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http://dx.doi.org/10.20396/bjos.v18i0.8657251
Volume 18
2019
e191502
Original Article
1 Universidade Estadual do Piauí
– UESPI, School of Dentistry,
Department of Clinical Dentistry,
Area of Integrated Clinic, Parnaíba,
PI, Brazil
Corresponding author:
Ana de Lourdes Sá de Lira
Universidade Estadual do Piauí,
Faculdade de Odontologia
Rua Senador Joaquim Pires 2076
Ininga.
Fone (86) 999595004
CEP: 64049-590 Teresina-PI-Brasil
email: anadelourdessl@hotmail.com
Received: January 17, 2019
Accepted: May 25, 2019
Anterior crossbite
malocclusion: prevalence
and treatment with
axed inclined plane
orthodontic appliance
Ana De Lourdes Sá De Lira1,*, Guilherme Henrique
Alves Da Fonseca1
Aim: To evaluate the prevalence of anterior crossbite and to
verify the effectiveness of the orthodontic appliance Inclined
Plane in the correction of this malocclusion. Methods: The
clinical examination was performed 702 children in the
deciduous or mixed dentition of 7 schools and in those
found the anterior crossbite was performed treatment with
xed Inclined Plane. Results: The prevalence of the anterior
crossbite was 2.14%, characterizing 15 of the 702 children
evaluated, of which 60% were female and 40% male, all of
which were dental crossbites. Only 12 accepted the treatment
with an average duration of 4.4 weeks. Conclusion: The
prevalence of anterior crossbite was 2.14%. The inclined plane
proved to be a viable and effective therapy in the correction of
anterior crossbite. It is one of the options of the orthodontic
treatment in patients in the deciduous or mixed dentition,
propitiating greater possibility of dentoskeletal development,
since the malocclusion is corrected. However this method
needs to be correctly indicated and its execution technique
rigorously followed.
Keywords: Orthodontics. Dentistry. Pediatric dentistry.
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Lira et al.
Introduction
Anterior crossbites are malocclusions observed relatively frequently during the period
of deciduous dentition and onset of mixed dentition, with a prevalence of around
7.6% of children1,2. It stands out due to its functional and aesthetic alterations, being
dened as an abnormal lingual vestibular relation of one or more teeth of the maxilla
in relation to the mandible, the two arches being in occlusion, with the anterior supe-
rior teeth occluding by lingual in relation to the inferior3.
In functional anterior crossbite, or pseudoclasse III, a protrusion of the mandible occurs
during occlusion that can be attributed to inclinations of the upper incisors for palatine
and vestibularization of the mandibular incisors, forcing an anterior positioning of the
mandible. It can be caused by hypertrophy of the tonsils and or adenoids, digital sucking
habits, paciers or even the upper lip. It can also be caused by an interference in the
trajectory of the mandibular closure, where premature contacts during centric occlusion
lead the child to adopt a deviant mandibular posture by accommodation4,5.
In the case of anterior crossbite is observed the involvement of a single tooth or set
of teeth, with the upper incisors inclined to the palate and / or the lower incisors to the
vestibular, maintaining a good positioning of the apical bases in relation to the base
of the cranium6.
The skeletal anterior crossbite is characterized by mandibular protrusion, maxillary
retrusion or the combination of both. It can be derived from the genetic inheritance
of the individual, or due to an endocrine disorder, such as, for example, acromegaly7,8.
Early treatment of dental, functional or skeletal crossbite ensures that craniofacial
development and occlusion occur normally, as obstacles are removed during the
active phase of growth9,10.
Class III malocclusion is of a relevant aesthetic and functional impairment. It is believed
that early diagnosis, during deciduous or mixed dentition, and orthodontic intervention
with one of the innumerable interceptive orthodontic appliances, specically the inclined
plane, will enable the harmonic growth of the jaws, even in skeletal Class III of functional
or environmental origin, once the dental interference has been corrected.
It is justied to perform this clinical research to prove that it is feasible to intercept
the evolution of Class III malocclusion, be it functional, dental or skeletal, if the ortho-
dontic intervention with specic devices, especially the inclined plane, is performed in
deciduous dentitions or mixed, prior to the maxillary growth spurt.
In view of the functional and aesthetic problems that the anterior crossbite can gener-
ate to the patient, the objective of this study was to evaluate the prevalence of anterior
crossbite and to verify the ecacy of the Inclined Plan orthodontic appliance in the
correction of this malocclusion.
Material and Methods
This study was approved by the Research Ethics Committee of the State Univer-
sity of Piauí - CEP / UESPI, under number 2.199.979, being of the transverse type,
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Lira et al.
non-random clinical intervention. It was a cross-sectional, quantitative, intervention
study. The sample calculation was based on the target population: children between 3
and 5 years or between 6 and 8 years old, specically in the school phase, of the city
of Parnaíba in 2017, totalizing 5.087 students.
The estimated sample size was 702 children, who were selected, according to the
inclusion criteria, as the population representative of the municipality of Parnaíba-PI.
The seventeen schools of the municipal network of the city of Parnaíba-PI were cho-
sen by lot to obtain the sample. This minimum number of participants is considered
sucient considering the proposed analyzes, the sampling error of 5%, and a 95%
condence level, indicating that the probability of the mistake made by the survey
does not exceed 5%11.
Inclusion criteria were children in the complete deciduous dentition (between 3 and
5 years of age) and those in the initial phase of the mixed dentition, with one to eight
permanent incisors (between 6 and 8 years of age) of both genders, with anterior
crossbite, without posterior crossbite. Children above this age range (even with only
previous crossbite) and children presenting with posterior crossbite or other type
of malocclusion associated with anterior crossbite were excluded from this study
because orthodontic intervention in these cases is more complex and should be
orthopedic and orthodontic, without indication of Fixed Inclined Plane (FIP), device to
be used in the research.
The researchers were trained in the Clinical School of Dentistry (CEO) of the State
University of Piauí by means of calibration exercises with 10 children not participating
in the sample plan, who received dental care at the CEO during their routine operation.
The training consisted of identifying the crossbite anterior by means of midline eval-
uation and clinical examination of the occlusion, observing if the upper incisors were
occluding behind the lower incisors and this analysis according to the methodology
described by Peres et al.11.
First, a supercial clinical examination of the children’s occlusion was performed,
observing whether the upper incisors were occluding behind the lower incisors, char-
acterizing the anterior crossbite. In children in whom this situation was present, a
thorough examination was performed to classify the crossbite into functional, dental
or skeletal.
The midline evaluation was performed because possible functional deviations could
occur during complete dental occlusion. For the diagnosis of functional cross-bite
in maximal habitual intercuspation (MIH), the patient presents a Class III dental rela-
tionship with anterior crossbite, while in the centric relation (CR), a Class I interarcos
relationship (normoclusion) , with top relationship between the upper and lower inci-
sors. The inclination of the upper incisors to the lingual and / or lower incisors to the
vestibular are the main factors responsible for the occlusal interference that lead the
patient to occlude with the mandible designed for anterior12.
In cases of dental anterior crossbite, a localized inclination of one or more teeth is
observed at the level of the alveolar process, without affecting the size or shape of the
bone bases. The teeth are not centralized in the alveolar process and the most import-
ant diagnostic factor is an asymmetry of the dentoalveolar arch. In cases of skeletal
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Lira et al.
crossbite, the concave prole is observed, deciency of the maxilla associated or not
to the excessive jaw in relation to the skull and anterior crossbite.
For the three types of anterior crossbite mentioned, the FIP was implanted because
it would correct the dental relationships in the anteroposterior direction, favoring the
normal development of the bone bases down and forward.
After a conversation with the parents and the explanation about the treatment alter-
natives, the reasons for choosing the FIP, which were due to the patient’s age and the
patient’s cooperation diculty, fast result and low cost.
The pilot study involving 10 children participating in the sample had the objective
of testing the proposed methodology. As a result, its viability was observed without
adjustments. To measure intra- and inter-examiner diagnostic reproducibility, 10% of
the total sample was double checked by each of the examiners, with the Kappa coe-
cient for intra- and inter-examiner agreement of 0.98 and 0.99, respectively.
The children who presented the malocclusion were referred to the orthodontics
department of the Clinical School of Dentistry (CEO) of the State University of Piauí
(UESPI) for their correct treatment. From each patient, two periapical radiographs
were taken from the upper and lower incisors, respectively, to visualize the germs
of the permanent successors and to verify if there was any extra tooth included in
the region of the incisors (mesiodentes) and if present, it would be extracted prior to
placement the appliance.
For the confection of the appliance, a pair of working models was obtained for each
patient. The lower model was isolated with thin layer of wax utility and then applied
a layer of self-curing acrylic resin on the middle and incisal thirds, buccal and lingual
side of canine to lower canine at a 45 ° angle, without making contact with the gingival
tissue to prevent inammation (Figure 1). Subsequently, the nishing and polishing of
the appliance was performed12.
For each tooth to be uncrossed, two teeth were used as support in the lower arch. For
the installation the “say-show-do” conditioning technique was used, obtaining, in this
way, patient acceptance and collaboration. Then, the adjustment of the apparatus
was carried out and soon after cementation with glass ionomer, due to its advantages
Figure 1. Appliance used in the research.
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Lira et al.
such as uoride release, good adhesion, biological compatibility, low volumetric and
thermal coecient of change, low solubility in the mouth. During the cementation, rel-
ative insulation and suction system were performed, essential for an effective cemen-
tation of the FIP12,13.
The children returned to the clinic for control examination on a weekly basis. If it were
observed that the bite had not yet been uncrossed, wear on the vestibular of the appa-
ratus could be accomplished by maintaining the 45 degree angulation so that only the
tooth (s) to be uncrossed touched the acrylic. Removal of the tooth would occur after
the uncrossing and the realignment of the teeth, using as a criterion the obtainment
of 2mm of overjet13.
The SPSS statistical package, version 23, was used to calculate proportion and per-
centage measures to characterize the prevalence. The degree of association between
the prevalence between genders was determined using the chi-square test and the
comparison between groups with Mann-Whitney Test and Kruskal-Wallis Test, con-
sidering a signicance level of 5%.
Results
The prevalence of anterior dental crossbite was 2.14%, characterizing 15 of the
702 children evaluated, with mean and standard deviation of age of 5.3 years ± 2.2,
which 60.11% were female (n= 422) and 39.89% male (n=280) with mean and
standard deviation of age of 5.5 years ± 2.3 for female and 5.1 years ± 2 for male
respectively. Table 1 shows data on treated children. With the result of the statis-
tical calculation χ² (chi-square), χ² (1) = 0.601, p = 0.44, it was verified that there
was no difference of statistically significant association between the genders of
the participants.
Table 1. Data of children who placed the plane inclined device
Case Gender Age Crossed incisors Treatment time
(weeks)
1 Male 5 anos 51, 52, 61, 62 4
2 Male 8 anos 11, 21 4
3 Female 5 anos 51, 52, 61, 62 3
4 Male 7 anos 11, 21 5
5 Female 8 anos 11, 21 5
6 Female 5 anos 51, 52, 61, 62 4
7 Female 8 anos 11 6
8 Male 4 anos 51, 52, 61, 62 4
9 Female 4 anos 51, 52, 61, 62 4
10 Female 8 anos 11, 21 5
11 Female 8 anos 11 6
12 Male 4 anos 51, 52, 61, 62 4
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Lira et al.
Among the 12 children who were treated, there were no differences between genders,
chi-square, χ² (1) = 0.331, p = 0.56, considering a signicance level of 5% with mean
age of 5.6 years for male gender and of 5.8 year for female gender . As for the treat-
ment time, the chi-square test was also performed, and it was veried that no statisti-
cally signicant differences were also found (χ² (chi-square), χ² (1) = 0.601, p = 0.44),
even estimating that 50% of the cases were treated in 4 weeks, 33.3% in 5 weeks, 8.3%
in 6 weeks and 8.3% also in 3 weeks. A non-parametric Mann-Whitney Test was per-
formed, which found that there was no statistically signicant difference between the
genders and the treatment time (U=15, p = 0.65). The Kruskal-Wallis non-parametric
test showed statistically signicant differences between the three groups of crossed
teeth (p = 0.02), suggesting that the group with 1 crossed tooth was the one that took
the most time to correct (9.5 weeks), followed by 2 teeth (8.8 weeks) and 4 teeth
(3.9 weeks) respectively (Table 2).
Discussion
In this cross-sectional study, a prevalence of lower anterior crossbite of 2.14% was
observed. This data corroborates those found in the studies of Morais et al.1 (2014)
and Fernandes et al.13 (2007), whose prevalence was 2.2% and 3.10% respectively.
The prevalence of anterior crossbite has been shown to be lower than that of pos-
terior crossbite13-15. This fact is understandable by the complex etiological factor of
the previous crossed bites that according to Lee15 (1978) is the result of traumatic
injuries, bone sclerosis or brous tissue barrier, inadequate bow length and upper lip
interposition habits.
When analyzing the gender in this study there was a higher prevalence for the female
gender (60%). This nding distances itself from that found by Woitchunas et al.14
(2001), which presented a tendency for males (56%).
Regarding the treatment of this malocclusion, Dias et al.16 (2018) armed that the
performance of the pediatric dentist in the early diagnosis constitutes a clinical instru-
ment of relevance because it allows the interceptive treatment, besides minimizing
future damages to the patients.
Table 2. Variables studied in the 12 treated children
Variables Test Valor p valor Signicance
Difference between
the genders chi-square test χ² (1) = 0.33 0.56 n.s
Treatment time chi-square test χ² (1) = 0.60 0.44 n.s
Relationship
between treatment
time and gender
Mann-Whitney test U= 0.15 0.65 n.s
Relationship
between number of
corrected teeth and
time of treatment
Kruskal-Wallis test
1 tooth (9.5 weeks)
2 teeth (8.8 weeks)
4 teeth (3.9 weeks)
0.02 *
n.s (not signicant); *(p ≤ 05)
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Lira et al.
For Figueiredo et al.10 (2014) a good treatment option is given with the at inclined at
appliance because it is a quick and low cost technique, corroborating this work, which
was adopted in 12 schoolchildren in the deciduous dentures and mixed.
When the treatment time was analyzed, half of the cases (6) were corrected in 4 weeks,
33.3% (4 cases) in 5 weeks, 8.3% (1 case) in 3 weeks and 8.3 (1 case) at 6 weeks, dif-
fering from Manjarrés and Silva17 (2017) who corrected ten cases of anterior crossbite
at 7 weeks.
Analyzing the groups of teeth that were crossed in this study it was veried that the
treatment became faster in descending order in the cases, where four crossed teeth
were found, followed by the two teeth crossed and with a crossed tooth. This fact sug-
gest that the more crossed teeth are supported on the plateau of the Inclined Plane
the shorter the treatment time.
Prakash and Durgesh18 (2011) treated two cases, the rst with a crossed incisor tooth
and the second with four crossed incisors in three weeks. Dias et al.16 (2018), when
treating a crossbite that affected a group of six teeth (53 to 63), obtained a four-week
uncrossing and Araujo et al.19 (2017) when treating a single-crossover case tooth got
its complete uncrossing in 2 weeks. These ndings show that the treatment time is
relative to each patient, but it is congured as a rapid treatment.
The treatment of the anterior crossbite should be started as soon as possible, so that
it allows adequate growth of the jaws and correct dental positioning. The treated
cases have been followed up and no relapse was observed. Guzzo et al.20 (2014) elu-
cidated that 51.6% of the interviewees in the city of Florianopolis-SC considered the
correction of crossbite at the Basic Health Units (BHU) necessary.
It was concluded that the prevalence of anterior crossbite was 2.14%. The Inclined
Plane proved to be a viable and effective therapy in the correction of anterior cross-
bite. It is one of the options of the orthodontic treatment in patients in the deciduous
or mixed dentition, propitiating greater possibility of dentoskeletal development, since
the malocclusion is corrected.
Because it is low cost, easy to make, effective and with reduced treatment time, it can
be used in undergraduate courses and in UBS. However this method needs to be cor-
rectly indicated and its execution technique rigorously followed.
References
1. Moraes SPT, Mota ELA, Amorim LDAF. [Factors associated with the incidence of malocclusion in the
deciduous dentition of children in a public hospital cohort from Northeast Brazil]. Rev Bras Saude
Mater Infant. 2014;14(4):371-82. doi: 10.1590/S1519-38292014000400007. Portuguese.
2. Pino Román IM, Concepción OLV, Garcia Vega PA. [Malocclusions according to the dental aesthetic
index in seventh- grade students from Santa Clara]. Rev Cient Villa Clara. 2014;18(4):177-9. Spanish.
3. Manoharan M, Disha P, Nagaveni NB, Roshan NM, Poornima P. Correction of anterior crossbite with
different approaches: a series of three cases. Int J Oral Health Med Res. 2016 Sep-Oct;3(3):41-3.
4. Paul S, Rao A, Chalakkal P, Mony S. Fixed appliance with expansion scren for the treatment of primary
anterior crossbite. J Clin Diagn Res. 2016 May;10(5):ZD03-4. doi: 10.7860/JCDR/2016/17986.7752.
8
Lira et al.
5. Wiedel AP, Bondemark L. Fixed versus removable orthodontic appliances to correct anterior
crossbite in the mixed dentition - a randomized controlled trial. Eur J Orthod. 2015 Apr; 37(2):123-7.
doi:10.1093/ejo/cju005.
6. Leite KCFL, Pires SKC, Leite FCF, Benetti PVN, Barbosa, OLC, Barbosa CCN. [Intercept of
anterior crossbite in the deciduos dentition using xed inclined plane: case report]. BJSCR.
2017 Jun-Aug;19(1):96-100. Portuguese.
7. De Clerck HJ, Prot WR. Growth modication of the face: a current perspective with
emphasis on class III treatment. Am J Orthod Dentofacial Orthop. 2015 Jul; 148(1):37-46.
doi: 10.1016/j.ajodo.2015.04.017.
8. Oltramari PVP, Garib DG, Conti ACCF, Henriques JFC, Freitas MR. [Orthopedical treatment of
Class III in different facial patterns]. Rev Dent Press Ortod Ortop Facial. 2005 Sep-Oct;10(5):72-82.
Portuguese. doi:10.1590/S1415-54192005000500008.
9. Oliveira PLE, Emmerich A. [The early diagnosis importance in the treatment of Angle Class III
malocclusion]. Rev Bras Pesq Saude. 2010;2(2):75-81. Portuguese.
10. Figueiredo PBA, Ferraz RP, Silva VC, Pinheiro Junior JM, Silva ARQ, Silva AI. [Treatment with inclined
plane for anterior crossbite: clinical case report]. RFO. 2014;19(2):229-33. Portuguese.
11. Peres MA, Traebert J, Marcenes W. [Calibration of examiners for dental caries epidemiology
studies]. Cad Saude Publica 2001; 17(1):153-59. Portuguese.
12. 12.Tanaka OM, Maciel JVB, Kreia TB, Ávila ALR, Pithon MM. The anterior dental crossbite: the
paradigm of interception in orthodontics. Rev Clin Pesq Odontol. 2016;6(1):71-8.
13. 13.Fernandes KP, Amaral MAT, Monico MA. [Malocclusion and the need for its orthodontic treatment
in deciduous dentition]. RGO. 2007 Jul/Set;53(3):223-7. Portuguese.
14. 14.Woitchunas DR, Busato C, Tocheto LR, Brockstedt RH. [Anterior cross-bite: diagnosis and
treatment of pseudoclass III - clinical case report]. Rev Fac Odontol UPE. 2001;6(2):23-8.
doi: 10.5335/rfo.v6i2.1572. Portuguese.
15. 15.Lee BD. Correction of Cross-bite. Dent Clin North Am. 1978;22(4):647-8.
16. 16.Dias GF, Alberton LP, Santos MB, Fernandes KNT, Alves FBT. [The relevance of the role of pediatric
dentistry in the diagnosis and early treatment of the anterior cross bite in children - case report]. Rev
Odontol Araçatuba. 2018 May-Aug;39(2):47-53. Portuguese.
17. 17.Manjarrés CR, Silva JAH. [Treatment of anterior cross bite with anterior inclined plane. Effector
on the dental arches]. Rev Odontop Latinoameric. 2017;7(1):44-53. Spanish.
18. 18.Prakash P, Durgesh BH. Anterior Crossbite Correction in Early Mixed Dentition Period Using
Catlan’s Appliance: A Case Report. ISRN Dent. 2011;29(8):1-5. doi: 10.5402/2011/298931.
19. 19.Araujo EC, Silva TE, Santos RSS, Brum SC, Barbosa CCN, Barbosa OLC. [Previous cross
bite treatment using pif: a vibrant aternative - case report]. Braz J Surg Clin Research.
2017 Sep-Nov;20(2):116-119. Portuguese.
20. 20.Guzzo SC, Finkler M, Junior CR, Reibnitz MT. [Preventive and interceptive orthodontics
in the primary health care network of the Brazilian Unied Health System: the viewpoint of
the dental surgeons of Florianopolis City Hall]. Cienc Saud Colet. 2014 Jan;19(2):449-60.
doi:10.1590/1413-81232014192.22852012. Portuguese.
