CASE REPORT

Treatment of unilateral posterior crossbite

with facial asymmetry in a female patient
with transverse discrepancy
Seok-Ki Junga and Tae-Woo Kimb
Seoul, Korea

A unilateral posterior crossbite with facial asymmetry is difcult to correct with orthodontic treatment alone. This
case report describes the orthodontic treatment and additional plasty without orthognathic surgery for a 19-year-
old woman with a transverse discrepancy. The posterior crossbite was resolved by expansion of the narrow
maxillary arch and space closure in the mandibular arch. This accelerated the correction of the functional shift
of the mandible. After resolution of the unilateral posterior crossbite, the problems of the anteroposterior molar
relationship were treated using orthodontic mini-implants. Mandibular angle reduction plasty was performed for
the asymmetric mandibular border to improve the facial appearance. After treatment, the patient had a more
symmetrical facial appearance, normal overjet and overbite, and midline coincidence. The treatment results re-
mained stable 1 year after treatment. This case report demonstrates that a minimally invasive treatment can suc-
cessfully correct a unilateral posterior crossbite with a transverse discrepancy. (Am J Orthod Dentofacial Orthop
2015;148:154-64)

G
enerally, when we establish the treatment plan
for patients with facial asymmetry, surgery is
included1 because facial asymmetry is usually
caused by skeletal problems.2 Orthodontic treatment
alone is a difcult choice in this situation.3 Patients
with facial asymmetry and a skeletal Class III malocclu-
sion must be treated by orthognathic surgery even if
there is no facial asymmetry. However, more consider-
ation is needed to treat patients with facial asymmetry
and a skeletal Class I relationship. Because correction
of the asymmetry is the only goal of the orthognathic
surgery in this case, satisfaction with the treatment
may be low after surgery. Moreover, patients with facial
asymmetry and a transverse discrepancy can be treated
with orthodontics alone.4 This case report describes
the treatment of a woman with a unilateral posterior
a
Postgraduate student, Department of Orthodontics, School of Dentistry, Dental
Research Institute, Seoul National University; clinical instructor, Department of
Orthodontics, Korea University Ansan Hospital, Seoul, Republic of Korea.
b
Professor, Department of Orthodontics, School of Dentistry, Dental Research
Institute, Seoul National University, Seoul, Republic of Korea.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Tae-Woo Kim, Department of Orthodontics, School
of Dentistry, Dental Research Institute, Seoul National University, 101 Daehakro,
Jongro-Gu, Seoul 110-749, Republic of Korea; e-mail, taewoo@snu.ac.kr.
Submitted, June 2014; revised and accepted, September 2014.
0889-5406/$36.00
Copyright ! 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.09.023
154
crossbite and facial asymmetry. She had a skeletal Class
I relationship. Her chin and mandibular midline were
deviated to the left side with a left posterior crossbite.
Because there was a transverse discrepancy, a nonsur-
gical approach for the correction of the occlusion could
be planned. Mandibular angle reduction plasty was
planned for the asymmetrical mandibular inferior
border. By avoiding orthognathic surgery, it was possible
to minimize the patient's discomfort.
DIAGNOSIS AND ETIOLOGY
The patient was a 19-year-old woman who visited
Seoul National University Dental Hospital in South Korea
for an orthodontic consultation. No specic medical
problems or temporomandibular joint symptoms were
observed. She had a skeletal Class I relationship and
facial asymmetry, with the chin deviated 4.5 mm to
the left. A slight maxillary deciency and a normal verti-
cal growth pattern were seen. A Class I molar relationship
on the right and a Class II molar relationship on the left
were observed, and a posterior crossbite from the left
lateral incisor to the left second molar was observed
(Fig 1). The mandibular dental midline was deviated
6.5 mm to the left. There was space between the
mandibular anterior teeth (Fig 2). The cant of the
occlusal plane was minor. In the lateral cephalometric
analysis, no mouth protrusion or problems of anterior
tooth inclination were found (Table I). The major
Jung and Kim
Fig 1. Pretreatment facial and intraoral photographs.
problems were summarized as frontal asymmetry, devi-
ation of the chin, left posterior crossbite, and mandib-
ular dental midline deviation. Furthermore, the patient
had a slight transverse centric occlusioncentric relation
discrepancy. This functional shift of the mandible
caused mandibular asymmetry, which could be observed
in the panoramic and posteroanterior radiographs
(Fig 3). In particular, the mandibular left inferior border
was much bulkier than right inferior border. This differ-
ence in mass was the cause of the facial asymmetry.
TREATMENT OBJECTIVES
The treatment objectives for the dentition were correc-
tion of the left posterior crossbite, making the maxillary
and mandibular midlines coincident, and closing the
mandibular arch space. The treatment objectives for the
skeleton were improving the facial asymmetry, including
American Journal of Orthodontics and Dentofacial Orthopedics
155
the deviation of the chin, and improving the transverse
discrepancy. Thus, facial symmetry, normal overjet and
overbite, and Class I canine-to-molar relationships could
be obtained.
TREATMENT ALTERNATIVES
Facial asymmetry and unilateral posterior crossbite
are difcult to treat with orthodontics alone. There-
fore, the rst plan was orthodontic treatment accom-
panied by orthognathic surgery. Extraction of the 2
maxillary third molars was planned. Leveling of maxil-
lary and mandibular arches and space closure of the
mandibular arch were planned as the presurgical or-
thodontic treatment. After that, the asymmetries of
the chin and mandible could be corrected with or-
thognathic surgery. Postsurgical orthodontic treat-
ment would nish correction of the malocclusion.
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156 Jung and Kim

Fig 2. Pretreatment dental casts.

The patient selected the second option because she

Table I. Comparison of cephalometric measurements
did not want orthognathic surgery.
Pretreatment Posttreatment
ANB angle (" ) 2.4 2.4 TREATMENT PROGRESS
A to N perpendicular (mm) #1.2 #1.2
Pog to N perpendicular (mm) #5.9 #5.5 Metal self-ligating brackets (0.022-in slot, Damon Q;
Bj
ork sum (" ) 393.0 401.4 Ormco, Glendora, Calif) were used for this treatment.
FMA (" ) 22.3 30.7 Initial leveling progressed with a 0.014-in nickel-
U1 to FH (" ) 108.7 108.4 titanium archwire. A lingual sheath was attached to the
U1 to SN (" ) 98.0 97.7
palatal side of the maxillary rst molar, and an expansion
IMPA (" ) 104.2 88.3
Interincisal angle (" ) 124.8 132.6 transpalatal arch was inserted into the lingual sheath (Fig
Upper lip to E-line (mm) #2.3 #4.9 4). Buccal root torque was given to the expansion trans-
Lower lip to E-line (mm) #0.1 #1.8 palatal arch to decompensate the inclination of the
Nasolabial angle (" ) 96.6 93.4 maxillary left rst molar (Fig 5). The relationship of the
left posterior teeth was improved to an edge bite after
This plan has the advantage of eliminating the pa- 4 months of leveling and expansion of the maxillary
tient's skeletal asymmetry, but at the cost of surgical arch. To resolve the minor cant of the maxillary left ante-
risk and nancial burden. rior teeth, a titanium orthodontic mini-implant (OMI;
The second plan was orthodontic treatment and diameter, 1.6 mm; length, 6.0 mm; Jeil Medical, Seoul,
additional plasty without orthognathic surgery. South Korea) was inserted between the mandibular left
Expansion of a narrow maxillary arch can help to premolars. Intermaxillary elastics were applied from the
correct the transverse discrepancy by releasing the OMI to the maxillary left canine and premolars. After
locking in the left posterior teeth. After that, maxillary leveling of the mandibular arch, elastomeric modules
left molar distalization and mandibular left molar were used to close the remaining space. After 7 months
mesialization were planned to correct the left molar of treatment, the unilateral posterior crossbite was cor-
relationship and the dental midline. Mandibular angle rected (Fig 6). Expansion of the maxillary arch relieved
reduction plasty and genioplasty were planned for the the functional shift of the mandible (Fig 5, B). In addi-
bulky left inferior border of the mandible. This plan tion, the reduced mandibular intermolar width helped
would minimize the burden of surgery while maxi- reduce the functional shift (Table II). After resolution of
mizing the reduction of asymmetry. The downside is the unilateral posterior crossbite, mandibular angle
that it is difcult to eliminate the asymmetry reduction plasty and genioplasty were done to improve
completely. the bulky left inferior border of the mandible. Despite

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Jung and Kim 157

Fig 3. Pretreatment lateral and frontal cephalograms and panoramic radiograph.

Fig 4. Intraoral photographs during initial alignment.

the improvement of the left posterior crossbite, a Class II relationships and the mandibular dental midline. At rst,
molar relationship remained. Distalization of the maxil- a titanium OMI was inserted between the maxillary sec-
lary left molars and mesialization of the mandibular ond premolar and the rst molar. After ligation between
left molars were planned to improve the molar the OMI and the second premolar, the molars were

American Journal of Orthodontics and Dentofacial Orthopedics July 2015 ! Vol 148 ! Issue 1
158 Jung and Kim

Fig 5. A, Pretreatment molar relationships; B, mechanics to resolve the crossbite.

Fig 6. Intraoral photographs after resolving the crossbite.

second molars, and distalization of the remaining anterior

Table II. Comparison of intercanine and intermolar
teeth was performed. At the same time, an OMI was in-
widths
serted between the mandibular left lateral incisor and
Pretreatment Posttreatment Retention the canine. The mandibular left molars were mesialized us-
Maxillary intercanine 33.17 37.55 37.55 ing elastomeric modules from the OMI. After 13 months,
width (mm) active treatment was nished, and all xed orthodontic
Mandibular intercanine 31.83 27.84 28.14
width (mm)
appliances were removed. Fixed lingual retainers were
Maxillary intermolar 55.47 57.46 57.37 attached to both arches, and circumferential retainers
width (mm) were placed additionally. The instructions to the patient
Mandibular intermolar 52.10 48.89 49.36 included full-time retainer use for 3 months and then
width (mm) nighttime use for 2 years at least.

distalized during 3 months using open-coil springs be- TREATMENT RESULTS

tween the second premolar and the rst molar (Fig 7). After The nal records (Figs 8-10) show that the unilateral
that, the OMI was moved between the maxillary rst and posterior crossbite was resolved, and the dental midline

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Jung and Kim
Fig 7. Intraoral photographs during molar distalization.
was coincident. The space in the mandibular arch was
closed, and the minor crowding of the maxillary arch
was resolved. The skeletal facial asymmetry was partly
resolved by the recovery of the mandibular functional
shift. The mandibular angle reduction plasty and the
genioplasty markedly improved the patient's frontal
appearance. Distalization of the maxillary left posterior
teeth was successful, and it contributed to the normal
overjet and the Class I canine-to-molar relationship.
The panoramic radiographs (Fig 10) show well-aligned
parallel roots of the teeth, and there are no signs of
root resorption. Comparison of measurements before
and after treatment (Table I) shows the increment of
the Frankfort-mandibular plane angle resulting from
the mandibular angle reduction plasty. In addition,
normalization of the inclination of the mandibular ante-
rior teeth was accomplished by space closure. In the
comparison of the dental casts before and after treat-
ment (Table II), maxillary intercanine and intermolar
widths increased by 4.4 and 2.0 mm, respectively. The
mandibular intercanine and intermolar widths decreased
by 4.0 and 3.2 mm, respectively. These changes were
well maintained during the retention period. The super-
imposition of the frontal cephalometric radiographs
showed expansion of the maxillary arch, constriction
of the mandibular arch, and coincidence of dental mid-
lines (Fig 11). A minor movement of the mandibular
condyle was also observed while correcting the func-
tional shift. The superimposition of the lateral cephalo-
metric radiographs showed the results of the mandibular
angle reduction plasty and the genioplasty, the distaliza-
tion of the maxillary molars, and the mesialization of the
American Journal of Orthodontics and Dentofacial Orthopedics
159
mandibular molars. The patient returned for reevalua-
tion at 1 year after debonding (Figs 12 and 13). Her oc-
clusion was well maintained. The occlusal relationships
of the premolars and molars were improved by settling.
The facial photographs showed a harmonious, accept-
able, and symmetrical appearance.
DISCUSSION
A compensated dentition is often found in patients
with a unilateral posterior crossbite.5 In this case report,
the buccal inclination of maxillary left molars and the
lingual inclination of mandibular left molars were kept
to compensate for the left posterior crossbite. If a simple
unilateral expansion of the maxillary dentition and
constriction of mandibular dentition had been done,
the compensatory movement of dentition would have
been intensied.6 This means that the buccal inclination
of the maxillary left molars and the lingual inclination of
the mandibular left molars would have been worse.7
These changes can cause adverse effects such as interfer-
ence with lateral movements of the mandible by the
opposite side. Therefore, the rst choice of treatment
for unilateral posterior crossbite is orthognathic surgery
followed by decompensation of the inclination of the
posterior teeth. However, in patients with a transverse
discrepancy such as our patient, bodily movement of
the mandible can be obtained partly by appropriate
centric-relation guidance. Thereby, improvement of
the occlusion can be obtained without orthognathic sur-
gery or without worsening of the compensation.
In this patient, habitual maximal intercuspation
caused narrow maxillary posterior teeth and wide
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160 Jung and Kim

Fig 8. Posttreatment facial and intraoral photographs.

Fig 9. Posttreatment dental casts.

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Jung and Kim 161

Fig 10. Posttreatment lateral and frontal cephalograms and panoramic radiograph.

Fig 11. Superimposition of the lateral and frontal cephalograms at pretreatment (black) and posttreat-
ment (red).

mandibular posterior teeth.8 To solve this problem, shift of the mandible can be also resolved. In addition,
normalization of the width is needed before everything generalized spacing in the mandibular arch was
else.9 Locked posterior teeth can be resolved by expan- observed in this patient. Generalized spacing can have
sion of the maxillary arch, and thereby, the functional a variety of causes, such as a tongue-thrusting habit,

American Journal of Orthodontics and Dentofacial Orthopedics July 2015 ! Vol 148 ! Issue 1
162
Fig 12. One-year follow-up facial and intraoral photographs.
low tongue posture, small tooth sizes, and a broad
arch.10 However, the cause in this patient was a little
different because there was no space in the maxillary
arch. Moreover, there was no mandibular prognathism
or a broad mandibular arch. A locked maxillary dentition
seemed to cause the generalized spacing in the mandib-
ular arch.11 As the treatment progressed, space closure in
the mandibular arch helped to decrease the intercanine
and intermolar widths. Reduction of the width of the
mandibular arch also helped to form the proper overjet
of the posterior teeth. After elimination of the locked
maxillary posterior dentition and the functional shift
of the mandible, the patient maintained the proper oc-
clusion with a proper overjet.
Meanwhile, molar distalization and mesialization
with OMIs were attempted in this patient. OMIs were
an important part of her orthodontic treatment.12
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Jung and Kim
Difcult tooth movements with traditional techniques
can be achieved using OMIs.13 Molar distalization is
just one of these techniques. There are several studies
about molar distalization with OMIs.14-16 There are
many ways to try, but most methods have reported
good results. In this report, we used open coil springs
and OMIs. The advantages of this method are that it
can prevent binding and heavy forces compared with
the total distalization method. Also, the total
distalization method often requires a complex
apparatus, but the open-coil method requires only a
simple device. The disadvantage of the open-coil
method is that reinsertion of the OMIs to the distal
side is needed after the molar distalization. However, it
is recommended because distalization of the anterior
portion after distalization of the molars can guarantee
reliable movements of the teeth.
Jung and Kim
Fig 13. One-year follow-up dental casts.
Intermaxillary elastics should be used minimally in a
patient with a transverse discrepancy because excessive
use of intermaxillary elastics can cause temporomandib-
ular disorder.17 In addition, relapse in the retention
period can be high.18 Therefore, for these patients,
actual tooth movements using OMIs are recommended.
Normalization of the intermaxillary relationship after
decompensation of the teeth causes recompensation of
the teeth.19,20 The new balance obtained can protect
the teeth in lateral and protrusive movements of the
mandible.21 This helps to maintain oral health.22
Orthognathic surgery has the disadvantages of sur-
gical risks and costs. These are especially considerable
for orthognathic surgery in a patient with skeletal
Class I asymmetry. In view of these risks and because
correcting the asymmetry is the only goal of treatment,
the patient's satisfaction can be low after orthognathic
surgery. In short, the differences after surgery might
not be signicant compared with the presurgical sta-
tus. Therefore, a well-established treatment plan and
diagnosis are important. If orthodontic treatment
without orthognathic surgery is possible, it can
decrease the surgical risks and costs and increase of
satisfaction of the patient.
CONCLUSIONS
This patient had a unilateral posterior crossbite with a
transverse discrepancy. She was treated successfully us-
ing an expansion transpalatal arch and OMIs. Good
alignment and occlusion were maintained 1 year after
appliance removal. Consideration of a hidden functional
American Journal of Orthodontics and Dentofacial Orthopedics
163
shift is important. Orthognathic surgery may not be
necessary in patients with Class I facial asymmetry. Mini-
mally invasive treatment can be planned for a patient
with a unilateral posterior crossbite and a transverse
discrepancy.
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