disorders among Palestinian
adolescents: A sex comparison. Cranio. 2019 Feb 07;:1-6. [PubMed]

Copyright © 2019, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution,
and reproduction in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, a link is provided to the Creative Commons license, and any changes made are
indicated.
Bookshelf ID: NBK499873PMID: 29763048

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Introduction

Etiology

Epidemiology

History and Physical

Evaluation

Treatment / Management

Questions

References

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