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Posterior crossbite--treatment and stability.
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PMID:  22666850     Owner:  NLM     Status:  MEDLINE    
Posterior crossbite is defined as an inadequate transversal relationship of maxillary and mandibular teeth. Even when eliminating the etiologic factors, this malocclusion does not have a spontaneous correction, and should be treated with maxillary expansion as early as possible. This treatment aims at providing a better tooth/skeletal relationship, thereby improving masticatory function, and establishing a symmetrical condyle/fossa relationship. Should posterior crossbite not be treated early, it may result in skeletal changes, demanding a more complex approach. Additionally, an overcorrection expansion protocol should be applied in order to improve the treatment stability. Although the literature has reported a high rate of relapse after maxillary expansion, the goal of this study was to demonstrate excellent stability of the posterior crossbite correction 21 years post treatment.
Renato Rodrigues de Almeida; Marcio Rodrigues de Almeida; Paula Vanessa Pedron Oltramari-Navarro; Ana Cláudia de Castro Ferreira Conti; Ricardo de Lima Navarro; Henry Victor Alves Marques
Publication Detail:
Type:  Case Reports; Journal Article    
Journal Detail:
Title:  Journal of applied oral science : revista FOB     Volume:  20     ISSN:  1678-7765     ISO Abbreviation:  J Appl Oral Sci     Publication Date:    2012 Mar-Apr
Date Detail:
Created Date:  2012-06-05     Completed Date:  2012-09-13     Revised Date:  2014-01-27    
Medline Journal Info:
Nlm Unique ID:  101189774     Medline TA:  J Appl Oral Sci     Country:  Brazil    
Other Details:
Languages:  eng     Pagination:  286-94     Citation Subset:  D; IM    
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MeSH Terms
Follow-Up Studies
Malocclusion / radiography,  therapy*
Palatal Expansion Technique*
Radiography, Panoramic
Time Factors
Treatment Outcome

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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Journal Information
Journal ID (nlm-ta): J Appl Oral Sci
Journal ID (iso-abbrev): J Appl Oral Sci
Journal ID (publisher-id): J. Appl. Oral. Sci.
ISSN: 1678-7757
ISSN: 1678-7765
Publisher: Faculdade de Odontologia de Bauru da Universidade de São Paulo
Article Information
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Received Day: 05 Month: 4 Year: 2010
Revision Received Day: 20 Month: 5 Year: 2010
Accepted Day: 20 Month: 5 Year: 2010
Print publication date: Season: Mar-Apr Year: 2012
Volume: 20 Issue: 2
First Page: 286 Last Page: 294
PubMed Id: 22666850
ID: 3894776
DOI: 10.1590/S1678-77572012000200026

Posterior crossbite - treatment and stability
Renato Rodrigues de ALMEIDA1
Marcio Rodrigues de ALMEIDA1
Paula Vanessa Pedron OLTRAMARI-NAVARRO1
Ana Cláudia de Castro Ferreira CONTI1
Ricardo de Lima NAVARRO1
Henry Victor Alves MARQUES2
1 DDS, MSc, PhD Full Professor, Department of Orthodontics, University of North Paraná (UNOPAR), Londrina, PR, Brazil.
2 DDS, MSc student, Department of Orthodontics, University of North Paraná (UNOPAR), Londrina, PR, Brazil.
Correspondence: Corresponding address: Marcio Rodrigues de Almeida - Avenida José Vicente Aiello, 170 - Tivoli - 17053-093 - Bauru - SP - Phone: (14) 3226-1411 - e-mail:


Posterior crossbite is defined as an inadequate transversal relationship of maxillary and mandibular teeth, i.e., the buccal cusps of the maxillary teeth are in contact with the central fossae of the mandibular teeth18,19. Some studies have suggested a posterior crossbite prevalence range between 8 to 16%11,18-20. The etiology of this malocclusion may comprise deleterious oral habits and early loss of primary teeth, among others7,20. Regarding the problems that affect the maxillomandibular complex, the transversal arch stands out because of its limited growth, as the first dimension to stop growing16.

This malocclusion does not show spontaneous correction, and should be treated with maxillary expansion as early as possible2,5,18-20. Therefore, an accurate diagnosis and treatment planning must be accomplished with the patient in centric relation6. This approach should consider not only the tooth intercuspation, but also the arch shape, since constricted arches have a triangular anatomy2,5.

The early treatment aimed at promoting a better tooth/skeletal relationship, thus improving masticatory function, and establishing a symmetrical condyle/fossa relationship4,9,10,15,19. The treatment proposed for an early posterior crossbite correction comprises fixed or removable appliances, such as the Haas expander. This orthopedic appliance increases the transversal dimension of the maxillary dental arch by opening the median palatine suture, and due to proclinate maxillary posterior teeth18,19.

In order to achieve a better stability, an overcorrection of the maxillary expansion is suggested, since at least one third of relapse is expected1,18. Furthermore, aiming at minimizing this effect, removable or fixed retainers are indicated for at least 3 months1.

Although this treatment protocol has been extensively discussed in the literature, few studies on a long-term basis have been reported3,13,17. The aim of this study was to demonstrate the stability of the posterior crossbite correction 21 years after treatment.


A 12.8 year-old Caucasian girl presented for treatment complaining of an unpleasant smile. This patient showed oral breathing, lip incompetence, and atypical swallowing aided by the mentonian musculature. Additionally, an increased facial lower third and a convex profile were verified. Intraoral evaluation showed a Class II, division 1 malocclusion, and bilateral posterior crossbite (Figures 1 and 2, Table 1).

The treatment plan proposed was palatal expansion, performed by a modified Haas-type expander (Figure 3), aiming at increasing the maxillary transversal dimension to correct the bilateral posterior crossbite. Activation of the screw was initiated immediately after appliance insertion with a complete turn. After that (Figure 3), the patient was instructed to keep the activation with 2/4 turns in the morning and 2/4 turns in the afternoon, during eight days. The expander was passively maintained for a period of three months, followed by a removable retainer, which was used for another six months. At that time, a comprehensive orthodontic treatment was initiated in order to improve the results obtained after expansion (Figure 4). The whole treatment, including maxillary expansion and the comprehensive phase, lasted about 1 year and 3 months, when a Hawley appliance and a 3x3 retainer were installed (Figures 5 and 6). The patient has been followed up for 21 years, and has as yet maintained stability of the results achieved with maxillary expansion (Figures 7-11).


This case report challenges some studies12,14 in which this enlargement method of treatment was found to have a poor stability result. In the present case, the patient had bilateral skeletal posterior crossbite, and a modified Haas-type expansion appliance was indicated20. Early correction of posterior crossbite has been recommended in order to prevent an inadequate skeletal transversal growth.

Few studies have assessed the longitudinal stability of maxillary expansion3,13,17. The present case was treated, and followed-up in the long term (21 years), showing stability of the posterior crossbite correction. Additionally, the cephalometric variables obtained at the end of the treatment remained stable throughout the period following the study. These results are in agreement with what is expected for a female patient at this age, when the growth rate has declined significantly (Table 1).

Similar findings have been assessed by Bartzella, et al.3 (2007), who verified 79% of stability in cases evaluated in the long term. However, it is worth noting that their sample was composed of patients with unilateral posterior crossbite. Moreover, these authors observed that the stability was similar, regardless of the expansion performed (whether rapid or slow).

Studies have shown that 50% of posterior crossbite cases treated at primary dentition had to be retreated at mixed dentition12,14. Although these results indicated a high-incidence relapse of early treatment, other advantages have been attributed to this intervention. According to Harrison and Ashby8 (2001), maxillary expansion in the primary dentition would decrease the risk of a posterior crossbite being perpetuated to a permanent dentition.

Rapid maxillary expansion promotes positive skeletal (orthopedic) and dental (orthodontic) effects, thus affording the correction of a maxillary transverse deficiency. Baccetti, et al.2 (2001) stated that a better prognosis is expected when applying this protocol at an early age. These authors verified that the maxillary skeletal width could be expanded without relapse in young patients. However, in adulthood they found greater skeletal rigidity, and consequently poor orthopedic results.


Based on this case report, a rapid maxillary expansion protocol carried out at mixed dentition was effective and stable 21 years post treatment.

1. Arat ZM,Gökalp H,Atasever T,Türkkahraman H. 99mTechnetium-labeled methylene diphosphonate uptake in maxillary bone during and after rapid maxillary expansionAngle OrthodYear: 200373554554914580022
2. Baccetti T,Franchi L,Cameron CG,McNamara JA Jr. Treatment timing for rapid maxillary expansionAngle OrthodYear: 200171534335011605867
3. Bartzela T,Jonas I. Long-term stability of unilateral posterior crossbite correctionAngle OrthodYear: 200777223724317319757
4. Bell RA,LeCompte EJ. The effects of maxillary expansion using a quad-helix appliance during the deciduous and mixed dentitionsAm J OrthodYear: 19817921521617008619
5. Berlocher WC,Mueller BH,Tinanoff N. The effect of maxillary palatal expansion on the primary dental arch circumferencePediatr DentYear: 19802127307001393
6. Celenza FV. The theory and clinical management of centric positionsll. Centric relation and centric relation occlusionInt J Periodontics Restorative DentYear: 19844662866597180
7. Hannuksela A,Väänänen A. Predisposing factors for malocclusion in 7-year-old children with special reference to a topic diseasesAm J Orthod Dentofacial OrthopYear: 19879242993033477948
8. Harrison JE,Ashby D. Orthodontic treatment for posterior crossbitesCochrane Database Syst RevYear: 20011
9. Järvinen S. Need for preventive and interceptive intervention for malocclusion in 3--5-year-old Finnish childrenCommunity Dent Oral EpidemiolYear: 198191146941870
10. Kantomaa T. Correction of unilateral crossbite in the deciduous dentitionEur J OrthodYear: 19868280833522254
11. Kisling E. Occlusal interferences in the primary dentitionASDC J Dent ChildYear: 19814831811916944317
12. Kurol J,Berglund L. Longitudinal study and cost-benefit analysis of the effect of early treatment of posterior cross-bites in the primary dentitionEur J OrthodYear: 19921431731791628683
13. Lagravere MO,Major PW,Flores-Mir C. Long-term dental arch changes after rapid maxillary expansion treatmenta systematic reviewAngle OrthodYear: 200575215516115825776
14. Lindner A. Longitudinal study on the effect of early interceptive treatment in 4-year-old children with unilateral crossbiteScand J Dent ResYear: 19899754324382617141
15. Myers DR,Barenie JT,Bell RA,Williamson EH. Condylar position in children with functional posterior crossbitesbefore and after crossbite correctionPediatr DentYear: 1980231901946938933
16. O'Grady PW,McNamara JA Jr,Baccetti T,Franchi L. A longterm evaluation of the mandibular Schwarz appliance and the acrylic splint expander in early mixed dentition patientsAm J Orthod Dentofacial OrthopYear: 2006130220221316905065
17. Sabri R. Treatment of a severe arch-length deficiency with anteroposterior and transverse expansionlong-term stabilityAm J Orthod Dentofacial OrthopYear: 2010137340141120197181
18. Silva OG Filho,Boas MCV,Capelozza L Filho. Rapid maxillary expansion in the primary and mixed dentitionsa cephalometric evaluationAm J Orthod Dentofacial OrthopYear: 199110021711791867168
19. Silva OG Filho,Montes LAP,Torelly LF. Rapid maxillary expansion in the dentition evaluated through posteroanterior cephalometric analysisAm J Orthod Dentofacial OrthopYear: 199510732682757879759
20. Silva OG Filho,Valladares J Neto,Rodrigues de Almeida R. Early correction of posterior crossbitebiomechanical characteristics of the appliancesJ PedodYear: 19891331952212593066


[Figure ID: f01]
Figure 1 

Pretreatment extraoral (A and B) and intraoral (C-G) photographs (parents authorized the publication of these pictures)

[Figure ID: f02]
Figure 2 

Initial lateral cephalograms (A) and panoramic radiograph (B)

[Figure ID: f03]
Figure 3 

Intraoral aspects. Occlusal view showing the Haas-type expansion appliance installed (A) and the radiographic aspect (B)

[Figure ID: f04]
Figure 4 

Intraoral (A-D) and radiographic (E) aspects of the fixed appliance

[Figure ID: f05]
Figure 5 

Extraoral (A and B) and intraoral (C-G) photographs at the completion of treatment. Radiographic aspect (H) (parents authorized the publication of these pictures)

[Figure ID: f06]
Figure 6 

Final lateral cephalograms (A) and panoramic radiograph (B)

[Figure ID: f07]
Figure 7 

First follow-up appointment photographs. Extraoral (A and B) and intraoral (D-H). Lateral cephalograms (C) (parents authorized the publication of these pictures)

[Figure ID: f11]
Figure 11 

Panoramic radiograph

[TableWrap ID: t01] Table 1 

Initial, final, 1st, and 2nd follow-up cephalometric measures

CEPHALOMETRIC PATTERN Initial Final 1st Follow-up 2nd Follow-up
VARIABLES   (12.83 years) (14.08 years) (21.41 years) (29.16 years)
NAP(º) 0.0 11.0 6.5 5.5 7.5
SNA(º) 82.0 83.0 82.0 82.0 82.0
SNB(º) 80.0 76.0 77.0 78.0 78.5
ANB(º) 2.0 7.0 5.0 4.0 3.5
FMA(º) 25.0 37.0 35.0 32.0 33.0
SN.GoGn(º) 32.0 42.0 42.0 40.0 40.0
SN.Gn(º) 67.0 74.0 73.0 71,5 72.0
SN.Ocl(º) 14.0 19.5 14.5 14.0 13.0
1.NA(º) 22.0 31.0 27.0 27.0 27.0
1-NA(mm) 4.0 5.5 5.5 5.5 5.0
1.NB(º) 25.0 15.5 23.5 22.0 24.0
1-NB(mm) 4.0 6.0 8.5 8.0 8.5
IMPA(º) 87.0 73.0 82.5 82.5 84.0
Co-A(mm) - 94.0 94.5 96.0 97.0
Co-Gn(mm) - 124.0 128.5 134.0 132.0
NLA(º) 110.0 118.0 114.0 117.0 115.0

Article Categories:
  • Case Report

Keywords: Orthodontics, Malocclusion, Palatal expansion technique.

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