The Saudi Dental Journal (2012) 24, 105113

King Saud University

The Saudi Dental Journal

www.ksu.edu.sa
www.sciencedirect.com

CASE REPORT

Simple removable appliances to correct anterior

and posterior crossbite in mixed dentition: Case report
Naif A. Bindayel

Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, P.O. Box 60169,
Riyadh 11545, Saudi Arabia
Received 20 October 2011; revised 5 December 2011; accepted 20 December 2011
Available online 30 January 2012

KEYWORDS
Anterior;
Posterior;
Crossbite;
Functional shift;
Treatment

Abstract Different techniques have been used to correct anterior and posterior crossbites in mixed
dentition. This case report illustrates the treatment of anterior and unilateral posterior crossbites
during the mixed dentition. The patient was a 9-year-old boy with a crossbite of the maxillary right
permanent central incisor and a unilateral right posterior crossbite, both expressed by a functional
shift in the sagittal and transverse dimensions. Two upper acrylic removable appliances, each with
an expansion jackscrew, were used to correct the crossbites. The total active treatment time was
4 months; the treatment outcomes were successfully maintained for the subsequent 4 months. General and pediatric dentists, as well as orthodontists, may nd this technique useful in managing
crossbite cases of the mixed dentition and utilizing the discussion and illustrations for further clinical guidance.
2012 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.

1. Introduction
Anterior crossbite can be a major esthetic and functional concern during the early stages of dental development. Anterior
crossbite is dened as a situation in which one or more primary
or permanent mandibular incisors occlude labially to their
* Tel.: +966 1 4673591; fax: +966 1 4679017.
E-mail address: nbindayel@ksu.edu.sa
1013-9052 2012 King Saud University. Production and hosting by
Elsevier B.V. All rights reserved.
Peer review under responsibility of King Saud University.
doi:10.1016/j.sdentj.2011.12.005

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antagonists (or when one or more maxillary incisors are lingual to their antagonists) (Daskalogiannakis, 2000). Crossbite
has a reported incidence of 45% and usually becomes evident
during the early mixed dentition period (Hannuksela and
Vaananen, 1987; Heikinheimo et al., 1987; Major and Glover,
1992). It results from a variety of factors such as palatal eruption of the maxillary incisors, trauma to the primary incisors,
supernumerary anterior teeth, overretained primary teeth,
odontomas, crowding in the incisor region, and inadequate
arch length (Valentine and Howitt, 1970; McEvoy, 1983;
Bayrak and Tunc, 2008).
Posterior (lateral) crossbite is another concern of the early
mixed dentition; several studies have reported its incidence to
range between 8% and 22% (Kutin and Hawes, 1969; Thilander
and Myrberg, 1973; Egermark-Eriksson et al., 1990). Patients
with normal occlusion in the primary dentition were shown to
develop a lateral crossbite in 3.1% by the time the permanent
dentition was reached (Legovic and Mady, 1999). In most cases,

106
the crossbite is accompanied by a mandibular shift that causes
midline deviation (Thilander and Myrberg, 1973; Kurol and
Berglund, 1992). The etiology of posterior crossbite can include
any combination of dental, skeletal, and neuromuscular functional components. However, it is usually associated with
reduction in maxillary arch width. This reduction can be induced by digit sucking, certain swallowing habits (Melsen
et al., 1979), or mouth breathingusually the result of upper
airway obstruction due to hypertrophied adenoid tissue (Bresolin et al., 1983; Oulis et al., 1994).
Anterior and posterior crossbites in the early mixed dentition are believed to be transferred from the primary to the permanent dentition and can have long-term effects on the growth
and development of the teeth and jaws (McNamara, 2002).
Anterior crossbite may lead to abnormal enamel abrasion or
proclination of the mandibular incisors, which, in turn, leads
to thinning of the labial alveolar plate and/or gingival recession (Valentine and Howitt, 1970). Mandibular shift caused
by abnormal mandibular movements may place strain on the
orofacial structures, causing adverse effects on the temporomandibular joints and masticatory system (Troelstrup and
Moller, 1970; Ingervall and Thilander, 1975). Spontaneous
correction of such malocclusion has been reported to be too
low to justify nonintervention (Kutin and Hawes, 1969;
Schroder and Schroder, 1984; Lindner et al., 1986), and the
rate of self-correction was shown to range from 0% to 9%
(Kutin and Hawes, 1969; Thilander et al., 1984). Therefore,
interceptive treatment is often advised to normalize the occlusion and create conditions for normal occlusal development.
Bonding brackets to the four maxillary incisors in combination with banding the two maxillary permanent rst molars
(2 4 xed appliance) is one of the methods used for the correction of anterior crossbite with xed appliances. It has been
reported to effectively manage anterior crossbite in the mixed
dentition (Dowsing and Sandler, 2004) as well as in the adult
dentition (Brooks and Polk, 1999). This method has the advantages of requiring little or no patient compliance or alteration
of speech. Other reported treatment modalities for correction
of anterior crossbite include rare earth magnetic appliances
(Xie, 1991), xed acrylic inclined planes (Croll, 1984), bonded
resin-composite slopes (Bayrak and Tunc, 2008), and multiple
sets of Essix-based appliances (Giancotti et al., 2011). Various
modes of treatment have been suggested for posterior crossbite
correction such as rapid maxillary expansion (Sandikcioglu
and Hazar, 1997; Erdinc et al., 1999) and slow expansion with
a quad-helix or a removable expansion plate (Bjerklin, 2000).
Removable appliances have the advantages of easier maintenance and oral hygiene care for young patients, utilization of
palatal anchorage, and the ability to move a selected block of
teeth (Littlewood et al., 2001). The literature includes management techniques for unilateral crossbite using removable appliances with midsagittal expansion screws. However, these
articles consist of only brief illustrations with general discussion
(Littlewood et al., 2001) and lack a display of extraoral images
and additional removable appliance components such as bite
planes (Ngan and Wei, 1990; Cunha et al., 1999). Other case reports reported appliances require special supplies (Piancino
et al., 2007) or attempted to correct combined sagittal and posterior vertical problems (Al-Sehaibany and White, 1998).
This case report aims to provide general and pediatric
dentists with a simple technique to manage anterior and
posterior crossbites in the mixed dentition. Illustrations of

N.A. Bindayel
treatment progress and appliance design are included for further clinical guidance.
2. Case report
A 9-year-old boy was referred by his pediatric dentist for an
orthodontic consultation regarding his anterior bite. Extraorally, he had a balanced face with a pleasant prole, with the
maxillary dental midline coincident with the facial midline
The chin was deviated to the right side by 3 mm from the facial
midline, and the entire maxillary right posterior segment was
tipped palatally (especially the right primary canine) (Figs.
19). He presented in the mixed dentition stage with Class I left
and half-cusp Class II right molar relationships (Figs. 1014).
The overbite was deep (100% on the left maxillary central incisor), and an anterior crossbite of the maxillary right permanent central incisor and unilateral (right) posterior crossbite
were evident. Both crossbites were being expressed as a result
of functional shifts in the sagittal (i.e., forward) and transverse
dimensions (to the right side). The mandibular dental midline
deviated from the maxillary dental midline (designated as the
mesial of the maxillary right central incisor) by 4 mm to the
right in centric occlusion. The panoramic radiograph showed
symmetric condylar shapes and positions bilaterally and
normally developing permanent successor tooth germs.
2.1. Treatment plan
Based on the above ndings, the patient was scheduled for
limited early interceptive treatment to restore normal occlusion and alleviate the underlying functional shift. To reach
these objectives, two treatment approaches were considered.
Quad-helix expansion combined with bite opening and bracket-bonding only the four maxillary incisors would permit
simultaneous correction of both anterior and posterior crossbites. However, expansion with the quad-helix would not
control the palatal tipping of the right posterior segment mesial to the rst molar (especially the primary maxillary right
canine). Therefore, a removable appliance was chosen to better control the canine and the adjacent palatal tipping.
The removable appliance option included the use of two
upper removable appliances. The rst incorporated a jackscrew set to act in an anteroposterior direction to tip the maxillary right permanent central incisor labially and bilateral
posterior bite planes (about 4 mm thick) to disengage the bite
and facilitate tooth movement (Fig. 15). That was followed by
another removable appliance with a midpalatal jackscrew and
bilateral posterior bite planes (of minimal thickness) to further
expand the right maxilla (differential expansion). Two Adams
clasps and two ball clasps were incorporated in both appliances to aid retention.
A set of two appliances, rather than one, was utilized
because of the proximity of the posterior aspect of the anterior
jackscrew site to the splitting line emerging anteriorly and
laterally from the midpalatal jackscrew. A Z-spring could have
been used anteriorly instead to overcome that lack of the
space; however, the jackscrew was more advantageous in terms
of appliance stability. The patients parents were asked to activate the jackscrew a quarter turn every second day. The patient
was instructed to wear the appliance full-time (day and night)
except for eating and teeth cleaning. After each meal and

Simple removable appliances to correct anterior and posterior crossbite in mixed dentition: Case report

Figure 19

107

Pre-treatment extraoral, intraoral photographs and panoramic radiograph.

before sleeping, the patient was asked to brush his teeth and
the appliance before reinserting it. The roll technique was demonstrated for teeth brushing, and the parents were asked to
monitor the brushing frequency and duration (minimum of 2
minutes). The patient was also instructed to handle the appliance gently and avoid holding its wire extensions or edges
while cleaning.

Upon treatment completion, an upper Hawley retainer was

planned to replace the second appliance to ensure stability of
the corrected malocclusion. Retention using a new appliance
was preferred over grinding the bite planes of the second one
to improve adaptation and patient comfort. The parents
consented to the treatment plan and were informed that a
second stage of comprehensive treatment for nal leveling

108

N.A. Bindayel

Figure 1014

Pre-treatment orthodontic study models.

Figure 15 Insertion of rst removable appliance to correct the anterior crossbite; maxillary occlusal (A), frontal (B), right lateral (C),
and left lateral intraoral views (D).

might be indicated upon clinical reevaluation during the early

permanent dentition stage.
2.2. Treatment progress
The rst appliance was used for 7 weeks to achieve a positive
overjet of the maxillary right central incisor. After anterior
crossbite correction, a bilateral, posterior open bite resulted
from use of the posterior bite planes that caused intrusion of

mostly the mandibular posterior segments. At this point, a

decrease in severity of the mandibular midline deviation
became evident (Figs. 1618). Use of the second appliance
was followed for 8 weeks (Fig. 19). Expansion was continued until the desired transverse correction of the maxillary
right posterior segment was achieved. The total active
treatment period was about 4 months. For both appliances,
the patient was seen during the rst week after appliance insertion to ensure comfort and monitor cooperation. Thereafter,

Simple removable appliances to correct anterior and posterior crossbite in mixed dentition: Case report

Figure 1618

109

Intraoral photographs after anterior crossbite correction.

Figure 19 Activated second removable appliance to correct the unilateral right posterior crossbite; frontal view (A), right lateral view
(B), maxillary occlusal view (C) and laboratory drawing of the appliance design (D).

follow-up appointments were scheduled every 34 weeks.

Upon completion of treatment, the anterior and posterior
crossbites had been corrected, the right molar relationship
was restored to Class I, the left molar relationship had a tendency to Class III, and chin asymmetry was reduced (Figs.
2027). Some occlusal adjustments were made to the maxillary
and mandibular right primary canines (inclined planes) to ensure a stable and functional relationship. The upper Hawley
was then used full-time (day and night) for 6 months. Use of
the Hawley retainer promotes retention and resolution of
any residual lateral posterior open bite. The patient was then
asked to wear the retainer only at night for another 4 months.
The case was followed up out of retention for an additional
4 months (Figs. 2832). Stable anterior and posterior relationships were evident, and continued spontaneous alignment of
the mandibular incisors was noticed. Furthermore, there was
a spontaneous decrease in the maxillary diastema.
3. Discussion
The pretreatment photographs demonstrated fair oral hygiene.
However, by the end of treatment, maxillary and mandibular
generalized marginal gingivitis were evident (Figs. 2027).
The inammation was followed by an improvement in oral

hygiene during the retention period. Despite the demonstration of proper oral hygiene measures to the patient, the
patients hygiene worsened during the treatment period, possibly because of such factors as lack of patient cooperation, lack
of motivation and follow-up by the dentist, lack of parental
support, and the hygienic demand of an intraoral appliance.
A study has shown that only 26.1% of a group of Saudi children aged 69 were caries free (Alamoudi et al., 1996). A more
recent investigation indicated that the prevalence of caries
among a sample of Saudi primary school children was
94.4% (Wyne et al., 2002). Therefore, more emphasis should
be focused on maintaining good oral hygiene before, during,
and after any dental treatment.
The case presented with a functional shift, a discrepancy
that is indicated for early management. The mixed dentition
period offers a great opportunity for occlusal guidance and
interception of malocclusion (Kocadereli, 1998). If treatment
is deferred to a later developmental stage, treatment may
become more complicated (Tse, 1997).
On extraoral evaluation, the patient displayed chin deviation to the right side in centric occlusion. Facial asymmetry
with chin deviation to the crossbite side is a known concurrent
nding in cases affected by mandibular functional shift (Pirttiniemi et al., 1990). Therefore, the treatment was provided

110

N.A. Bindayel

Figure 2027

Post-treatment extraoral and intraoral photographs.

Figure 2832

Four months post-retention intraoral photographs.

to help avoid growth imbalance of both skeletal and dentoalveolar structures (Vadiakas and Viazis, 1992).

In cases of unilateral crossbite, determining the correct

treatment approach for each individual case is the key to

Simple removable appliances to correct anterior and posterior crossbite in mixed dentition: Case report
treatment success and stability. The clinician must rst distinguish crossbites of dental origin from those of skeletal origin.
Dental crossbite involves localized tipping of a tooth or teeth
and does not involve the basal bone (Bayrak and Tunc,
2008). Pseudo Class III malocclusion is another example of
dental anterior crossbite that needs to be differentiated from
sagittal skeletal discrepancies. It involves retroclination of
maxillary incisors that cause the mandible to shift forward
(Rabie and Gu, 2000). That is why treatment of these cases
should aim to correct maxillary incisor inclination (Hagg
et al., 2004). Moyers has distinguished pseudo Class III malocclusion from cases with simple linguoversion. The latter involves palatal positioning of one or more maxillary anterior
teeth and does not produce a positional relationship brought
about by early interference (Moyers, 1988).
The maxillary arch displayed an asymmetric shape due to
palatal tipping of the right posterior segment. The asymmetry
might have developed as a consequence of the premature anterior bite forcing the mandible to shift to the right side. The mesial and distal line angles of the respective maxillary and
mandibular left central incisors acted as a guide plane during
development of the shift, resulting in an axial tipping of these
teeth. Therefore, treatment was geared to alleviate the anterior
crossbite rst and then control the remaining transverse
discrepancy. It should be noted that cases with symmetrical
arches could benet from symmetric expansion even in the
presence of unilateral crossbite and mandibular shift. In such
cases, the amount of intermaxillary transverse discrepancy is
usually reduced to less than a full bilateral crossbite. Although
the second appliance was designed to express more expansion
on the right side, minor expansion of the opposite side
unavoidably occurred. Thus, the expansion of both sides must
be carefully monitored in such cases. Overcorrection is usually
recommended for posterior crossbite cases; however, we
limited correction of the right side to avoid any undesired
overexpansion of the left (unaffected) side.
Before treatment, the molar relationship was Class I on the
left side and a half-cusp Class II on the right. In crossbite cases
with a mandibular shift, studies have indicated that molars on
the crossbite side showed a partial Class II relationship (Hesse
et al., 1997). Furthermore, tomogram studies have supported
that nding by showing asymmetric condylar positioning in
those cases. The condyle on the noncrossbite side was found
to be positioned downward and forward, while on the crossbite side it was centered in the articular fossa (Hesse et al.,
1997). In the present case, the right molar relationship had
been corrected to a Class I relation by the end of treatment.
Another study showed that, out of 65 Class II subdivision patients having a unilateral crossbite with a shift, 50% of the subdivision relationships that accompanied the crossbite were
resolved after its correction (Ben-Bassat et al., 1993).
In regard to the bite plane, clear instructions should be included to specify the thickness of the acrylic and the amount of
tooth separation. For the rst appliance, an acrylic thickness
of 4 mm was specied (i.e., barely enough to disengage the
anterior crossbite tooth). For the second appliance, a minimal
acrylic thickness was requested. The clinician must always
communicate effectively with the laboratory technician to produce the required amount of bite opening. Increased and
unnecessary amounts of bite opening may lead alteration of
the vertical relationship and the patients decreased compliance. From clinical observation, the author has noticed that

111

managing similar cases without use of the posterior bite plane

did not produce the desired outcome, wherein expansion might
be only expressed on the noncrossbite side (i.e., the freed side).
Generally, the recommended activation frequency of similar appliances is every second or third day (Kennedy and
Osepchook, 2005). In this case, we followed an every-otherday activation protocol, which was found to be efcient and
effective in the management of this case. Activation every third
day is recommended during the rst week of therapy for
improved patient comfort and acceptance. Other authors
advocate activation twice a week (Al-Sehaibany and White,
1998) and once a week (Cunha et al., 1999).
By the end of the treatment, and because of increased
palatal tipping of the maxillary right primary canine, the inclined planes had been adjusted on both the maxillary and
mandibular right primary canines. Selective grinding has been
shown to aid in correcting and retaining cases having unilateral posterior crossbite with a shift (Lindner, 1989; Tsarapatsani et al., 1999).
The duration of treatment with removable appliances is reported to range from 6 to 12 weeks (Kennedy and Osepchook,
2005). With a slower expansion rate, treatment can take up to
6 (Al-Sehaibany and White, 1998) and 12 months (Cunha
et al., 1999). The rst and second appliance therapies lasted
for 7 and 8 weeks, respectively, which is in agreement with
the above-mentioned range.
Treatment objectives were met by the end of the presented
therapy. It has been shown that correction of crossbite with
functional shift in the mixed dentition can be successful in
84% to 100% of cases (Bell and LeCompte, 1981; Hermanson
et al., 1985; Ranta, 1988; Egermark-Eriksson et al., 1990;
Bjerklin, 2000; Thilander and Lennartsson, 2002). The type
of appliance, follow-up period, and criteria used for the denition of success also affect the reported success rate (Kennedy
and Osepchook, 2005).
The Hawley retainer was used for 6 months. The recommended retention period for similarly treated cases is 4
6 months (or for a period at least equal to that required for
crossbite correction) (Kennedy and Osepchook, 2005). After
being out of retention for 4 months, the case demonstrated
good stability. An extended retention period would add to
the stability of the posterior crossbite correction; therefore,
other cases must be evaluated and judged individually. It has
been shown that early treatment with slow expansion for a unilateral crossbite with a shift was found to be stable (Bartzela
and Jonas, 2007).
The mandibular incisors underwent continued spontaneous
alignment throughout the treatment period. This can be attributed to the overjet correction that allowed the maxillary incisors to fully overlap the mandibular ones and enabled the
latter to tip back to their original places. Such spontaneous
alignment is an example of how early treatment can produce
additional favorable effects on the developing dentition.
Increased treatment time and cost have been associated
with the use of removable appliances versus xed (eg, quadhelix) for crossbite correction (Hermanson et al., 1985; Ranta,
1988). Nevertheless, treatment of the present case was conned
to the expected treatment time and matched the reported treatment duration using similar removable appliances. This highlights the importance of case selection and the necessity of
enlisting patient and parental compliance before the start of
treatment.

112
4. Conclusions
A simple removable appliance for the correction of anterior
and posterior unilateral crossbite with functional shift was
presented. Thorough clinical assessment and accurate diagnosis must be performed in order to plan proper treatment strategies and appliance design. General practitioners and pediatric
dentists can utilize this technique to manage cases with similar
malocclusions.
Ethical Statement
The consent of the parents of the patient were sought prior to
and approved the inclusion of his case and his photograph in
this study.
Conict of interest
No conict of interest declared.

Acknowledgment
The author would like to address Dr. Moataz B. Alruwaithis
valued contributions during the process of the development of
this manuscript.
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