Dental crossbite

CROSSBITE
Crossbite is a discrepancy in the buccolingual relationship of the upper and lower
teeth.

Under normal circumstances the maxillary arch overlaps the mandibular arch both
labially and buccally. But when the mandibular teeth, single tooth or a segment of
teeth, overlap the opposing maxillary teeth labially or buccally, a crossbite is said
to exist.
 CROSSBITE
Classification of Crossbite Based on Etiological Structure

1. Dental crossbite.
2. Skeletal crossbite.
3. Functional crossbite.
 Classification of cross bite

Cross Bite

Dental Skeletal cross Functional

cross bite bite cross bite

Anterior Posterior
Anterior Posterior Anterior Posterior
functional functional
cross bite cross bite cross bite cross bite
cross bite cross bite

Unilateral Bilateral Unilateral Bilateral

dental cross dental cross skeletal skeletal
bite bite cross bite cross bite
A. DENTAL CROSSBITE
Crossbite which confined to the dentition is referred to as dental crossbite.

B. SKELETAL CROSSBITE
It refers to a crossbite which is due to malformation of the jaws. Maxillary
retrognathim, mandibular prognathism or a combination of both can result in skeletal
crossbite, e.g. skeletal class III malocclusion.
C. FUNCTIONAL CROSSBITE

Functional crossbites are usually caused due to the presence of occlusal interference leading to
displacement of the mandible anteriorly or laterally to achieve maximum intercuspation.
Example; when there is an edge to edge incisors relationship in centric relation, the patient tends to
habitually move the mandible forward, so as to achieve maximum intercuspation. This may lead to
pseudo Class III malocclusion. If the patient moves the mandible laterally to achieve maximum
intercuspation due to the presence of occlusal interference a unilateral posterior crossbite may appear.
Based on Location
1. Anterior crossbite
• Single tooth crossbite (Instanding tooth).
• Segmental crossbite.
2. Posterior crossbite
Posterior crossbites can also be further classified:
a. According to the number of teeth involved
• Single tooth crossbite.
• Segmental crossbite.
b. According to the existence of the crossbite on one side or both sides of the arch
• Unilateral crossbite.
• Bilateral crossbite.
c. According to the extent of the crossbite
• Buccal crossbite.
• Lingual crossbite (scissor bite).
ANTERIOR CROSSBITE
It is a condition, where mandibular anterior teeth overlap the maxillary anteriors (reverse
overjet). due to lingual position of maxillary anterior teeth in relation to the mandibular
anterior teeth.
It may be single tooth crossbite or segmental anterior crossbite depending on the number
of teeth involved in crossbite. It may or may not be associated with forward displacement
of the mandible.
POSTERIOR CROSSBITE
It refers to a condition where there is an abnormal transverse relationship between upper and lower
posterior teeth. It may be single tooth crossbite or segmental crossbite, unilateral or bilateral, buccal
or lingual.
Buccal crossbite: the buccal cusps of the lower posterior teeth occlude buccal to the buccal cusps of
the upper teeth.
Lingual crossbite: the buccal cusps of the lower teeth occlude lingual to the palatal cusps of the upper
teeth. This is also known as a scissors bite.
Posterior Crossbite Usually Seen As:
Unilateral buccal crossbite with displacement: usually arises when the mandible displaced
laterally due to the presence of deflecting contact either from a displaced tooth or because of
narrowing of the maxilla which result in cusp to cusp relationship of posterior teeth in occlusion.

Unilateral buccal crossbite without displacement: usually arises either due to displacement
of tooth or due to underlying skeletal asymmetry of the arch when a greater number of teeth are
involved.
Posterior Crossbite Usually Seen As:
Bilateral buccal crossbite: usually associated with skeletal discrepancy (Cl III).
Unilateral lingual crossbite: usually due to displacement of teeth as a result of crowding.
Bilateral lingual crossbite (scissors bite): usually associated with skeletal discrepancy (Cl II).
A. Normal occlusion
B. Unilateral buccal crossbite
C. Bilateral buccal Crossbite
D. Bilateral Lingual Crossbite
(scissors bite)
A. Bilateral buccal Crossbite
 Etiology of Crossbite

A. Etiology of Dental Crossbite

1. Crowding: due to lack of space in the dental arch.
2. Anomalies of teeth number, size, and shape: like supernumerary teeth,
macrodontia.
3. Premature loss or prolong retention of primary teeth: lead to crowding and
displacement of permanent teeth into crossbite position.
4. Occlusal interference/prematurities
B. Etiology of Skeletal Crossbite

1. Hereditary or discrepancy in the size of the dental arches: skeletal Cl III and Cl II.
2. Habits: thumb sucking, mouth breathing, etc.
3. Cleft lip and palate: the scar tissue of the cleft repair restricts maxillary growth.
4. Trauma or pathology of the TMJ: it can restrict mandibular growth.

Generally, the greater the number of teeth in crossbite, the greater is the skeletal
component of the etiology.
 TREATMENT OF CROSSBITE
Crossbites, anterior or posterior especially functional crossbite with mandibular
displacement should be corrected as soon as they are detected. If the condition is
left untreated it may develop into severe skeletal malocclusion.

Correction of Anterior Crossbite

Anterior crossbites, in addition to be frequently associated with displacement, can

lead to movement of a lower incisor labially through the labial supporting tissues,
resulting in gingival recession. In this case early treatment is advisable.
Dental Anterior Crossbite

1. Tongue blade therapy

2. Removable orthodontic appliance
3. Fixed orthodontic appliance
Dental Anterior Crossbite

1. Tongue blade therapy: used to treat the developing anterior crossbite by placing a wooden tongue
blade behind the tooth erupting in crossbite and biting on it using the lower teeth as a fulcrum for a
period of 5-10 minutes. Usually the tooth will erupt into normal position over a period of time.

Tongue blade therapy

 2. Removable orthodontic appliance: can be used with:

• Z-spring to correct single tooth in crossbite.

• Recurved Z-spring to correct more than single tooth in crossbite.
• Screw to correct single tooth or segmental crossbite.
Removable appliances should incorporate posterior bite plane to open the bite anteriorly during
correction of anterior crossbite. For treatment to be successful, there must be some overbite present
to retain the corrected incisor position.

Recurved Z-spring
Hawley appliance with Z-spring
& posterior bite plan
Skeletal Anterior Crossbite in Growing Patient

1. Orthopedic appliances
• Facemask with rapid maxillary expander: can be used in case of skeletal anterior crossbite due to
maxillary retrognathism.
• Chin cup: can be used in case of skeletal anterior crossbite due to mandibular prognathism.

2. Functional appliances:
Frankel III appliance may be used to correct a developing Class III skeletal jaw relation with anterior
crossbite.
Skeletal Anterior Crossbite in Adults

Non-growing patients with severe skeletal anterior crossbite can be treated by either mandibular set
back or maxillary advancement surgical procedures.

• Lefort I maxillary advancement For retrognathic maxilla

• Bilateral saggital split (BSSO) mandibular setback For prognathic mandible
• Surgically assisted RPE
• Surgery should ideally be deferred until growth is complete; otherwise continued mandibular
growth will result in skeletal relapse.
Correction of Posterior Crossbite

Correction of posterior crossbite is usually achieved by expansion of the arch or

segment of the arch. The inclination of the affected teeth should also be evaluated.
Upper arch expansion is more likely to be stable if the teeth to be moved were
tilted palatally initially.

Quad helix
Correction of Posterior Crossbite

Single Tooth Crossbite

• Extraction: if the tooth in crossbite is severely displaced.
• Movement of the displaced tooth into the line of the arch using:
a. Removable appliance with screw or T spring.
b. Fixed appliance if bodily movement is required.
• Fixed orthodontic appliance with cross-elastics: if correction of a crossbite
requires movement of the opposing teeth in opposite directions.
Unilateral Segmental Buccal Crossbite

• With displacement: bilateral expansion of the arch using:

a. Removable appliance with expansion screw.
b. Quad helix appliance.
c. Fixed orthodontic appliance: mild degree of arch
expansion can be brought about by using arch wires
or appliances like transpalatal arch.

• Without displacement: unilateral segmental expansion of

the arch.
Bilateral Buccal Crossbite

• Acceptance with no treatment

• In severe skeletal cases, rapid maxillary expander (HYRAX) can be used for growing
patient. For adults surgically assisted expansion with HYRAX can be used.
• Bilateral buccal crossbite in patients with a repaired cleft palate: expansion of the
upper arch by stretching of the scar tissue is often indicated using a Quad helix appliance
Treatment for a bilateral crossbite without displacement should be approached with
caution, as partial relapse may result in a unilateral crossbite with displacement.
In addition, a bilateral crossbite is probably as efficient for chewing as the normal
buccolingual relationship of the teeth.
Dental Expansion (Slow Maxillary Expansion Devices)
Slow expansion has been also termed dentoalveolar expansion. The most commonly used appliances
are:
Removable Appliance with Jackscew: it can be used in both arches, usually activated by turning the
screw 1-2 quarter turn (0.25-0.5 mm) /week.
Coffin Spring: it is removable type, ideal to treat unilateral cross bites, and usually activated by pulling
the two parts of the appliance apart manually or by using special pliers at the base of Omega wire.
Quad Helix Appliance: it can be used as a removable or fixed expansion appliance. The quad-helix
consists of two anterior and two posterior helices. The appliance is capable of producing differential
expansion, i.e. it can be activated to produce different expansion levels in the premolar and molar
regions.
Fixed Orthodontic Appliance: mild degree of arch expansion can be brought about by using arch wires
or appliances like transpalatal arch.
 Skeletal Expansion (Rapid Maxillary Expansion Devices)

1. The Rapid maxillary expander is essentially a dentofacial orthopedic appliance, which

tends to produce its changes by splitting the mid-palatine suture. The rationale is being that if
extreme forces are applied on to the palatal shelves, the interlying suture splits and results in true
skeletal changes. The teeth are generally used for the purpose of transmitting the forces onto the
maxillary bone proper. The most commonly used type is HYRAX RME appliances. There are also
different types of RME like Isaacson RME appliances, Hass RME appliance.

Hass RME appliance HYRAX RME appliances

Acivation of the RME Appliance
Rapid expansion typically is done by turning the screw 1-2 quarter turn (0.25-0.5 mm) daily
especially for HYRAX which most commonly used. With rapid or semi-rapid expansion, a diastema
usually appears between the central incisors as the bones separate in this area. Expansion usually
is continued until the maxillary lingual cusps occlude with the lingual inclines of the buccal cusps of
the mandibular molars.

Retention Following RME Therapy

When expansion has been completed, a 3-month period of retention with the appliance in place is
recommended. After the 3-month retention period, the fixed appliance can be removed, but a
removable retainer that covers the palate is often needed as further insurance against early
relapse. Traspalatal arch provides retention if further treatment is being accomplished
immediately.
Notes:
• Unilateral buccal crossbite with displacement may be associated with a centreline shift in the
lower arch in the direction of the mandibular displacement on closure, and this differentiates it from
unilateral buccal crossbite without displacement which may occur due to skeletal asymmetry.

• Expansion of the upper buccal segment teeth will result in some tipping down of the palatal cusps.
This has the effect of hinging the mandible downwards leading to an increase in lower face height,
which may be undesirable in patients who already have an increased lower facial height and/or
reduced overbite. If expansion is indicated in these patients, buccal capping or buccal root torque to
the buccal segment teeth is required to resist this tendency.
Notes:

• For correction to be successful there should be a good post-treatment overbite for stability. Over
correction and prolong retention after expansion is mandatory for a stable result.

• Crossbites in the deciduous or mixed dentition may result from premature contact between the
deciduous canines with a resultant lateral mandibular displacement. These may be treated by
grinding the canines tips (just the enamel) to eliminate the premature contact.