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Anterior CrossbiteEarly Diagnosis and Treatment of an

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Dr. Sawsan Tabbaa, DDS., MS is an Assis-

tant Professor, Department of Orthodontics,

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orthodontics private practice in Ballston Spa,

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University of Buffalo, NY.

Dr. C. Brian Preston, BDS, PhD is a Professor and Chairman

of the Department of Orthodontics, School of Dental Medi-

cine, State University of New York at Buffalo.

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orthodontics in Olean, NY.

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American Board of Orthodontics. and an Assis-

tant Professor in the Department of Orthodon-

tics, School of Dental Medicine, State University

of New York at Buffalo.

Dr. Wael Y. Elias, DMD is a diplomate of

the American Board of Oral and Maxillofa-

cial Pathology and the American Board of

Orthodontics. He is a faculty and Clinical

instructor in the Department of Orthodontics,

School of Dental Medicine State University of

New York at Buffalo, NY and the King Abdulaziz University,

Dental School, Jeddah, Saudi Arabia.

Abdulfatah A. Hanoun, DDS, G.Dip, M.Sc is

a visiting research scholar and post-doctoral

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of New York at Buffalo in Buffalo, NY.

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3January 2015

Introduction

Early orthodontic intervention is appropriate in pa-tients exhibiting certain occlusal problems that could continue to worsen, while also becoming more difficult

to treat, at a later stage of dental and skeletal development. If such problems are not diagnosed and treated early enough, they could hinder the normal craniofacial development of the respective child. Interceptive orthodontic treatment reduces the complexity of some malocclusions during the mixed dentition phase of dental development; however, a follow-up orthodontic treatment is usually required when the perma-nent dentition has been established.1

Examples of beneficial early interceptive orthodontic treat-ment include, but are not limited to: • Early treatment of deep bites to prevent the lower

anterior teeth from impinging on the palatal tissue and to redirect mandibular growth to achieve a nor-mal facial height;

• Early treatment of open bites to eliminate parafunc-tional habits, such as thumb sucking and tongue thrusting;2

• Early orthodontic treatment of severe crowding to provide space for the permanent teeth during eruption;3

• Elimination of Class II division I malocclusions that present with a protrusive maxilla and/or maxillary teeth. The aim here is to provide facial harmony, improve the child’s self-image, and perhaps reduce the probability of incisor fractures.

• Early management of maxillary anterior crossbites in order to establish a correct relationship between the maxilla and the mandible, achieve proper function, improve the child’s facial profile, and in some cases, eliminate the need for surgery at a later date.

Anterior Crossbite: An Overview and Case StudyAnterior crossbite is an orthodontic problem that pres-

ents with a reverse overjet of one or more of the anterior teeth. As with many orthodontic problems, the underlying etiology could be either skeletal or dental, or a combina-tion of these two factors. The precise treatment of an an-terior crossbite would thus be directed at the predominant etiologic factor.

EtiologySkeletal causes

The anterior posterior skeletal discrepancy is one of the main causes of the anterior crossbite. For example, any excessive mandibular growth may lead to a segment crossbite on the anterior incisors. In addition, the retarded development of the maxilla in the sagittal plane may also result in an anterior crossbite. For instance, the small or collapsed maxillary arch associated with cleft palate will also cause an anterior crossbite in the majority of these patients. The skeletal causes of the anterior crossbite are generally inherited. They are manifested as size or position discrepancies in the maxilla, the mandible, or both. A long mandible or anteriorly positioned glenoid fossa, short or

Early Diagnosis and Treatment of an

Anterior CrossbiteLEARNING OBJECTIVES

The overall objective of this article is to provide the partici-pant with information on the treatment of anterior crossbites. Upon completing this course, the participant will be able to:

1. Determine the circumstances under which early orthodontic intervention is appropriate.

2. Identify a case in which early orthodontic intervention was used successfully to treat an anterior crossbite.

3. Identify the outcomes of orthodontic treatment, including those that affect the patient’s quality of life.

ABSTRACT

Early orthodontic intervention can have numerous benefits for patients. Treating an anterior crossbite with early inter-vention can improve function, appearance and self-esteem. In the case report included in this article, an 8-year-old girl was treated successfully for an anterior crossbite. In this instance, an acrylic bite jumper may have saved the patient from future surgery while improving her occlusal function and social interactions.

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posteriorly positioned maxilla, and even a short anterior cranial base should be considered indicators of the skeletal nature of the anterior crossbite.4 The skeletal etiological factors can be elaborated under any of the following three categories or any combination of these: genetic/syndromic causes; maxillary deficiency; and mandibular excess.

Genetic factorsMany syndromes that affect facial development have

at least some basis in genetics. Syndromes such as cleft lip and palate, Crouzon syndrome, and Apert syndrome are associated with a degree of midface deficiency that, in many instances, results in an anterior crossbite due to the maxillary skeletal deficiency. The midface deficiency observed in these syndromic patients can be aggravated by the restriction of maxillary growth that may result from scar tissue associated with the surgical correction of the cleft lip and/or palate.5

Congenital maxillary deficiencyPrenatally, undue pressure against the developing fetal

face can lead to distortion of the rapidly growing facial areas. On rare occasions, a limb is pressed across the face in utero, resulting in a severe maxillary deficiency at birth6 and a Class III malocclusion. If the maxilla is small or positioned posteriorly, the effect is direct. If it lacks vertical growth, the effect is indirect and, due to the fact that the mandible rotates upward and forward, produces a man-dibular prognathism that is not due primarily to the size of the mandible.7

Mandibular excessMandibular prognathism can be familial, in which case

there is the belief that the etiology in these instances can be of a hereditary nature. In rare occasions, endocrinal distur-bance such as an increase in circulating growth hormone may result in acromegaly, which is characterized by an abnormally large mandible.8

Dental causesThe most common etiologic factor for non-skeletal

anterior crossbites is a lack of space for the permanent incisors.9 The early loss of maxillary deciduous teeth, impacted or lost permanent posterior teeth, or impacted canines would allow the maxillary anterior teeth to drift distally and palatally. In most children with an-terior crossbites involving multiple teeth, a skeletal discrepancy should be considered. A labially positioned supernumerary tooth, over-retained deciduous tooth with delayed exfoliation, trauma to the deciduous teeth or permanent tooth bud, or even a lip biting habit may lead to an abnormal axial inclination of upper incisors, which is another cause of dental anterior crossbites. In addition, the premature tooth contact during mandibu-lar closure may lead to a pseudo-Class III, another cause of dental anterior crossbites.10

DiagnosisIn order to determine the main cause of an anterior cross-

bite, it is important to differentiate between skeletal and den-tal problems. In this regard, midface deficiency or mandibular overgrowth will result in a Class III tendency, which is usually manifested in the sagittal plane. A prominent feature of the Class III facial pattern is an anterior crossbite dental relation-ship. A single tooth in an anterior crossbite is usually associ-ated with some degree of dental crowding.11 This generally results from a dental etiological factor. On the other hand, a segment crossbite (which involves several teeth rather than a single tooth) is more likely to result from a skeletal etiological factor, which can be confirmed by radiographs such as lateral cephalograms. Moreover, if an anterior crossbite is associated with a bilateral posterior crossbite, the skeletal factor should be considered where the retro-positioned or small maxilla relative to the mandible could be the main etiological cause. However, a radiographic confirmation is always required.

A lateral cephalometric X-ray offers an important diagnostic tool, particularly if it is suspected that a skeletal imbalance may be responsible for an anterior crossbite and an incipient Class III malocclusion. The Steiner and the McNamara analyses provide two different cephalometric

Early Diagnosis and Treatment of Anterior Crossbite

5January 2015

methods for measuring the severity of skeletal jaw imbal-ances in the sagittal plane.12,13 Whenever the cephalometric analysis shows radiographic evidence of moderate to se-vere skeletal anterior-posterior discrepancy associated with an anterior crossbite, the skeletal cause should be taken into consideration.

The location of the tooth having crossbite can be used as a diagnostic indicator of skeletal or dental etiology of the anterior crossbite. In the skeletal crossbite, the teeth are often normally positioned on the basic bone of the jaw. On the other hand, a deflection of a tooth from the

normal position is most likely to be associated with the dental crossbite.10 In addition, the closure pathway should be examined for any premature contact, which could be the cause of an anterior dental crossbite associated with a pseudo Class III relationship. As an example, the prema-ture incisor contact during closure may result in the devel-opment of anterior mandibular displacement manifested as a dental anterior crossbite.

At the same time, dental study models provide an im-portant tool when it comes to diagnosing dental problems, such as crowding and lack of space due to tooth size arch

Skeletal Anterior Crossbite Dental Anterior Crossbite

Etiology/cause Genetic and hereditary in most cases

(familial)

Maxilla and mandible size discrepancy

(long mandible and/or short maxilla)

Lack of space, TSALD

No maxilla and mandible size

discrepancy

Anterior crossbite prevalence Retrognathic maxilla: 25%

Prognathic mandible: 20%

Combination of both: 22%

Dental cause only 33%

Differential diagnosis Skeletal Anterior Crossbite Dental anterior crossbite

a- Molar and canine relationship Class III Class I

b- Maxillary incisor inclination Proclined Upright or retroclined

c- Transverse discrepancy Coule be associated with posterior

crossbite in some cases.

None

d- Sagittal discrepancy Significant AP discrepancy between the

maxilla and mandible

No significant discrepancy between the

maxilla and mandible

e- Mandibular growth pattern Often vertical (except in cases of true

mandibular prognathism)

Normal

f- Position of teeth Normally positioned Deflected tooth position

g- Number of teeth in the crossbite Segment crossbite Mainly a single-tooth crossbite

TABLE 1. Skeletal And Dental Anterior Crossbite Indicators

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length discrepancy (TSALD) that may result in an anterior dental crossbite. The study models allow clinicians to mea-sure and compare the relationship that exists between the combined sizes of the teeth and the amount of space that is available to accommodate them. In the past, measurements were made directly on plaster study models. Nowadays, digital models, in combination with specific software, make it possible to determine tooth and arch sizes with greater ease.14,15

Table 1 provides a synopsis of the major characteristics of skeletal and dental anterior crossbites.

Treatment optionsTreatment options depend on the specific etiology of

the condition and, to a great degree, on the skeletal and dental age of the patient.Treatment of a skeletal anterior crossbite (Class III malocclusion)

For growing children with an antero-posterior (sagit-tal) and/or vertical maxillary deficiency, the treatment of choice is maxillary traction with a reverse-pull headgear (face mask) to move the maxilla anteriorly and, in some cases, slightly inferiorly. This traction allows new bone to be added at the posterior and superior circum-maxillary sutures, which effectively increases the size of the maxilla. While it is easier and more effective to move the maxilla forward at a young chronologic age (about eight years), recent reports indicate that some positive sagittal changes can be produced up to the beginning of adolescence.16,17

Growing children who have a Class III malocclusion because of a mandibular excess are more difficult (some-times impossible) to treat without some surgical interven-tion. In these instances the treatment of choice may be mandibular restraining devices such as a chin cup, de-signed to inhibit the growth of the mandible.18,19

Functional appliances may also be used in an effort to promote maxillary development and to limit, if possible, mandibular prognathism. A good example of such a functional appliance is represented by the Frankel-III

appliance, made with the mandible positioned posteriorly and rotated open and with pads designed to stretch the upper lip forward.20

For adult and adolescent patients who have finished their growth, orthopedic treatment options such as growth modification are difficult if not impossible. For these pa-tients, the alternatives are either a camouflage treatment or a surgical correction of the mandibular prognathism. Camouflage treatment involves extracting lower first premolars, followed by retracting the mandibular incisor teeth. Although this method may correct an anterior cross-bite in mild cases, it is not advised as a treatment modality in more severe cases of mandibular protru sion. In moder-ate to severe cases of mandibular prognathism, the treat-ment option of choice is surgical correction by mandibular setback, on its own or in combination with a maxillary advancement procedure.21,22

Treatment of a dental anterior crossbiteAs noted earlier, the most common etiologic factor for

a non-skeletal (dental) anterior crossbite is a lack of space for the permanent incisors. It is thus important in these cases to manage the space problem while attempting to correct the anterior crossbite.

If the developing crossbite is discovered prior to completion of the incisor eruption and before an overbite has been established, the adjacent primary teeth can be extracted to provide the necessary space for the permanent incisors. In instances where the overbite has been estab-lished, an appliance may be required to correct the developing crossbite.

Tipping maxillary and mandibular anterior teeth out of a crossbite can solve the crossbite problem in most instanc-es. This can be done by using a removable appliance with finger-springs for facial movement of the maxillary incisors or, in some cases, an active labial bow for lingual move-ment of the mandibular incisors.

It is important to create enough space for the teeth before moving them lingually in case of tipping lower incisors.23,24

Early Diagnosis and Treatment of Anterior Crossbite

7January 2015

Case StudyThis case study focuses on an 8-year-old girl who

presented with a relatively severe anterior crossbite. An anterior crossbite is a good example of a malocclusion that usually requires early intervention.

Although there is considerable debate as to whether a Class III malocclusion will benefit from early treat-ment, it is generally well accepted that it is important to treat this type of malocclusion as soon as it mani-fests. It is believed that the early diagnosis and timely correction of an anterior crossbite may prevent the oc-currence of functional shifts of the mandible, abnormal wear of the permanent teeth, and temporomandibular joint problems. More importantly, timely treatment of the problem could reduce the need for orthogna-thic surgery in adulthood. It should be noted that early treatment may not eliminate the need for further orthodontic treatment at a later stage, but it is likely to

lessen the severity of the eventual malocclusion.25,26 The bite jumper treatment described in this case study is most useful for correcting an anterior crossbite that has a dental etiology versus a skeletal one. It also would be more appropriate if the patient presented with a low-to-normal mandibular plane angle.

HistoryMedical: The patient presented as a healthy 8-year-old

female (Figure 1).Dental: The oral hygiene of the patient was considered

to be adequate and there was no history of craniofacial trauma.

Etiology: The patient and her guardian did not provide a family history of Class III malocclusion. This patient’s malocclusion could be attributed to an altered eruption pattern of the permanent incisor teeth, possibly resulting from dental crowding.

Figure 1. Pre-treatment extraoral and intraoral photographs.

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DiagnosisSkeletal:• The Patient exhibited a Class III tendency because of

a relative underdevelopment of her maxilla. Her Sella, Nasion to point “A” (SNA) value was 77.3° (normal value, 82.0° + 3.5°).

• The patient’s vertical facial development was normal, with a tendency toward a slightly skeletal deep bite pattern; she had a low mandibular plane angle (SN-GoGn) value of 24.9° compared with the normal value of 32.9° + 5.2°. (Figure 2)

Dental: • The bilateral molar relationships were Angle Class I.• There was an anterior crossbite that included the central

and lateral teeth (Figure 1).• The maxillary incisors were retroclined (94.9°) when

compared with the normal upper incisors to an SNA value of 102.1° + 5.5°.

Soft Tissue:• The patient’s soft-tissue profile was slightly concave

because of a retruded upper lip; her nasiolabial angle was 136.7° compared with the normal value of 102.0° + 8.0°.

Treatment Objectives• To maintain an Angle Class I molar relationship.• To eliminate the anterior crossbite, properly align the

anterior teeth, and obtain a positive overbite and posi-tive overjet.

• To retain all of the permanent teeth during the initial phase of orthodontic treatment, anticipating that a more definitive phase of treatment could be required at a later stage of development.

TreatmentIt was decided that the best course of treatment would be

to begin with a phase of dental leveling followed by hav-ing the patient wear an acrylic bite jumper appliance. Serial extraction and protraction facemask treatment were alterna-tive treatments that were considered but ruled out. When the patient presented for treatment, the need for four premolar extractions could not be determined with any certainty. At that time, the negative consequences of extracting in a defi-cient maxillary arch was considered. Given the absence of a family history of Class III malocclusion, the relatively minor skeletal maxillary deficiency, the angulations of the maxil-lary and mandibular incisors, and the Class I molar occlu-sion, facemask therapy was not used during the first phase of orthodontic treatment. However, the use of a facemask in the future will depend on the age and the further facial and skeletal development of the patient.

Figure 2. Initial lateral cephalometric X-ray, traced and measured.

Figure 3. The bite-jumper appliance. This removable appliance consists of an acrylic slope covering the anterior teeth, with a wire framework following the lingual contours of the teeth for retention.

Early Diagnosis and Treatment of Anterior Crossbite

9January 2015

Banding and Bite Jumper ApplianceThe patient’s maxillary first permanent molars were

banded and the maxillary incisors were bonded with 0.018-inch Unitek’s Victory Series (3M ESPE) brackets. A 0.016-inch nickel titanium arch wire was used to level and align the maxillary anterior teeth. Following the phase of dental leveling, the patient wore an acrylic bite jumper appliance for four months (Figure 3). The appliance was removable; however, the patient was instructed to wear the appliance full time, except for cleaning purposes. The patient was seen every four to six weeks while wearing the bite jumper. Some adjustments were made to the bite plate to reduce the bulk of the appliance; however, the slope of the bite plane was maintained throughout treatment. No retention was needed in the maxillary jaw once the proper overjet was obtained.

Treatment Outcome• The Class I molar relationship was preserved.

• A positive incisor overjet was obtained. (Figure 4)• The soft-tissue profile was greatly improved (Figure 5).

The patient’s profile changed from concave with a retrusive maxilla to normal and straight (Figure 6).

DiscussionCephalometric evaluation of the patient before and

after appliance therapy revealed an improvement in the maxilla from deficient to normal. After treatment, the SNA value increased from 77.3° to 81.1°, which was close to the accepted normal value of 82.0° +3.5°. After the early phase of orthodontic treatment, the maxillary incisors were somewhat proclined. The mandibular incisors were uprighted and the mandibular plane angle was maintained. There was great improvement in the soft-tissue profile (Figure 6 & 7).

The patient’s mother reported an improvement in her daughter’s social interactions and eating patterns. After the elimination of the crossbite, the child became

Figure 4. Post-treatment extraoral and intraoral photographs.

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“proud of her smile.” Her eating habits improved be-cause of the improved ability to bite and chew—and the patient’s weight improved as a result of her better eating habits.

ConclusionAlthough the results for Phase I treatment were accept-

able in terms of obtaining a positive overjet, it must be noted that follow-up and facemask treatments may be nec-essary in the future if the patient’s skeletal growth exhibits a prominent Class III tendency.

If this child had not been diagnosed and treated early, her maxilla would have continued to be trapped behind her mandible, resulting in permanent maxillary deficiency and contributing to an unattractive concave profile. Surgery is usually the ideal treatment for adults exhibit-ing a concave profile because of maxilla deficiency. Early

intervention to eliminate the anterior crossbite saved this patient from having invasive surgery if she ever seeks treatment in adulthood.

AcknowledgmentsWe would like to thank the patient and her family for

their compliance and cooperation. The patient’s mother stated: “I would like to thank you for your concern and for encouraging my daughter to receive early orthodontic treatment. Early diagnosis may have saved my daughter from future surgery. Her new smile is not just an esthetic advantage; it has truly improved her chewing function. My daughter enjoys her meals now and is able to drink from a cup without a straw and do simple things like biting into an apple. I hope dentists use this case study to help other children and to understand the importance of early diagnosis and prevention.”

Figure 5. A comparison of pre, progress and post treatment extra and intra oral photographs.

Early Diagnosis and Treatment of Anterior Crossbite

11January 2015

References1. King GJ, Brudvik P. Effectiveness of interceptive orthodontic treat-

ment in reducing malocclusions. Am J Orthod Dentofacial Orthop. 2010;137:18-25.

2. English JD. Early treatment of skeletal openbite malocclusions. Am J Orthod Dentofacial Orthop. 2010;121:563-565.

3. Gianelly AA. Treatment of crowding in the mixed dentition. Am J Orthod Dentofacial Orthop. 2002;121:569-571.

4. Millett D, Welbury R. Clinical problem solving in orthodontics and pediatric dentistry, ELSEVIER Churchill Livingstone. 2005:40.

5. Powers D. Jimson weed intoxication in adolescents. Virginia Medical Monthly. 1976;102(12):1051-1053.

6. Poswillo D. The aetiology and pathogenesis of craniofacial deformity. Development. 1988;103:207-212.

7. Sarver DM, Johnston MW. Skeletal changes in vertical and anterior displacement of the maxilla with bonded rapid palatal expansion ap-pliances. AJO-DO. 1989;95(6):462-466.

8. Melmed S, et al. Guidelines for acromegaly management. J Clin Endo-crin Metab. 2002;87(9):4054-4058.

9. Ngan P, Hu AM, Fields, Jr. HW. Treatment of Class III problems begins with differential diagnosis of anterior crossbites. Pediatr Dentistry. 1997;19(6):386-395.

10. Premkumar S. Orthodontics. ELSEVIER, New Delhi. 2008:495-496.11. Abu Alhaija ES, Al-Khateeb SN. Skeletal, dental and soft tissue

changes in Class III patients treated with fixed appliances and lower premolar extractions. Australian Orthodontic Journal. 2011;27(1):40-45.

12. Kantor ML, Norton LA. Normal radiographic anatomy and common anomalies seen in cephalometric films. AJO-DO. 1987;91(5):414-426.

13. Popovich F, Thompson GW. Craniofacial templates for orthodontic case analysis. Amer J Orthodont. 1977;71(4):406-420.

14. Poosti M, Jalali T. Tooth size and arch dimension in uncrowded versus crowded Class I malocclusions. J Contemp Dental Practice. 2007;8(3):45-52.

15. Leifert MF, et al. Comparison of space analysis evaluations with digital models and plaster dental casts. AJO-DO. 2009;136(1):16 e1-4; discus-sion 16.

16. Merwin D, et al. Timing for effective application of anteriorly directed orthopedic force to the maxilla. AJO-DO. 1997;112(3):292-299.

17. Franchi L, Baccetti T, McNamara JA. Postpubertal assessment of treat-ment timing for maxillary expansion and protraction therapy followed by fixed appliances. AJO-DO. 2004;126(5):555-568.

18. Sakamoto T, et al. A roentgenocephalometric study of skeletal changes during and after chin cup treatment. American Journal of Orthodontics. 1984;85(4):341-350.

19. Sugawara J, et al. Long-term effects of chincap therapy on skeletal profile in mandibular prognathism. AJO-DO. 1990;98(2):127-133.

20. Ulgen M, Firatli S. The effects of the Frankel’s function regulator on the Class III malocclusion. AJO-DO. 1994;105(6):561-567.

21. Trauner R, Obwegeser H. The surgical correction of mandibular prog-nathism and retrognathia with consideration of genioplasty. I. Surgical procedures to correct mandibular prognathism and reshaping of the chin. Oral Surgery, Oral Medicine, and Oral Pathology. 1957;10(7):677-689.

22. Bell WH. Le Forte I osteotomy for correction of maxillary deformities. J Oral Surgery. 1975;33(6):412-426.

23. Borrie F, Bearn D. Early correction of anterior crossbites: a systematic review. J Orthodont. 2011;38(3):175-184.

24. Negi KS, Sharma K.R. Treatment of pseudo Class III malocclusion by modified Hawleys appliance with inverted labial bow. Journal of the Indian Society of Pedodontics and Preventive Dentistry, 2011;29(1):57-61.

25. Proffit WR, Fields Jr. HW, Sarver DM. Contemp Orthodontics, 4th ed. St. Louis, MO: Mosby; 2007:431-443.

26. Graber TM, Vanarsdall Jr. RL, Vig KWL. Orthodontics: Current Prin-ciples and Techniques. St. Louis, MO: Mosby; 2005:543-545.

Webliography1. King GJ, Brudvik P. Effectiveness of interceptive orthodontic treat-

ment in reducing malocclusions. Am J Orthod Dentofacial Orthop. 2010;137:18-25.

Figure 6. Comparison of pre-treatment and post-treatment profiles.

Figure 7. Final lateral cephalometric x-ray, traced and measured.

12

1. Interceptive orthodontic treatment reduces the complexity of some malocclusions during the __________ dentition phase of dental development.

a. primary b. mixedc. secondaryd. all of the above

2. Early treatment of deep bites is performed to __________.a. prevent the lower anterior teeth from impinging on the palatal

tissueb. redirect mandibular growth to achieve a normal facial heightc. save moneyd. a and b

3. Early treatment of open bites is performed to __________.a. redirect maxillary growth to achieve a normal facial heightb. eliminate parafunctional habitsc. save timed. a and b

4. The elimination of a Class II division I malocclusion that presents with a protrusive maxilla and/or maxillary teeth is aimed at __________.

a. providing facial harmonyb. improving the child’s self-imagec. possibly reducing the probability of incisor fracturesd. all of the above

5. Early orthodontic treatment of severe crowding is performed to __________.

a. create the correct overjetb. create the correct overbitec. provide space for the permanent teeth during eruptiond. all of the above

6. An anterior crossbite exists if __________ present(s) with a reverse overjet.

a. only one tooth b. only if more than one toothc. if one or more teethd. if at least three teeth

7. The anterior posterior skeletal discrepancy is __________ cause of the anterior crossbite.

a. an infrequentb. a mainc. the onlyd. none of the above

8. The skeletal cause of the anterior crossbite is __________.a. manifested as size discrepancies in the maxilla/mandible/

bothb. manifested as position discrepancies in the maxilla/mandible/

bothc. generally inheritedd. all of the above

9. __________ should be considered indicators of the skeletal nature of the anterior crossbite.

a. An anteriorly positioned glenoid fossab. A short anterior cranial basec. A short or posteriorly positioned maxillad. all of the above

10. A long mandible is always an indication of a __________ malocclusion. a. severe Class III b. severe Class II div 1 c. severe Class II div 2 d. none of the above

11. __________ is associated with a degree of midface deficiency that can result in an anterior crossbite. a. Cleft lip and palateb. Apert syndromec. Crouzon syndromed. all of the above

12. In a cleft lip and palate patient, midface deficiency can be aggravated by the restriction of maxillary growth that may result from __________. a. thumb sucking b. mouth breathingc. scar tissued. all of the above

13. A severe maxillary deficiency at birth can result, on rare occasions, from __________ pressing across the face in utero. a. a digit b. a limb c. the mother’s bladderd. all of the above

14. Mandibular prognathism is __________ due primarily to the size of the mandible. a. always b. neverc. not alwaysd. none of the above

15. A chin cup is designed to __________.a. push the mandible forwardb. inhibit growth of the mandiblec. push the maxilla forwardd. all of the above

16. __________ may lead to an abnormal axial inclination of upper incisors. a. A labially positioned supernumerary toothb. An over-retained deciduous tooth with delayed

exfoliationc. Trauma to the deciduous teeth or permanent tooth budd. all of the above

CEQuizEarly Diagnosis and Treatment of Anterior Crossbite

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13January 2015

Early Diagnosis and Treatment of Anterior Crossbite

CE ANSWER FORM

17. A pseudo-Class III can result from __________ tooth contact during mandibular closure.a. delayedb. prematurec. lack of d. any of the above

18. A segment crossbite is likely to result from __________.a. a dental etiological factorb. a skeletal etiological factorc. thumb suckingd. none of the above

19. The Steiner and the McNamara analyses provide two different cephalometric methods for measuring the severity of __________ imbalances.a. dental elementb. skeletal jawc. functionald. all of the above

20. The early loss of maxillary deciduous teeth, impacted or lost permanent posterior teeth, or impacted canines allows the maxillary anterior teeth to __________. a. erupt all at the same timeb. drift mesially and buccallyc. drift distally and palatallyd. all of the above

21. For growing children with an antero-posterior (sagittal) and/or vertical maxillary deficiency, the treatment of choice is __________ to move the maxilla anteriorly and, in some cases, slightly inferiorly.a. a Herbst applianceb. maxillary traction with a reverse-pull headgear (face mask)c. a rapid maxillary expanderd. all of the above

22. Early management of maxillary anterior crossbites is per-formed in order to establish a correct relationship between the maxilla and the mandible, as well as to __________. a. improve the child’s facial profileb. achieve proper functionc. in some cases, eliminate the need for surgery at a

later dated. all of the above

23. The Frankel-III appliance __________.a. is made with the mandible positioned posteriorly and

rotated openb. is made with the mandible positioned posteriorly and

rotated openc. has pads designed to stretch the upper lip forwardd. all of the above

24. There is __________ debate as to whether a Class III malocclusion will benefit from early treatment.a. nob. somec. considerable d. none of the above

25. If a developing dental crossbite is discovered prior to completion of the incisor eruption and before an overbite has been established, the adjacent primary teeth can be __________ to provide the necessary space for the permanent incisors.a. treated orthodonticallyb. reduced interproximally using a standard IPR techniquec. extractedd. none of the above

26. Tipping maxillary and mandibular anterior teeth out of a crossbite can be done by using __________ .a. a removable appliance with finger-springs for facial movement

of the maxillary incisorsb. an active labial bow for lingual movement of the mandibular

incisorsc. a chin cupd. a or b

27. In some patients whose crossbite has been treated, follow-up and facemask treatments may be necessary in the future if the patient’s __________.a. skeletal growth exhibits a prominent Class III tendencyb. thumb sucking habit continuesc. maxilla develops only unilaterallyd. a or b

28. A deflection of a tooth from the normal position is most likely to be associated with the __________ crossbite.a. skeletalb. dentalc. bilaterald. all of the above

29. Surgery is usually the ideal treatment for adults exhibiting a __________ profile because of maxilla deficiency. a. concaveb. convexc. flat d. all of the above

30. It is easier and more effective to move the maxilla forward __________.a. in adolescenceb. at a young chronologic agec. in adulthoodd. a and c

14

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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

QUIZ ANSWERSFill in the circle of the appropriate answer that corresponds to the question on previous pages.

EDUCATIONAL OBJECTIVES1. Determine the circumstances under which early orthodontic intervention is

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