European Journal of Orthodontics, 2023, 45, 266–270

https://doi.org/10.1093/ejo/cjac061
Advance Access publication 7 October 2022
Original Article

Spontaneous correction and new development of posterior

crossbite from the deciduous to the mixed dentition
Meryam Khda1, Stavros Kiliaridis1,2 and Gregory S. Antonarakis1,
Division of Orthodontics, University Clinics of Dental Medicine, University of Geneva, Geneva, Switzerland
1

Department of Orthodontics and Dentofacial Orthopedics, Dental School/Medical Faculty, University of Bern, Bern, Switzerland
2

Correspondence to: Meryam Khda, Division of Orthodontics, University Clinics of Dental Medicine, University of Geneva, Switzerland. E-mail: [email protected]

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Summary
Aim: To determine (a) the prevalence of spontaneous correction of posterior crossbites from the deciduous to the mixed dentition and (b) the
development of new posterior crossbite cases during the eruption of the first permanent molars, in orthodontically untreated children.
Materials and methods: A cohort of pupils aged 4–12 years participated in annual dental screenings, from 2001 to 2019. Data were collected
prospectively but examined retrospectively. Children were selected who had been initially screened in their deciduous dentition and on at least
one consecutive year, presenting with a posterior crossbite in the deciduous or mixed dentition. Those with a posterior crossbite in the de-
ciduous dentition were evaluated to see whether the crossbite persisted in the mixed dentition, and vice versa.
Results: Of the 2571 children participating in the annual dental screenings, 1076 children were in the deciduous dentition at their first screening
appointment, with 693 having attended at least two screening appointments. Of these 693 children, 70 had a posterior crossbite in the de-
ciduous dentition (10.1%). The crossbite persisted in the mixed dentition in only 16 out of these 70 children. Twenty-six out of the 623 children
who did not have a posterior crossbite in the deciduous dentition developed one in the mixed dentition.
Limitations: The retrospective data collection, multiple examiners carrying out the dental screenings, and the absence of data on para-
functions and oral habits were some of the limitations of the present study.
Conclusions: In the present sample, 1 in 10 children have a posterior crossbite in the deciduous dentition, which is however autocorrected in
about three-quarters of cases. On the other hand, 4% of children developed a new crossbite in the mixed dentition. It may thus be reasonable
in cases with posterior crossbite in the deciduous dentition to wait for the first permanent molars to erupt before initiating treatment.

Introduction aetiologies, common ones include functional factors such as

Posterior crossbite is a common malocclusion defined as the thumb sucking, pacifier sucking, or mouth breathing (8–11).
maxillary teeth being positioned palatally to the mandibular Posterior crossbites rarely cause aesthetic problems, but it has
teeth. Its treatment constitutes an important part of daily been suggested that they may be associated with temporo-
orthodontic practice, as it has been reported to be one of the mandibular joint problems although good-quality evidence
most prevalent malocclusions in the deciduous dentition (1). to support this notion is lacking (12–14). Moreover, skeletal
The worldwide prevalence of posterior crossbite in the per- asymmetric growth has also been reported as a consequence
manent dentition is approximately 9.4% while in the mixed of untreated posterior crossbite (1, 15, 16). The indications
dentition it is approximately 11.7% (2). Compared to the rest for correction are therefore mostly related to the improve-
of the world, Europe seems to have the highest prevalence of ment of function and asymmetry.
posterior crossbite in the permanent dentition with a rate of The objectives of treatment in cases of unilateral posterior
13.1%, while the highest prevalence in the mixed dentition is functional crossbite will be to eliminate the mandibular shift.
found in Asia with a prevalence of 17.8% (2). These differ- Grinding of the deciduous canines that create premature con-
ences may be explained by ethnicity as well as the differences tacts seems to be an effective early interceptive orthodontic
in the prevalence of non-nutritive sucking habits that can in- treatment for unilateral posterior crossbite (17). This can allow
fluence the development of the occlusion (3, 4). Interestingly, for a correction in some but not in all children systematically.
twin studies show that the presence of a posterior crossbite Otherwise, various orthodontic appliances can also be used (17).
does not seem to be heritable (5). If it is however decided not to treat a posterior crossbite
The majority of posterior crossbites in the deciduous den- in the deciduous dentition, it has been observed by various
tition are unilateral (6) with a predominance of unilateral authors that the permanent molars in some cases do not
functional crossbites (7). The unilateral functional crossbite erupt into a crossbite, implying that there is a spontaneous
is caused by a shift of the teeth between the retruded contact autocorrection of the posterior crossbite in some children
position and maximal intercuspation. This transverse discrep- (18–20). Interestingly, however, it has also been seen that new
ancy can reflect a maxilla that is too narrow, a mandible that cases of posterior crossbite also develop between the ages of
is too wide, or a combination of both. Among the different 3 and 7 years (20).

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please
email: [email protected]
M. Khda et al. 267

Based on this information, on the one hand, it may be im- dentition on the first permanent molars, once these teeth
portant to start treatment as early as possible so that the un- had erupted.
wanted functional and asymmetric growth consequences are For the children who did not have a posterior crossbite in
avoided. On the other hand, if spontaneous correction of pos- the deciduous dentition, all children who underwent at least
terior crossbites occurs in some children, it may be reasonable one subsequent screening visit in the mixed dentition were
to withhold treatment until at least the first permanent molars also selected. This was done to be able to evaluate the possi-
have erupted to avoid overtreatment at an early age. bility of the development of a new posterior crossbite in the
To complement the existing data to help answer the ques- mixed dentition on the first permanent molars.
tion of the benefits of waiting for the eruption of the first per- Evaluation of all dental screening forms was carried out
manent molars before treating posterior crossbites, the aim by two examiners, who consulted with the senior author in
of the present study was twofold. First, we wanted to deter- case of disagreement. Descriptive statistics were calculated in
mine the prevalence of spontaneous correction of posterior order to obtain prevalence rates for the presence of posterior
crossbites from the deciduous to the mixed dentition, in an crossbite in the deciduous dentition, as well as its progression
orthodontically untreated sample of primary school pupils, into the mixed dentition.
and second to determine the development of new posterior

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crossbite cases during this period.
Results
A total of 2571 children participated in the dental screening
Materials and methods
visits from 2001 to 2019, and 1076 of these children were in
The present study, based on epidemiological data, was exempt the deciduous dentition at their first screening appointment
from formal ethics approval, following an initial appraisal by (for flow chart see Figure 1). Among these 1076 children, all
the local commission for research ethics (Req-2019-00856). of those who had come for at least two screening visits, once
Each year, pupils aged 4–12 years, from two primary schools in the deciduous and once in the mixed dentition and ful-
in the city of Geneva, Switzerland, participate in annual filled the inclusion and exclusion criteria, were evaluated, and
dental screenings at the University of Geneva (Switzerland). this resulted in data from 693 children being analysed. Of
Data were analysed from children who participated in these these 693 children, 70 children had a posterior crossbite in
dental screenings between the years 2001 and 2019. The years the deciduous dentition, corresponding to a prevalence rate
of follow-up varied from one child to another, depending on of 10.1% (Table 1).
age and attendance. The number of screenings attended by Among the 70 children (41 girls; 29 boys) who had a pos-
each child may vary between one and nine consecutive visits, terior crossbite in the deciduous dentition, 16 of them still
although some children may also have non-consecutive visits had a posterior crossbite in the mixed dentition, on their first
if a year was missed due to sickness or absence. Since data permanent molars once erupted. The posterior crossbite dis-
collection was undertaken over a period of almost 20 years, appeared in 54 of the children (77.1%) in the mixed dentition
various people were involved. All examiners however were (Table 2).
supervised by four orthodontists who had been calibrated to The data from the 623 children without a posterior crossbite
the senior author. in the deciduous dentition, but with subsequent screening
To carry out this epidemiological study, eligible children visits, were also analysed. Of these children, 26 developed a
were selected according to predefined inclusion and exclusion posterior crossbite on their first permanent molars once in
criteria. the mixed dentition, corresponding to 4.2% of these children
(Table 3). In total, the prevalence of posterior crossbite in
Inclusion criteria the mixed dentition among the 693 children who had been
- Children having been screened for the first time in their followed up from the deciduous to the mixed dentition was
deciduous dentition; and 6.1% (n = 42).
- Children with a minimum of two consecutive dental In this sample of 70 children with a posterior crossbite in
screenings, including one in the deciduous dentition and the deciduous dentition, 45.7% had a right-sided crossbite
one in the mixed dentition (follow-up). while 35.7% had a left-sided crossbite, and 14.3% had a bi-
lateral crossbite (Table 4). In three of the children, the sided-
Exclusion criteria ness of the posterior crossbite was not specified on the dental
- Children never having been screened in their deciduous screening form. From the children where spontaneous pos-
dentition; terior crossbite correction was observed, none of these chil-
- Children having already undergone orthodontic treat- dren were found to have a bilateral posterior crossbite in the
ment prior to their initial or subsequent screening visit; deciduous dentition.
- Children having only been screened once; In the sample of 26 children (12 girls; 14 boys) having de-
- Children with unreadable screening forms or missing es- veloped a posterior crossbite on their first permanent molars
sential data; in the mixed dentition, 46.2% had a left-sided crossbite, while
- Children with systemic health issues, syndromes, or 26.9% had a right-sided crossbite, and 26.9% had a bilateral
craniofacial anomalies. crossbite (Table 4).

Data from screening visits from children diagnosed with

a posterior crossbite in the deciduous dentition, on at least Discussion
the second deciduous molars on one side, were selected. The present study found a prevalence of posterior crossbite
Data from the subsequent follow-up screening visits were in approximately 10% of the children in our sample in the
analysed to see if the crossbite persisted in the mixed deciduous dentition. These posterior crossbites showed
268 European Journal of Orthodontics, 2023

Table 4. Distribution of posterior crossbites by sidedness.

Total Right Left Bilateral

crossbite crossbite crossbite

n n % n % n %

Crossbite in de- 67 32 45.7 25 35.7 10 14.3

ciduous dentition
Crossbite in 26 7 26.9 12 46.2 7 26.9
mixed dentition

Please note that data on crossbite sidedness were missing from three
individuals in the deciduous dentition.

who did not have a posterior crossbite in the deciduous denti-

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tion developed a posterior crossbite in the mixed dentition at
the level of the first permanent molars (roughly 4%).
It has been shown in previous cross-sectional studies that
the prevalence of posterior crossbite decreases from the de-
ciduous to the mixed dentition (21). Not all cross-sectional
studies find similar results, however (22). Nevertheless, lon-
gitudinal studies on orthodontically-untreated individuals
are the gold standard for assessing spontaneous correction.
Figure 1. Flow chart of participant inclusion in the study. Previous studies dealing with the self-correction of posterior
crossbites diagnosed in the deciduous dentition present het-
Table 1. Prevalence of posterior crossbite in the deciduous dentition. erogeneous findings with wide-ranging prevalence rates.
These prevalence rates of self-correction range from 12.2%
n % (18) to 21.4% (23) to 28% (24) to 37% (20) and up to
82.8% (19) respectively. A large variability is thus seen be-
Deciduous dentition on the first dental 693 tween these studies, although the prevalence most similar to
screening appointment (with follow-up)
our study (namely 77.1%) was from the study of Dimberg et
Posterior crossbite in the deciduous 70 10.1 al. (20) who evaluated a relatively large sample. One of the
dentition
possible reasons for this heterogeneity between studies may
No posterior crossbite in the deciduous 623 89.9 be explained by the difference in the sample sizes or the geo-
dentition
graphical origin and non-nutritive sucking habits of the sam-
ples evaluated.
Table 2. Prevalence of spontaneous correction of posterior crossbite in The study of Dimberg et al. (20) also found that 6% of
the mixed dentition. children developed a new crossbite during the transition of
the dentition. This was similar to the 4% found in the present
n % study. Another study looking at the evolution of posterior
Posterior crossbite in the decidu- 70 crossbites in the mixed dentition found no autocorrection in
ous dentition (with follow-up) their sample (25). The sample of untreated children was ra-
No crossbite on the first 54 77.1 ther small, but nevertheless, this may indicate that perhaps
permanent molars in mixed autocorrection is possible early on in life, but that if a pos-
dentition terior crossbite persists in the mixed dentition or is devel-
Crossbite on the first permanent 16 22.9 oped in the mixed dentition, then there is almost no hope of
molars in mixed dentition autocorrection from that point onwards.
The sample of our study is based on a large sample, and this
Table 3. Prevalence of posterior crossbite in mixed dentition.
is one of the major strengths of this study. With regard to the
limitations of the present study, it is important to stress that
n %
the database used may have contained some missing data, as
the information collected may have sometimes been incom-
No crossbite in the deciduous 623 plete. Since data collection was undertaken over a period of
dentition (with follow up) almost 20 years, various people were involved in this, and
Crossbite on the first permanent 26 4.2 the accuracy of the data may be put into question. However,
molars in mixed dentition all examiners were supervised by four orthodontists who had
No crossbite on the first perman- 597 95.8 been calibrated to the senior author. Moreover, children were
ent molars in mixed dentition excluded from this study if essential data were altogether
missing or undecipherable. Some data on posterior crossbites
were incomplete, with the sidedness of the posterior crossbite
spontaneous autocorrection in more than three-quarters of not specified, but these children were still included in the
cases once the first permanent molars erupted in the mixed study. In addition, since the dental screening was carried out
dentition. On the other hand, interestingly, some children on an annual basis on specific dates, it appears that some
M. Khda et al. 269

children may have changed school or been absent on the day scientific evidence available to show which treatment mo-
of the dental screening (due to sickness or leave for example) dality is more effective (17). The objective in all cases of func-
which reduces the final sample. The follow-up of some of the tional posterior crossbite is to eliminate the interference to
children is therefore limited. Finally, data on parafunctions correct a possible functional shift and restore normal contacts
and oral habits were not available. It would have been very between the two dental arches, which may help in restoring
interesting to have these data since the presence of a posterior symmetrical function (30).
crossbite may be related to these, but the retrospective nature In conclusion, the present study has shown that spontan-
of the present study means that this was not a possibility since eous correction of posterior crossbites from the deciduous to
these data were not available. the mixed dentition occurs in more than three-quarters of pu-
What is of particular interest to practitioners is the clinical pils in Swiss primary schools in the Geneva area. Although
implications of the results on spontaneous posterior crossbite the results are difficult to generalize, these data indicate that
correction. Indeed, if spontaneous correction of posterior early treatment is not systematically necessary and that it may
crossbite occurs in more than three-quarters of children with be appropriate to wait for the eruption of the first permanent
posterior crossbite during the transition from the deciduous molars before starting treatment. A clinical recommendation
to the early mixed dentition, it may be more judicious to for orthodontists might therefore be not to start treatment

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wait for the eruption of the first permanent molars before of posterior crossbite before the eruption of the first per-
initiating treatment. Furthermore, since almost 1 in 20 chil- manent molar, perhaps except in exceptional cases with very
dren without a posterior crossbite in the deciduous dentition asymmetric facial growth. One must therefore be vigilant of
develop posterior crossbites following the eruption of the first spontaneous correction of posterior crossbites, carrying out
permanent molars, this is an additional argument in favour regular check-ups on young patients who are at greater risk
of avoiding early deciduous dentition treatment. The need of developing crossbites on the permanent teeth, such as those
for early treatment, although effective for crossbite correc- with thumb-sucking habits.
tion, is therefore put into question. In addition, the fact that
collaboration may be easier in older children may also be a Funding
reason pushing practitioners to delay treatment until the child
No funding was obtained for the present work.
is in the mixed dentition. Although some authors advocate
for early correction of functional posterior crossbites to nor-
malize masticatory function and to ensure normal growth (1, Conflict of interest statement
26), they also add that treatment success after correction in
the deciduous dentition is highly questionable (1). In fact, it The authors declare that they have no conflicts of interest.
has been observed that more than one in four children treated
for posterior crossbite in the deciduous dentition will show Data availability
relapse within 30 months of correction (27). Data will be made available from the corresponding author
A study by Malandris and Mahoney (6) seems to support upon reasonable request.
the recommendation of postponing treatment, stating that
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