Anterior Cross-bite conference on 16092010

Anterior Cross-bite

Chainarong KaosampanChaoprayayomraj Hospital16 September 2010

CONTENTS1. Definition

2. Classification

3. Etiology

4. Clinical Features

5. Diagnosis

6. Management

7. Treatment

8. Conclusion

An abnormal labio - lingual relationship between

one or more maxillary & mandibular incisor teeth

Definition:

Lee BD.; 1978

Classification of anterior cross-bites

The simple dental cross-bite The functional or pseudo cross-bite The skeletal cross-bite

Rob Veis; 2008

Simple dental cross-bite

Abnormal eruption of the permanent incisors Trauma to the primary incisors with displacement of

the permanent tooth bud Delayed exfoliation of a primary incisor with palatal

deflection of the erupting permanent incisor

Etiology

Rob Veis; 2008


Supernumerary anterior teeth Odontomas Congenitally abnormal eruption patterns Arch perimeter deficiency A habit of biting the upper lip

Etiology

Rob Veis; 2008

Functional cross-bite

Early occlusal interference Habitual forward positioning of the mandible to

obtain maximum intercuspation may lead to an anterior cross bite

Etiology

Rob Veis; 2008

Skeletal cross-bite

Genetic Due to deficient anterior growth of

maxilla Excessive abnormal mandibular

growth in anteriorly Combination

Etiology

Rob Veis; 2008

Characteristics


The cross-bite usually involves only one or two teeth The anterior posterior skeletal relationship is normal The facial profile is normal in CR and CO One or both of the arches is/are narrow

Major PW & Glover K; 1992McEvoy ; 1983

Characteristics


The mandible has a smooth arc of closure into an Angle Class I molar and cuspid relationship, with a coincident CR and CO

An abnormal axial inclination of either the maxillary or mandibular anterior teeth occurs as they erupt, while the other teeth are usually in a normal occlusal scheme

Graber; 1972McEvoy ;1983Moyers; 1973

Characteristics


In CO: Incisors cross-bite Molars Class III relationship The maxillary incisors are generally retroclined

and the mandibular incisors may be proclined The gonial angle is average near 120 degrees

Major PW & Glover K; 1992

Characteristics


In CR the opposing incisors generally contact edge to edge with the molars separated but in an Angle Class I relation.

Occlusal interference anterior shift of the mandible In CR or in a relaxed postural position normal facial

profile convexity


Characteristics

Skeletal cross-bite

In CR straight or concave profile In CR & CO Class III molar relationship and an

anterior cross-bite The mandibular closure smooth without any

occlusal interferences


Characteristics

Skeletal cross-bite

Maxillary incisors proclined Mandibular incisors retroclined ANB the maxilla is relatively retracted or the

mandible is positioned anteriorly The gonial angle obtuse (130 -140 degrees)


History

Clinical Examination

Study Models

Radiograph Lateral cephalogram

OPG

Patient with anterior skeletal cross-bite

Diagnosis

Roc Veis; 2003

Management

The simple dental cross-bite

The functional or pseudo cross-bite

The skeletal cross-bite

Should be treated early

Early treatment may not be successful

Management

Rationale for early treatment

Exaggerated gingival inflammation and recession of the investing tissues surrounding the mal-opposed teeth

Occlusal trauma Enamel abrasion or fractures of the anterior

teeth Development of abnormal chewing and

swallowing problemsMajor PW, Glover K; 1992McEvoy; 1983Payne RC; 1981Croll TP; 1984

Management

Rationale for early treatment

Abnormal growth of the maxilla and the mandible Development of a permanent class III dentofacial

abnormality TMJ dysfunction. Early correction canines and premolars into

Class I Improve the self esteem of the child

Major PW, Glover K;1992McEvoy ;1983Payne RC; 1981Croll TP; 1984Rabie AB; 2000

Management

The following steps should be included in a clinical examination

Evaluate the number of teeth involved in the cross-bite and their inclination

Examine the profile Examine the arc of closure Note the relative positions of the primary and permanent molars

in both centric occlusion and centric relation Attempt to manipulate the mandible posteriorly to obtain a more

favourable relationship with the maxilla Complete a space analysis

Roc Veis; 2003

Evaluate the number of teeth involved in the cross-bite and their inclination

- Dental cross-bite one or two teeth- Functional Class III maxillary Incisors retroclined and mandibular incisors proclined- Skeletal Class III maxillary incisors proclined and mandibular incisors retroclined

Management

Examine the profile

- Rest position with their lips together but with their teeth out of contact.- Facial profile for any signs of a skeletal mandibular prognathism.

Management

Examine the arc of closure

- Skeletal Class III smooth uninterrupted arc- Functional cross-bite anterior shift - Dental cross-bite may or may not shift forward

Management

Note the relative positions of the primary and permanent molars in both CO and CR

- Skeletal Class III mesiocclusion maintained in CR & CO- Simple dental cross-bite flush terminal plane of the molars in both CR and CO- Functional pseudo-Class III shift to a Class III relationship

Management

Attempt to manipulate the mandible posteriorly to obtain a more favourable relationship with the maxilla

- Edge to edge position or nearly so functional rather than a skeletal or dental component.

Management

Complete a space analysis

- Reducing the size of primary cuspids, extraction of the primary cuspids, and/or expansion of the arches

Management

Treatment of anterior cross-bites

The simple dental cross-bite The functional or pseudo cross-bite

Selective griding


Use of tongue blade

Denamur TJ.; 1984


Lower anterior inclined plane


Reversed SSC

Croll TP.; 1996


Nine

วิธีการที่ดั้งเดิมเป็นที่รู้จักกันดีและมีความง่ายในการแก้ไข ant. cx. bite คือการใส่ SSC กลับด้าน มีข้อดีคือไม่ต้องใส่ active appliance ที่มีความซับซ้อนมากกกว่ามีข้อเสียคือในด้านความสวยงาม และข้อจำกัดจากความยากในการ adapt preform crown และการใช้ประโยชน์จาก incline slope ซึ่งปรับไม่ได้ นอกจากนั้นอาจจะมีปัญหา crown หลุดและเด็กกลืนลงไปได้วิธีการนี้จะทำให้ฟันเคลื่อยแบบ simple tipping แต่ไม่สามารถใช้ใน case ที่มี crowding หรือ skeletal crossbite ได้ นอกจากนั้นยังทำให้ฟันซี่ตรงกันข้ามเคลื่อนที่ไปในอีกทิศทางด้วย ดังนั้นจึงไม่เหมาะสมถ้าฟันซี่ตรงข้ามมีตำแหน่งที่ดีอยู่แล้ว

Compomer / Resin-composite slope with Acetate crown

Croll & Helpin; 2002Croll TP.; 1996

Estreia et al.; 1991


Nine

จากข้อเสียของ SSC จึงเปลี่ยนมาใช้วัสดุที่มีสีเหมือนฟัน ซึ่งสามารถปรับแต่งได้ง่ายให้เหมาะสมในผู้ป่วยแต่ละคนCroll & Helpin 2002 เลือกใช้ clear acetate crown ร่วมกับ compomer เนื่องจากมี chemical bone กับ enamel และยังกรอแต่งได้ง่ายกว่า resin compositeวิธีการนี้จะต้องสร้าง OJ/OB ที่เหมาะสมจึงจะสามารถแก้ไข ant. cx. bite ได้ และเลือกสีของวัสดุให้มีความแตกต่างจากสีฟันเล็กน้อยเพื่อให้ง่ายต่อการ removeEstreia และคณะได้ทำการประเมินจากฟันที่ได้รับการรักษาด้วยวิธีการนี้จำนวน 15 ซี่ พบว่าสามารถแก้ไข cx. bite ได้ภายในเวลา 1 wk. โดยไม่มีการ damage ต่อฟันหรือ periodontium

Bonded Resin-Composite Slopes

Bayraka, Tunca 2008


Removable appliance


Fixed appliance

R.M. SKEGGS & P.J. SANDLER; 2002


The skeletal cross-bite

Growth modification Camouflage Orthognathic surgery



Growth modification

Protraction facemask ± RME


Growth modification

Chin cap appliance


Growth modification

Frankel III appliance


Camouflage

Jun Young Choi et al; 2008


Othognathic surgery

Conclusion

With proper diagnosis,

the general dentist and

the pediatric specialist

can successfully treat simple

and functional anterior cross-bites.

Thank you

Anterior Cross-bite conference on 16092010

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