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Early Diagnosis and Treatment of an Anterior

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Author Profiles

Dr. Sawsan Tabbaa, DDS., MS is an Assis- Dr. Yogi Kothari, DMD is a Diplomate of the tant Professor, Department of , American Board of Orthodontics. and an Assis- School Dental Medicine, State University of tant Professor in the Department of Orthodon- New York at Buffalo. tics, School of Dental Medicine, State University of New York at Buffalo.

Dr. Michelle L. Burlingame, DMD, MS has an orthodontics private practice in Ballston Spa, Dr. Wael Y. Elias, DMD is a diplomate of NY. Dr. Burlingame attended dental school at the American Board of Oral and Maxillofa- the University of Connecticut and completed cial Pathology and the American Board of her residency program in orthodontics at the Orthodontics. He is a faculty and Clinical University of Buffalo, NY. instructor in the Department of Orthodontics, School of Dental Medicine State University of New York at Buffalo, NY and the King Abdulaziz University, Dr. C. Brian Preston, BDS, PhD is a Professor and Chairman Dental School, Jeddah, Saudi Arabia. of the Department of Orthodontics, School of Dental Medi- cine, State University of New York at Buffalo. Abdulfatah A. Hanoun, DDS, G.Dip, M.Sc is a visiting research scholar and post-doctoral Rishi Kothari, DDS has a private practice in fellow in the Department of Orthodontics, orthodontics in Olean, NY. School of Dental Medicine, State University of New York at Buffalo in Buffalo, NY.

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2 Early Diagnosis and Treatment of an Anterior Crossbite

ABSTRACT LEARNING OBJECTIVES

Early orthodontic intervention can have numerous benefits The overall objective of this article is to provide the partici- for patients. Treating an anterior crossbite with early inter- pant with information on the treatment of anterior crossbites. vention can improve function, appearance and self-esteem. In Upon completing this course, the participant will be able to: the case report included in this article, an 8-year-old girl was 1. Determine the circumstances under which early treated successfully for an anterior crossbite. In this instance, orthodontic intervention is appropriate. an acrylic bite jumper may have saved the patient from future 2. Identify a case in which early orthodontic intervention surgery while improving her occlusal function and social was used successfully to treat an anterior crossbite. interactions. 3. Identify the outcomes of orthodontic treatment, including those that affect the patient’s quality of life.

Introduction • Early management of maxillary anterior crossbites in arly orthodontic intervention is appropriate in pa- order to establish a correct relationship between the tients exhibiting certain occlusal problems that could and the , achieve proper function, Econtinue to worsen, while also becoming more difficult improve the child’s facial profile, and in some cases, to treat, at a later stage of dental and skeletal development. If eliminate the need for surgery at a later date. such problems are not diagnosed and treated early enough, they could hinder the normal craniofacial development of the Anterior Crossbite: An Overview and Case Study respective child. Interceptive orthodontic treatment reduces Anterior crossbite is an orthodontic problem that pres- the complexity of some during the mixed ents with a reverse overjet of one or more of the anterior dentition phase of dental development; however, a follow-up teeth. As with many orthodontic problems, the underlying orthodontic treatment is usually required when the perma- etiology could be either skeletal or dental, or a combina- nent dentition has been established.1 tion of these two factors. The precise treatment of an an- terior crossbite would thus be directed at the predominant Examples of beneficial early interceptive orthodontic treat- etiologic factor. ment include, but are not limited to: • Early treatment of deep bites to prevent the lower Etiology anterior teeth from impinging on the palatal tissue Skeletal causes and to redirect mandibular growth to achieve a nor- The anterior posterior skeletal discrepancy is one of mal facial height; the main causes of the anterior crossbite. For example, • Early treatment of open bites to eliminate parafunc- any excessive mandibular growth may lead to a segment tional habits, such as thumb sucking and tongue crossbite on the anterior incisors. In addition, the retarded thrusting;2 development of the maxilla in the sagittal plane may also • Early orthodontic treatment of severe crowding to result in an anterior crossbite. For instance, the small or provide space for the permanent teeth during eruption;3 collapsed maxillary arch associated with cleft palate will • Elimination of Class II division I malocclusions that also cause an anterior crossbite in the majority of these present with a protrusive maxilla and/or maxillary patients. The skeletal causes of the anterior crossbite are teeth. The aim here is to provide facial harmony, generally inherited. They are manifested as size or position improve the child’s self-image, and perhaps reduce the discrepancies in the maxilla, the mandible, or both. A long probability of incisor fractures. mandible or anteriorly positioned glenoid fossa, short or

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posteriorly positioned maxilla, and even a short anterior anterior crossbites is a lack of space for the permanent cranial base should be considered indicators of the skeletal incisors.9 The early loss of maxillary deciduous teeth, nature of the anterior crossbite.4 The skeletal etiological impacted or lost permanent posterior teeth, or impacted factors can be elaborated under any of the following three canines would allow the maxillary anterior teeth to categories or any combination of these: genetic/syndromic drift distally and palatally. In most children with an- causes; maxillary deficiency; and mandibular excess. terior crossbites involving multiple teeth, a skeletal discrepancy should be considered. A labially positioned Genetic factors supernumerary , over-retained deciduous tooth Many syndromes that affect facial development have with delayed exfoliation, trauma to the deciduous teeth at least some basis in genetics. Syndromes such as cleft or permanent tooth bud, or even a lip biting habit may lip and palate, , and lead to an abnormal axial inclination of upper incisors, are associated with a degree of midface deficiency that, which is another cause of dental anterior crossbites. In in many instances, results in an anterior crossbite due to addition, the premature tooth contact during mandibu- the maxillary skeletal deficiency. The midface deficiency lar closure may lead to a pseudo-Class III, another cause observed in these syndromic patients can be aggravated by of dental anterior crossbites.10 the restriction of maxillary growth that may result from scar tissue associated with the surgical correction of the Diagnosis cleft lip and/or palate.5 In order to determine the main cause of an anterior cross- Congenital maxillary deficiency bite, it is important to differentiate between skeletal and den- Prenatally, undue pressure against the developing fetal tal problems. In this regard, midface deficiency or mandibular face can lead to distortion of the rapidly growing facial overgrowth will result in a Class III tendency, which is usually areas. On rare occasions, a limb is pressed across the face manifested in the sagittal plane. A prominent feature of the in utero, resulting in a severe maxillary deficiency at birth6 Class III facial pattern is an anterior crossbite dental relation- and a Class III . If the maxilla is small or ship. A single tooth in an anterior crossbite is usually associ- positioned posteriorly, the effect is direct. If it lacks vertical ated with some degree of dental crowding.11 This generally growth, the effect is indirect and, due to the fact that the results from a dental etiological factor. On the other hand, mandible rotates upward and forward, produces a man- a segment crossbite (which involves several teeth rather dibular that is not due primarily to the size than a single tooth) is more likely to result from a skeletal of the mandible.7 etiological factor, which can be confirmed by radiographs such as lateral cephalograms. Moreover, if an anterior Mandibular excess crossbite is associated with a bilateral posterior crossbite, Mandibular prognathism can be familial, in which case the skeletal factor should be considered where the retro- there is the belief that the etiology in these instances can be positioned or small maxilla relative to the mandible could of a hereditary nature. In rare occasions, endocrinal distur- be the main etiological cause. However, a radiographic bance such as an increase in circulating growth hormone confirmation is always required. may result in , which is characterized by an A lateral cephalometric X-ray offers an important abnormally large mandible.8 diagnostic tool, particularly if it is suspected that a skeletal imbalance may be responsible for an anterior crossbite and Dental causes an incipient Class III malocclusion. The Steiner and the The most common etiologic factor for non-skeletal McNamara analyses provide two different cephalometric

4 Early Diagnosis and Treatment of Anterior Crossbite

methods for measuring the severity of skeletal imbal- normal position is most likely to be associated with the ances in the sagittal plane.12,13 Whenever the cephalometric dental crossbite.10 In addition, the closure pathway should analysis shows radiographic evidence of moderate to se- be examined for any premature contact, which could be vere skeletal anterior-posterior discrepancy associated with the cause of an anterior dental crossbite associated with a an anterior crossbite, the skeletal cause should be taken pseudo Class III relationship. As an example, the prema- into consideration. ture incisor contact during closure may result in the devel- The location of the tooth having crossbite can be used opment of anterior mandibular displacement manifested as as a diagnostic indicator of skeletal or dental etiology of a dental anterior crossbite. the anterior crossbite. In the skeletal crossbite, the teeth At the same time, dental study models provide an im- are often normally positioned on the basic of the portant tool when it comes to diagnosing dental problems, jaw. On the other hand, a deflection of a tooth from the such as crowding and lack of space due to tooth size arch

TABLE 1. Skeletal And Dental Anterior Crossbite Indicators

Skeletal Anterior Crossbite Dental Anterior Crossbite

Etiology/cause Genetic and hereditary in most cases Lack of space, TSALD (familial) No maxilla and mandible size Maxilla and mandible size discrepancy discrepancy (long mandible and/or short maxilla)

Anterior crossbite prevalence Retrognathic maxilla: 25% Dental cause only 33% Prognathic mandible: 20% Combination of both: 22%

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 None crossbite in some cases.

d- Sagittal discrepancy Significant AP discrepancy between the No significant discrepancy between the maxilla and mandible maxilla and mandible

e- Mandibular growth pattern Often vertical (except in cases of true Normal mandibular prognathism)

f- Position of teeth Normally positioned Deflected tooth position

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

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length discrepancy (TSALD) that may result in an anterior appliance, made with the mandible positioned posteriorly dental crossbite. The study models allow clinicians to mea- and rotated open and with pads designed to stretch the sure and compare the relationship that exists between the upper lip forward.20 combined sizes of the teeth and the amount of space that is For adult and adolescent patients who have finished available to accommodate them. In the past, measurements their growth, orthopedic treatment options such as growth were made directly on plaster study models. Nowadays, modification are difficult if not impossible. For these -pa digital models, in combination with specific software, tients, the alternatives are either a camouflage treatment make it possible to determine tooth and arch sizes with or a surgical correction of the mandibular prognathism. greater ease.14,15 Camouflage treatment involves extracting lower first Table 1 provides a synopsis of the major characteristics premolars, followed by retracting the mandibular incisor of skeletal and dental anterior crossbites. teeth. Although this method may correct an anterior cross- bite in mild cases, it is not advised as a treatment modality Treatment options in more severe cases of mandibular protru­sion. In moder- Treatment options depend on the specific etiology of ate to severe cases of mandibular prognathism, the treat- the condition and, to a great degree, on the skeletal and ment option of choice is surgical correction by mandibular dental age of the patient. setback, on its own or in combination with a maxillary Treatment of a skeletal anterior crossbite (Class III advancement procedure.21,22 malocclusion) For growing children with an antero-posterior (sagit- Treatment of a dental anterior crossbite tal) and/or vertical maxillary deficiency, the treatment of As noted earlier, the most common etiologic factor for choice is maxillary traction with a reverse-pull headgear a non-skeletal (dental) anterior crossbite is a lack of space (face mask) to move the maxilla anteriorly and, in some for the permanent incisors. It is thus important in these cases, slightly inferiorly. This traction allows new bone to cases to manage the space problem while attempting to be added at the posterior and superior circum-maxillary correct the anterior crossbite. sutures, which effectively increases the size of the maxilla. If the developing crossbite is discovered prior to While it is easier and more effective to move the maxilla completion of the incisor eruption and before an forward at a young chronologic age (about eight years), has been established, the adjacent primary teeth can be recent reports indicate that some positive sagittal changes extracted to provide the necessary space for the permanent can be produced up to the beginning of incisors. In instances where the overbite has been estab- adolescence.16,17 lished, an appliance may be required to correct the Growing children who have a Class III malocclusion developing crossbite. because of a mandibular excess are more difficult (some- Tipping maxillary and mandibular anterior teeth out of times impossible) to treat without some surgical interven- a crossbite can solve the crossbite problem in most instanc- tion. In these instances the treatment of choice may be es. This can be done by using a removable appliance with mandibular restraining devices such as a cup, de- finger-springs for facial movement of the maxillary incisors signed to inhibit the growth of the mandible.18,19 or, in some cases, an active labial bow for lingual move- Functional appliances may also be used in an effort to ment of the mandibular incisors. promote maxillary development and to limit, if possible, It is important to create enough space for the teeth mandibular prognathism. A good example of such a before moving them lingually in case of tipping lower functional appliance is represented by the Frankel-III incisors.23,24

6 Early Diagnosis and Treatment of Anterior Crossbite

Case Study lessen the severity of the eventual malocclusion.25,26 The This case study focuses on an 8-year-old girl who bite jumper treatment described in this case study is presented with a relatively severe anterior crossbite. An most useful for correcting an anterior crossbite that has anterior crossbite is a good example of a malocclusion that a dental etiology versus a skeletal one. It also would be usually requires early intervention. more appropriate if the patient presented with a low- Although there is considerable debate as to whether to-normal mandibular plane angle. a Class III malocclusion will benefit from early treat- ment, it is generally well accepted that it is important History to treat this type of malocclusion as soon as it mani- Medical: The patient presented as a healthy 8-year-old fests. It is believed that the early diagnosis and timely female (Figure 1). correction of an anterior crossbite may prevent the oc- Dental: The oral hygiene of the patient was considered currence of functional shifts of the mandible, abnormal to be adequate and there was no history of craniofacial wear of the permanent teeth, and temporomandibular trauma. joint problems. More importantly, timely treatment Etiology: The patient and her guardian did not provide of the problem could reduce the need for orthogna- a family history of Class III malocclusion. This patient’s thic surgery in adulthood. It should be noted that malocclusion could be attributed to an altered eruption early treatment may not eliminate the need for further pattern of the permanent incisor teeth, possibly resulting orthodontic treatment at a later stage, but it is likely to from dental crowding.

Figure 1. Pre-treatment extraoral and intraoral photographs.

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Diagnosis Treatment Objectives Skeletal: • To maintain an Angle Class I molar relationship. • The Patient exhibited a Class III tendency because of • To eliminate the anterior crossbite, properly align the a relative underdevelopment of her maxilla. Her Sella, anterior teeth, and obtain a positive overbite and posi- Nasion to point “A” (SNA) value was 77.3° (normal tive overjet. value, 82.0° + 3.5°). • To retain all of the permanent teeth during the initial • The patient’s vertical facial development was normal, phase of orthodontic treatment, anticipating that a more with a tendency toward a slightly skeletal deep bite definitive phase of treatment could be required at a later pattern; she had a low mandibular plane angle (SN- stage of development. GoGn) value of 24.9° compared with the normal value of 32.9° + 5.2°. (Figure 2) Treatment Dental: It was decided that the best course of treatment would be • The bilateral molar relationships were Angle Class I. to begin with a phase of dental leveling followed by hav- • There was an anterior crossbite that included the central ing the patient wear an acrylic bite jumper appliance. Serial and lateral teeth (Figure 1). extraction and protraction facemask treatment were alterna- • The maxillary incisors were retroclined (94.9°) when tive treatments that were considered but ruled out. When the compared with the normal upper incisors to an SNA patient presented for treatment, the need for four premolar value of 102.1° + 5.5°. extractions could not be determined with any certainty. At Soft Tissue: that time, the negative consequences of extracting in a defi- • The patient’s soft-tissue profile was slightly concave cient maxillary arch was considered. Given the absence of a because of a retruded upper lip; her nasiolabial angle was family history of Class III malocclusion, the relatively minor 136.7° compared with the normal value of 102.0° + 8.0°. 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 3. The bite-jumper appliance. This removable appliance consists of an acrylic slope covering the anterior teeth, with a Figure 2. Initial lateral cephalometric X-ray, traced and wire framework following the lingual contours of the teeth for measured. retention.

8 Early Diagnosis and Treatment of Anterior Crossbite

Banding and Bite Jumper Appliance • A positive incisor overjet was obtained. (Figure 4) The patient’s maxillary first permanent molars were • The soft-tissue profile was greatly improved (Figure 5). banded and the maxillary incisors were bonded with The patient’s profile changed from concave with a retrusive 0.018-inch Unitek’s Victory Series (3M ESPE) brackets. maxilla to normal and straight (Figure 6). A 0.016-inch nickel titanium arch wire was used to level and align the maxillary anterior teeth. Following the phase Discussion of dental leveling, the patient wore an acrylic bite jumper Cephalometric evaluation of the patient before and appliance for four months (Figure 3). The appliance was after appliance therapy revealed an improvement in the removable; however, the patient was instructed to wear maxilla from deficient to normal. After treatment, the SNA the appliance full time, except for cleaning purposes. The value increased from 77.3° to 81.1°, which was close to patient was seen every four to six weeks while wearing the the accepted normal value of 82.0° +3.5°. After the early bite jumper. Some adjustments were made to the bite plate phase of orthodontic treatment, the maxillary incisors to reduce the bulk of the appliance; however, the slope of were somewhat proclined. The mandibular incisors were the bite plane was maintained throughout treatment. No uprighted and the mandibular plane angle was maintained. retention was needed in the maxillary jaw once the proper There was great improvement in the soft-tissue profile overjet was obtained. (Figure 6 & 7). The patient’s mother reported an improvement in Treatment Outcome her daughter’s social interactions and eating patterns. • The Class I molar relationship was preserved. After the elimination of the crossbite, the child became

Figure 4. Post-treatment extraoral and intraoral photographs.

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

“proud of her smile.” Her eating habits improved be- intervention to eliminate the anterior crossbite saved this cause of the improved ability to bite and chew—and the patient from having invasive surgery if she ever seeks patient’s weight improved as a result of her better eating treatment in adulthood. habits. Acknowledgments Conclusion We would like to thank the patient and her family for Although the results for Phase I treatment were accept- their compliance and cooperation. The patient’s mother able in terms of obtaining a positive overjet, it must be stated: “I would like to thank you for your concern and noted that follow-up and facemask treatments may be nec- for encouraging my daughter to receive early orthodontic essary in the future if the patient’s skeletal growth exhibits treatment. Early diagnosis may have saved my daughter a prominent Class III tendency. from future surgery. Her new smile is not just an esthetic If this child had not been diagnosed and treated early, advantage; it has truly improved her chewing function. her maxilla would have continued to be trapped behind My daughter enjoys her meals now and is able to drink her mandible, resulting in permanent maxillary deficiency from a cup without a straw and do simple things like and contributing to an unattractive concave profile. biting into an apple. I hope dentists use this case study to Surgery is usually the ideal treatment for adults exhibit- help other children and to understand the importance of ing a concave profile because of maxilla deficiency. Early early diagnosis and prevention.”

10 Early Diagnosis and Treatment of Anterior Crossbite

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 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. Figure 6. Comparison of pre-treatment and post-treatment 13. Popovich F, Thompson GW. Craniofacial templates for orthodontic profiles. 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. Figure 7. Final lateral cephalometric x-ray, traced and measured. 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. References 26. Graber TM, Vanarsdall Jr. RL, Vig KWL. Orthodontics: Current Prin- 1. King GJ, Brudvik P. Effectiveness of interceptive orthodontic treat- ciples and Techniques. St. Louis, MO: Mosby; 2005:543-545. 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 Webliography Orthod Dentofacial Orthop. 2002;121:569-571. 1. King GJ, Brudvik P. Effectiveness of interceptive orthodontic treat- 4. Millett D, Welbury R. Clinical problem solving in orthodontics and ment in reducing malocclusions. Am J Orthod Dentofacial Orthop. pediatric dentistry, ELSEVIER Churchill Livingstone. 2005:40. 2010;137:18-25.

January 2015 11 Early Diagnosis and Treatment of Anterior Crossbite

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1. Interceptive orthodontic treatment reduces the complexity of 9. ______should be considered indicators of the skeletal some malocclusions during the ______dentition phase of nature of the anterior crossbite. dental development. a. An anteriorly positioned glenoid fossa a. primary b. A short anterior cranial base b. mixed c. A short or posteriorly positioned maxilla c. secondary d. all of the above d. all of the above 10. A long mandible is always an indication of a ______2. Early treatment of deep bites is performed to ______. malocclusion. a. prevent the lower anterior teeth from impinging on the palatal a. severe Class III tissue b. severe Class II div 1 b. redirect mandibular growth to achieve a normal facial height c. severe Class II div 2 c. save money d. none of the above d. a and b 11. ______is associated with a degree of midface deficiency 3. Early treatment of open bites is performed to ______. that can result in an anterior crossbite. a. redirect maxillary growth to achieve a normal facial height a. Cleft lip and palate b. eliminate parafunctional habits b. Apert syndrome c. save time c. Crouzon syndrome d. a and b d. all of the above

4. The elimination of a Class II division I malocclusion that presents 12. In a cleft lip and palate patient, midface deficiency can be with a protrusive maxilla and/or maxillary teeth is aimed at aggravated by the restriction of maxillary growth that may ______. result from ______. a. providing facial harmony a. thumb sucking b. improving the child’s self-image b. c. possibly reducing the probability of incisor fractures c. scar tissue d. all of the above d. all of the above

5. Early orthodontic treatment of severe crowding is performed 13. A severe maxillary deficiency at birth can result, on rare to ______. occasions, from ______pressing across the face a. create the correct overjet in utero. b. create the correct overbite a. a digit c. provide space for the permanent teeth during eruption b. a limb d. all of the above c. the mother’s bladder d. all of the above 6. An anterior crossbite exists if ______present(s) with a reverse overjet. 14. Mandibular prognathism is ______due primarily to the a. only one tooth size of the mandible. b. only if more than one tooth a. always c. if one or more teeth b. never d. if at least three teeth c. not always d. none of the above 7. The anterior posterior skeletal discrepancy is ______cause of the anterior crossbite. 15. A chin cup is designed to ______. a. an infrequent a. push the mandible forward b. a main b. inhibit growth of the mandible c. the only c. push the maxilla forward d. none of the above d. all of the above

8. The skeletal cause of the anterior crossbite is ______. 16. ______may lead to an abnormal axial inclination of a. manifested as size discrepancies in the maxilla/mandible/ upper incisors. both a. A labially positioned supernumerary tooth b. manifested as position discrepancies in the maxilla/mandible/ b. An over-retained deciduous tooth with delayed both exfoliation c. generally inherited c. Trauma to the deciduous teeth or permanent tooth bud d. all of the above d. all of the above

12 CE ANSWER FORM Early Diagnosis and Treatment of Anterior Crossbite

17. A pseudo-Class III can result from ______tooth contact 24. There is ______debate as to whether a Class III during mandibular closure. malocclusion will benefit from early treatment. a. delayed a. no b. premature b. some c. lack of c. considerable d. any of the above d. none of the above

18. A segment crossbite is likely to result from ______. 25. If a developing dental crossbite is discovered prior to a. a dental etiological factor completion of the incisor eruption and before an overbite b. a skeletal etiological factor has been established, the adjacent primary teeth can c. thumb sucking be ______to provide the necessary space for the d. none of the above permanent incisors. a. treated orthodontically 19. The Steiner and the McNamara analyses provide two b. reduced interproximally using a standard IPR technique different cephalometric methods for measuring the severity c. extracted of ______imbalances. d. none of the above a. dental element b. skeletal jaw 26. Tipping maxillary and mandibular anterior teeth out of a c. functional crossbite can be done by using ______. d. all of the above a. a removable appliance with finger-springs for facial movement of the maxillary incisors 20. The early loss of maxillary deciduous teeth, impacted or lost b. an active labial bow for lingual movement of the mandibular permanent posterior teeth, or impacted canines allows the incisors maxillary anterior teeth to ______. c. a chin cup a. erupt all at the same time d. a or b b. drift mesially and buccally c. drift distally and palatally 27. In some patients whose crossbite has been treated, d. all of the above follow-up and facemask treatments may be necessary in the future if the patient’s ______. 21. For growing children with an antero-posterior (sagittal) and/ a. skeletal growth exhibits a prominent Class III tendency or vertical maxillary deficiency, the treatment of choice is b. thumb sucking habit continues ______to move the maxilla anteriorly and, in some c. maxilla develops only unilaterally cases, slightly inferiorly. d. a or b a. a Herbst appliance b. maxillary traction with a reverse-pull headgear (face mask) 28. A deflection of a tooth from the normal position is most c. a rapid maxillary expander likely to be associated with the ______crossbite. d. all of the above a. skeletal b. dental 22. Early management of maxillary anterior crossbites is per- c. bilateral formed in order to establish a correct relationship between d. all of the above the maxilla and the mandible, as well as to ______. a. improve the child’s facial profile 29. Surgery is usually the ideal treatment for adults exhibiting b. achieve proper function a ______profile because of maxilla deficiency. c. in some cases, eliminate the need for surgery at a a. concave later date b. convex d. all of the above c. flat d. all of the above 23. The Frankel-III appliance ______. a. is made with the mandible positioned posteriorly and 30. It is easier and more effective to move the maxilla rotated open forward ______. b. is made with the mandible positioned posteriorly and a. in adolescence rotated open b. at a young chronologic age c. has pads designed to stretch the upper lip forward c. in adulthood d. all of the above d. a and c

January 2015 13 Early Diagnosis and Treatment of Anterior Crossbite www.dentallearning.net/ACB-ce CE ANSWER FORM (E-mail address required for processing)

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*E-mail: AGD Codes: 370, 373 *Telephone: License Renewal Date: EDUCATIONAL OBJECTIVES QUIZ ANSWERS 1. Determine the circumstances under which early orthodontic intervention is Fill in the circle of the appropriate appropriate. answer that corresponds to the 2. Identify a case in which early orthodontic intervention was used successfully to question on previous pages. treat an anterior crossbite. 3. Identify the outcomes of orthodontic treatment, including those that affect the A B C D A B C D patient’s quality of life. 1. 16. 2. A B C D 17. A B C D COURSE EVALUATION 3. A B C D 18. A B C D Please evaluate this course using a scale of 3 to 1, where 3 is excellent and 1 is poor. 1. Clarity of objectives ...... 3 2 1 4. A B C D 19. A B C D 2. Usefulness of content ...... 3 2 1 5. A B C D 20. A B C D 3. Benefit to your clinical practice...... 3 2 1 4. Usefulness of the references...... 3 2 1 6. A B C D 21. A B C D 5. Quality of written presentation...... 3 2 1 7. A B C D 22. A B C D 6. Quality of illustrations...... 3 2 1 7. Clarity of quiz questions...... 3 2 1 8. A B C D 23. A B C D 8. Relevance of quiz questions...... 3 2 1 9. A B C D 24. A B C D 9. Rate your overall satisfaction with this course . . . . . 3 2 1 10. Did this lesson achieve its educational objectives? Yes No 10. A B C D 25. A B C D 11. Are there any other topics you would like to see presented 11. A B C D 26. A B C D in the future? ______12. A B C D 27. A B C D ______13. A B C D 28. A B C D COURSE SUBMISSION: Dental Learning, LLC 1. Read the entire course. 500 Craig Road, First Floor 14. A B C D 29. A B C D 2. Complete this entire answer sheet in Manalapan, NJ 07726 A B C D A B C D either pen or pencil. *If paying by credit card, please note: 15. 30. 3. Mark only one answer for each question. Master Card | Visa | AmEx | Discover 4. Mail answer form or fax to 732-303-0555. *Account Number Price: $29 CE Credits: 2 For immediate results: ______Save time and the environment 1. 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