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Early Transverse Treatment Steven D Early Transverse Treatment Steven D. Marshall, Karin A. Southard, and Thomas E. Southard Expansion of the maxillary arch to improve transverse inter-arch relationships during the primary or mixed dentition stage is considered early transverse treatment as part of a two-phase treatment protocol. Traditionally, early expansion has been used to correct posterior crossbite. More recently, it has been suggested that early transverse treatment may be beneficial, in the absence of posterior crossbite, to improve arch length deficiency, and to facilitate correction of skeletal class II malocclusions. In this article, the rationale for early transverse treatment in the presence and absence of posterior crossbite is reviewed. Semin Orthod 11:130–139 © 2005 Elsevier Inc. All rights reserved. orrection of posterior crossbite is the most common rea- mandibular teeth. Posterior buccal crossbite occurs when the Cson for early transverse treatment. Figure 1 displays the lingual cusps of the maxillary teeth are buccal to the opposing orthodontic records of a typical case with the following his- buccal cusps of the mandibular teeth. tory: The mother states that their general dentist identified a What is the incidence of posterior crossbite in the de- crossbite in her daughter and recommended that she see an ciduous and mixed dentitions? Estimates range from 7% to orthodontist. Past medical and dental history is noncontrib- 23% with a greater prevalence of unilateral crossbite coupled with utory. Clinical and radiographic examination reveal an Angle a lateral shift of the mandible. Class I malocclusion in the primary dentition, maxillary mid- In a sample of 898 four-year-old Swedish children, Thi- line coincident with the face, and a functional shift to the lander and coworkers identified crossbites in 9.6%.1 Simi- right from centric relation to centric occlusion with corre- larly, in a study of 238 nursery school and 277 second-grade sponding deviation of the chin and mandibular midline. You children, Kutin and Hawes2 found 8% of 3- to 5-year-olds inform the mother of your findings, and she asks whether (1:12) and 7.2% of 7- to 9-year-olds (1:13) had some form of you would recommend treatment now or wait until her posterior crossbite. The prevalence of crossbite was not daughter is older. Should you attempt correction now or greatly different between girls and boys. This finding is in wait? And when you treat her, what is the most appropriate contrast to the findings of Helm, who examined over 3000 treatment? The purpose of this article is to address these and children, ages 6-18 years, and reported significantly more other topical questions, using the best available evidence, crossbites in girls (14%) than in boys (9%).3 Hanson and and to provide insights into the early treatment of transverse coworkers found that the percentage of 227 children, ages 3 problems. to 5 years, who presented with posterior crossbites exceeded 23%.4 In two studies, approximately 80% of observed cross- Background bites were reported to be unilateral posterior crossbites asso- ciated with lateral functional shifts of the mandible.1,5 Posterior crossbite can present as unilateral or bilateral mal- What are the etiologies of posterior crossbite? A range of occlusions of the primary, mixed, or permanent dentitions. possible causes includes genetics, environmental factors, and habits. Canine involvement is often seen and considered part of a Posterior crossbite frequently results from transverse max- posterior crossbite even though canines are not, by defini- tion, posterior teeth. Nomenclature is based on the position illary skeletal deficiency that may have an underlying con- of the maxillary teeth. Posterior lingual crossbite, the most genital, developmental, traumatic, or iatrogenic (eg, cleft pal- 6 common posterior crossbite, exists when the buccal cusps of ate repair) basis. Additional causes include asymmetric the maxillary teeth are lingual to the buccal cusps of the growth of the maxilla or mandible, discrepant widths of basi- lar maxilla and mandible, premature loss or prolonged reten- tion of primary teeth, crowding, abnormalities in eruption Department of Orthodontics, University of Iowa, Iowa City, IA. sequence, impaired nasal breathing during critical growth Address correspondence to Thomas E. Southard, DDS, MS, Department of periods, aberrations in tooth anatomy, and improper func- Orthodontics, College of Dentistry, University of Iowa, Iowa City, IA 52242. 2,6-9 Phone: (319) 335-7288; Fax: (319) 335-6847; E-mail: tom-southard@ tion of the temporomandibular joints. Oral digit habits uiowa.edu have also been implicated as an etiologic factor. However, at 130 1073-8746/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.sodo.2005.04.006 Early transverse treatment 131 least one study found no difference in the prevalence of suck- should be used to support the chairside examination, but are ing habits when examining patients with or without sponta- not a substitute for findings made directly from the patient. neous correction of a posterior crossbite.1 In a frontal facial examination, lateral deviation of the chin Can spontaneous correction of posterior crossbites oc- can usually be noted. If this is noted, the underlying cause, be cur? Yes. However, controlled studies have reported wide varia- it a functional lateral shift from centric relation to unilateral tion in rates of spontaneous correction in the primary and early crossbite occlusion or a true skeletal asymmetry, must be mixed dentition, ranging from 8% to 45%. ascertained. If there is any doubt about a lateral shift being Kutin and Hawes reported a spontaneous correction rate present it is prudent to disarticulate the occlusion for a week of only 8% in their sample of 515 children, 5 to 9 years of or two before reexamining. A bite plate can be used to disar- age.2 However, Kurol and Bergland found 45% (9 of 20) ticulate the occlusion. However, if patient compliance is a spontaneous correction of posterior crossbite in untreated concern, especially in younger patients, insertion and mild children ages 3 to 5.5 Linder found 16% (6 of 38) spontane- activation of a fixed (Hyrax) expander will disarticulate the ous correction of posterior crossbite in untreated children occlusion effectively to allow visualization of a lateral shift. aged4to9.10 Finally, Thilander and coworkers found 21% (6 The patient and parents should be informed that a definitive of 28) spontaneous correction of posterior crossbite in a ran- treatment plan may not be possible until the presence or 1 domized clinical trial of 61 children ages 4 to 13. absence of a lateral shift has been documented. What is the rationale for early correction of posterior In the absence of a lateral shift, findings of chin asymmetry crossbite with a functional shift? Evidence suggests that a and unilateral crossbite establish the presence of a true uni- lateral shift of the mandible into unilateral crossbite occlusion may lateral skeletal asymmetry. Posteroanterior or submental ra- promote adaptive remodeling of the temporomandibular joint and diographs are helpful in assessing the presence and magni- asymmetric mandibular growth. Favorable improvement of man- tude of maxillary or mandibular asymmetry. Unilateral dibular asymmetry associated with a mandibular shift is seen in crossbite found in the absence of skeletal asymmetry and patients treated in the early mixed dentition. lateral shift is most commonly the result of aberration of Research has documented that when patients shift into a transverse tooth positions. Study casts are needed to further unilateral crossbite in maximum intercuspation, there is an analyze variation in transverse tooth inclinations and arch asymmetric condylar position with the condyle on the non- symmetry. Bilateral crossbite occlusion may be seen without crossbite side distracted relative to the glenoid fossa.11-13 The lateral shift and without chin asymmetry. This transverse fact that most unilateral crossbites do not spontaneously cor- discrepancy requires further classification using knowledge rect and that functional shifts are rarely detected in adults of the patient’s sagittal relationship and the patient’s study with unilateral crossbite suggests that adaptive remodeling of casts. the temporomandibular joint occurs and that children with unilateral crossbite and functional shift develop an asymme- try of the mandible.14 As such, even when adaptive change to Sagittal Relationships posterior crossbite occurs, it may not provide freedom from Transverse interarch relationships change as sagittal inter- temporomandibular disorders.15 Some have suggested that arch relationships change. That is, transverse discrepancies for patients in the mixed dentition stage, adaptive remodel- can be relative or absolute, and this determination is made by ing in the temporomandibular joints may have already oc- examining the patient’s study casts. A relative transverse dis- curred.16 However, there is still adequate time for growth crepancy exists when the posterior teeth do not show proper 17 modification in the early mixed dentition. A recent study transverse cusp-fossa relationships in centric relation, but has shown that favorable improvement of a mandibular properly occlude (or will properly occlude with correct tooth asymmetry associated with a mandibular shift is seen in pa- alignment) when the canines of the casts are placed in Class I tients treated in the early mixed dentition. That is, if the occlusion.19 For
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