ABSTRACT : The following case report is of a 19 year-old female patient who presented with Angle's

Class III malocclusion and anterior crossbite on a Skeletal class III base with a hypodivergent growth

pattern. There was gingival recession with respect to her lower right central incisor which was severe for

her age and in part, caused by the crossbite malocclusion. No CO-CR discrepancy was noted. The objective

of the orthodontic treatment was correction of the Class III malocclusion, correction of the anterior

crossbite, restoration of the periodontal health of compromised central incisor and improvement of facial

esthetics. Treatment consisted of fixed orthodontic mechanotherapy using preadjusted edgewise

appliance. Results showed a marked improvement in the occlusal harmony and facial esthetics.

1 2Dr.Mohammad Tariq , Dr.Sarah Asif 1Professor& Chairman, Department of Orthodontics and Dentofacial Orthopedics,

Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh2Senior Resident, Department of Orthodontics and Dentofacial Orthopedics,

Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh

INTRODUCTION :

Moyer's defined anterior tooth crossbite as a dental

malocclusion resulting from the abnormal axial inclination of

maxillary anterior teeth.[1] Correction of crossbite is

recommended when it is seen for the first time because it

eliminates functional shifts and wear on the erupted

permanent teeth, and possibly dentoalveolar asymmetry

which eventually increases arch circumference providing

sufficient space for the permanent teeth to erupt. An early

correction of developing or a frankly developed crossbite also

makes future treatment more comprehensible by eliminating

at least that problem from the list.[2,3,9]

Though lack of an adequate space for the maxillary incisors to

erupt is considered to be one of the most common cause of

anterior crossbite, it is also seen to develop due to a labially

positioned supernumerary tooth causing lingual deflection of

the permanent tooth or any trauma causing displacement of

the developing permanent tooth germ or an arch-length

deficiency causing a lingual deflection of permanent anterior

teeth during eruption or any habit of biting upper lip or in case

of repaired cleft lip.[4,5,9]

Anterior crossbites require an immediate and effective

treatment to prevent anterior teeth mobility and fracture and

also to obviate any future periodontal and temporomandibular

joint disturbances.[6-8]

Depending upon the etiology of the anterior crossbite;

skeletal or dental, and the stage of dentition; mixed or

permanent, a variety of treatment approaches can be used to

prevent, intercept or correct it. A meticulous diagnosis must

be performed by the orthodontist before beginning with the

treatment mechanics.[9]

Treatment modalities for correction of anterior crossbite

include tongue blade therapy, inclined plane, removable

appliance with finger spring, maxillary 2x4 appliance,

bonded resin-composite slopes, fixed orthodontic

mechanotherapy or orthognathic surgical procedures.9-10

CORRECTION OF ANTERIOR CROSSBITE IN

A FEMALE ADULT PATIENT- A CASE REPORT

Journal of Dental Sciences

University

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 70

University J Dent Scie 2018; Vol. 4, Issue 3

CaseReport

Key words:

Anterior Crossbite,

Class III Skeletal Base,

CO-CR discrepancy.

Conflict of interest: Nil

No conflicts of interest : Nil

This case report describes the effective correction of anterior

crossbite in an adult using fixed orthodontic mechanotherapy.

CASE REPORT ;

A 19 years old female patient presented with chief complaint

of forwardly and irregularly placed upper front teeth and a non

pleasing smile. Upon the initial extraoral clinical

examination, she exhibited a symmetrical mesoprosopic face

with concave profile and prominent chin. Smile analysis

revealed a non-consonant smile arc with a low smile line and

Morley's ratio of 70%. (Figure 1)

The intraoral examination revealed a bilateral Angle's Class

III molar and canine relationship and anterior crossbite with

respect to 11,12 & 41,42,43. The facial as well as the dental

midlines were coincident. The maxillary arch was symmetric

and U shaped with palatally placed 11 &12 and rotated 13

&23. The mandibular arch was symmetric and U-shaped with

spacing between 31 &41.The mandibular right central incisor

was associated with grade II mobility and gingival recession.

The functional findings revealed no signs or symptoms of

temporomandibular disorder. Upon further examination there

was absence of any occlusal interferences or an anterior shift

from centric relation (CR) to centric occlusion (CO) during

mandibular closure.

Cephalometric findings revealed a Skeletal class III relation

(SNA=78°, SNB=79°, ANB=-1°, Wits= 0 mm). The patient

had a hypodivergent growth pattern (FMA=19° and Gonial

angle=119 °). The dentoalveolar findings suggested normally

positioned maxillary incisors and retroclined mandibular

incisors (Max 1-Na=6.5mm, Max 1-NA=30°, Mand 1-APog=

1mm, IMPA=88° and Interincisal angle= 135°). Soft tissue

cephalometric analysis revealed retrusive upper and lower lip

w.r.t S and E line. (Figure 2& 5)

Model analysis revealed a total discrepancy of 4mm in the

maxillary arch and 1 mm in the lower arch.

TREATMENT GOALS :

The goals were to obtain a good facial balance with

optimum static and functional occlusion. The treatment

objectives were:

· Correction of Anterior Crossbite

Leveling and alignment of arches

Correction of Overjet and Overbite

Achieving Class 1 Molar and canine relation B/L

Correction of gingival recession & mobility w.r.t 41

Retention

TREATMENT PLAN :

The treatment plan proposed was non extraction fixed

orthodontic mechanotherapy.

TREATMENT SEQUENCE :

The patient underwent fixed orthodontic mechanotherapy

with MBT preadjusted edgewise appliance (0.022x 0.028

inch slot). A removable lower acrylic posterior bite plate was

used to disocclusion so that the palatally positioned incisors

could be moved forward. In the intial step of leveling and

alignment only upper bonding and banding was done. An

initial 0.016-inch round nickel titanium arch wire was placed

for the alignment of the upper arch. At the end of 16 weeks,

alignment of the upper anteriors was complete and the upper

incisors which were in crossbite had been moved out

successfully. Also at this stage, lower arch bonding and

banding was done and the use of posterior bite plate was

discontinued.

Upon completion of the alignment and progression to 0.019 x

0.025 inch stainless steel wires in both maxillary and

mandibular arch, class III force was applied using elastics.

Settling elastics were used for three weeks following which

the patient was debonded and removable upper and lower

retainers were given.

RESULTS :

The final outcome showed attainment of all functional and

·····

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 71

University J Dent Scie 2018; Vol. 4, Issue 3

esthetic goals. The radiographic evaluation confirmed the

correction of the inclination of upper and lower incisors. An

ideal amount of overjet and overbite were established and

crossbite corrected. Also, after successful completion of the

fixed orthodontic treatment, there was marked improvement

in the periodontal condition of the lower right central incisor.

The mobility was reduced to grade 0 and a significant amount

of bone formation was noted on the periapical radiograph

around the lower central incisor. (Figure 3&4)

DISCUSSION:

Balanced facial esthetics with a harmonious soft tissue profile

and a stable occlusion along with functional considerations

are considered to be one of the most important objectives of

orthodontic therapy. An anterior crossbite detected in the

mixed dentition is usually an alarming situation for the

orthodontist since it may adversely restrict the forward

maxillary alveolar growth and further complicate the

crowding of the maxillary anterior teeth in patients with arch

length deficiency problems. For these reasons, anterior

crossbites are said to be corrected as soon as they are

discovered.[10-11]

While attempting the correction of anterior crossbite certain

variables are to be considered.

Firstly, the presence or absence of an anterior shift from

centric relation to centric occlusion during mandibular

closure should be diagnosed. Patients with an anterior shift

are categorized as pseudo Class III and usually have a Class I

molar relationship in CR. When no anterior shift is detected,

the probability increases that a true Class III malocclusion is

present, and also that the anterior crossbite has an underlying

skeletal discrepancy. Secondly, anterior arch length must be

assessed while attempting to align the maxillary incisor in

palatal crossbite. If inadequate arch length is available, first

attempt must be made to create sufficient space. During fixed

appliance orthodontic mechanotherapy, open coil springs are

often utilized for space regaining in order to move the teeth

out of crossbite. However in cases of severe crowding,

extractions are documented. Thirdly, correction of the torque

of the roots of the maxillary incisor roots which were in

crossbite, is almost always required, since the teeth in

crossbite have their roots positioned lingually and the long

axis of these teeth is in a greater labial inclination than normal

which is more likely to relapse following treatment. Hence,

for the correction and better control of torque, brackets with

built-in torque are used in an inverted fashion and bonded on

the labial surface of the crown.

Lastly, the alignment of mandibular anterior teeth should

always be delayed until the maxillary anterior teeth have been

moved out of crossbite. [9-11]

CONCLUSION :

Thorough diagnosis and careful treatment planning along

with appropriate execution of the orthodontic mechanics is

the surest way to achieve successful and predictable results

with minimal side effects. A remarkable improvement in the

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University J Dent Scie 2018; Vol. 4, Issue 3

dental and soft tissue profile as well as the self-esteem of the

patient was seen.

REFERENCES

1. Moyers, R.E. Handbook of Orthodontics, 4th ed, Year

Book Medical Publishers, Inc; Chicago, 1988, pg 418.1.

2. Langberg BJ, Arai K, Miner RM. Transverse skeletal and

dental asymmetry in adults with unilateral lingual

posterior crossbite. Am J Orthod Dento Orthop 127:6-

15,2005.

3. Adkins MD, Nanda RS, Currier GF. Arch perimeter

changes on rapid palatal expansion. Am J Orthod 97:10-

19,1990.

4. Mc Donald, Dentistry for the Child and Adolescent, 8th

Ed.,Elsevier, a division of Reed Elsevier India Pvt. Ltd.,

2005, chap.27 pg. 651-653.

5. Lee BD. Correction of crossbite. Dent Clin North Am.

1978 Oct; 22(4):647-68.

6. Valentine F, Howitt JW.Implications of early anterior

crossbite correction. ASDC J Dent Child. 1970 Sep-Oct;

37(5):420-7.

7. Estreia F, Almerich J, Gascon F. Interceptive correction

of anterior crossbite. J Clin Pediatr Dent. 1991 Spring;

15(3):157-9.

8. Jacobs SG.Teeth in cross-bite: the role of removable

appliances.Aust Dent J. 1989 Feb;34(1):20-8.

9. Profit WR. Contemporary orthodontics. Mosby, 4th

edition, 2007.

10. Graber TM. Orthodontics: Principles and Practice. W. B.

Saunders, Philadelphia, Pa, USA, 5th edition, 2012

11. Bishara SE.Textbook of orthodontics.W.B. Saunders,

Philadelphia, Pa, USA, 2001.

CORRESPONDING AUTHOR:

Dr. Sarah Asif

Senior Resident,

Department of Orthodontics and Dentofacial Orthopedics,

Dr.Ziauddin Ahmad Dental College, Aligarh Muslim

University, Aligarh, Uttar Pradesh, India, Pincode -202002

Email : sarahasif87@gmail.com

Contact number : 09634319370

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 73

University J Dent Scie 2018; Vol. 4, Issue 3