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versión impresa ISSN 1678-7757
J. Appl. Oral Sci. vol.20 no.2 Bauru marzo/abr. 2012
Renato Rodrigues de AlmeidaI; Marcio Rodrigues de AlmeidaI; Paula Vanessa Pedron Oltramari-NavarroI; Ana Cláudia de Castro Ferreira ContiI; Ricardo de Lima NavarroI; Henry Victor Alves MarquesII
IDDS, MSc, PhD Full Professor, Department of Orthodontics, University of North Paraná (UNOPAR), Londrina, PR, Brazil
IIDDS, MSc student, Department of Orthodontics, University of North Paraná (UNOPAR), Londrina, PR, Brazil
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.
Key words: Orthodontics. Malocclusion. Palatal expansion technique.
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 expansion. Angle Orthod. 2003;73(5):545-9. [ Links ]
2- Baccetti T, Franchi L, Cameron CG, McNamara JA Jr. Treatment timing for rapid maxillary expansion. Angle Orthod. 2001;71(5):343-50. [ Links ]
3- Bartzela T, Jonas I. Long-term stability of unilateral posterior crossbite correction. Angle Orthod. 2007;77(2):237-43. [ Links ]
4- Bell RA, LeCompte EJ. The effects of maxillary expansion using a quad-helix appliance during the deciduous and mixed dentitions. Am J Orthod. 1981;79(2):152-61. [ Links ]
5- Berlocher WC, Mueller BH, Tinanoff N. The effect of maxillary palatal expansion on the primary dental arch circumference. Pediatr Dent. 1980;2(1):27-30. [ Links ]
6- Celenza FV. The theory and clinical management of centric positions: ll. Centric relation and centric relation occlusion. Int J Periodontics Restorative Dent. 1984;4(6):62-86. [ Links ]
7- Hannuksela A, Väänänen A. Predisposing factors for malocclusion in 7-year-old children with special reference to a topic diseases. Am J Orthod Dentofacial Orthop. 1987;92(4):299-303. [ Links ]
8- Harrison JE, Ashby D. Orthodontic treatment for posterior crossbites. Cochrane Database Syst Rev. 2001;(1):CD000979. [ Links ]
9- Järvinen S. Need for preventive and interceptive intervention for malocclusion in 3--5-year-old Finnish children. Community Dent Oral Epidemiol. 1981;9(1):1-4. [ Links ]
10- Kantomaa T. Correction of unilateral crossbite in the deciduous dentition. Eur J Orthod. 1986;8(2):80-3. [ Links ]
11- Kisling E. Occlusal interferences in the primary dentition. ASDC J Dent Child. 1981;48(3):181-91. [ Links ]
12- Kurol J, Berglund L. Longitudinal study and cost-benefit analysis of the effect of early treatment of posterior cross-bites in the primary dentition. Eur J Orthod. 1992;14(3):173-9. [ Links ]
13- Lagravere MO, Major PW, Flores-Mir C. Long-term dental arch changes after rapid maxillary expansion treatment: a systematic review. Angle Orthod. 2005;75(2):155-61. [ Links ]
14- Lindner A. Longitudinal study on the effect of early interceptive treatment in 4-year-old children with unilateral crossbite. Scand J Dent Res. 1989;97(5):432-8. [ Links ]
15- Myers DR, Barenie JT, Bell RA, Williamson EH. Condylar position in children with functional posterior crossbites: before and after crossbite correction. Pediatr Dent. 1980;2(3):190-4. [ Links ]
16- OGrady PW, McNamara JA Jr, Baccetti T, Franchi L. A long-term evaluation of the mandibular Schwarz appliance and the acrylic splint expander in early mixed dentition patients. Am J Orthod Dentofacial Orthop. 2006;130(2):202-13. [ Links ]
17- Sabri R. Treatment of a severe arch-length deficiency with anteroposterior and transverse expansion: long-term stability. Am J Orthod Dentofacial Orthop. 2010;137(3):401-11. [ Links ]
18- Silva Filho OG, Boas MCV, Capelozza Filho L. Rapid maxillary expansion in the primary and mixed dentitions: a cephalometric evaluation. Am J Orthod Dentofacial Orthop. 1991;100(2):171-9. [ Links ]
19- Silva Filho OG, Montes LAP, Torelly LF. Rapid maxillary expansion in the dentition evaluated through posteroanterior cephalometric analysis. Am J Orthod Dentofacial Orthop. 1995;107(3):268-75. [ Links ]
20- Silva Filho OG, Valladares Neto J, Rodrigues de Almeida R. Early correction of posterior crossbite: biomechanical characteristics of the appliances. J Pedod. 1989;13(3):195-221. [ Links ]
Marcio Rodrigues de Almeida
Avenida José Vicente Aiello, 170 - Tivoli
17053-093 - Bauru - SP
Phone: (14) 3226-1411
Received: April 05, 2010
Modification: May 20, 2010
Accepted: May 20, 2010