ONLINE ONLY

Treatment of posterior crossbite comparing 2

appliances: A community-based trial
Fabiana Godoy,a Juliana Godoy-Bezerra,b and Aronita Rosenblattc
Recife, Pernambuco, Brazil

Introduction: The aim of this community-based trial was to compare the effectiveness of the quad-helix
appliance and removable plates for treating posterior crossbite. Methods: Ninety-nine patients were randomly
divided into 3 groups: quad-helix, expansion plate, and untreated. All subjects were in the mixed dentition, had
posterior crosssbite, no sucking habits, no previous orthodontic treatment, and no Class III malocclusion. The
following aspects were evaluated: posterior crossbite correction, maxillary and mandibular intermolar and
intercanine expansions, length of treatment, cost-benefit analysis, success rate, and number of
complications. Results: The length of treatment and the costs were higher in the expansion plate group than
in the quad-helix group. The success rates were similar for the quad-helix and the expansion plate groups,
and the number of complications was higher in the quad-helix group. No self-correction was observed in the
untreated group, and relapses occurred in both experimental groups. Conclusions: The average treatment
time was significantly shorter and 11% less expensive than in the quad-helix group, making it the more
cost-effective choice for treatment. (Am J Orthod Dentofacial Orthop 2011;139:e45-e52)

P
osterior crossbite is a malocclusion seen
frequently in the deciduous and mixed dentitions
(8% and 22%, respectively).1-4 It can be unilateral
or bilateral and might develop during the mixed
dentition.3,5,6 The etiology of this malocclusion can be
dental, skeletal, or functional alone, or in combination.
The most common form of posterior crossbite is
unilateral with functional shift of the mandible toward
the crossbite side.
Unilateral posterior crossbite might be associated
with mandibular displacement. Some reports suggest
that posterior crossbite might increase the risk of later
temporomandibular joint dysfunction; however, other
studies found this association weak and inconsistent.7-10
Early treatment of posterior crossbites by means of
maxillary expansion is currently advocated to redirect the
erupting teeth into their normal positions and to eliminate
premature occlusal contacts, thereby favoring beneficial
dentoskeletal changes during growth periods.6,11,12
From the School of Dentistry, University of Pernambuco, Recife, Pernambuco,
Brazil.
a
PhD student, Department of Pediatrics.
b
PhD student, Department of Pediatrics.
c
Professor, Department of Pediatrics.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Fabiana Godoy, Rua Zeferino Galv~ao, 100/1204, Boa Via-
gem- Recife, PE, Brazil, CEP: 51 111-000; e-mail, fabianagodoy10@gmail.com.
Submitted, January 2010; revised and accepted, June 2010.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.06.017
For treatment of children with posterior crossbite,
various methods have been suggested: rapid maxillary
expansion, quad-helix appliance (QDH), removable
plates, and grinding.13-16 However, the choice of
treatment during the mixed dentition is focused on the
transversal expansion of the maxillary teeth.15
Earlier studies showed equal effectiveness for the QDH
and removable plates in the treatment of posterior
crossbite.13-16 On the other hand, 2 systematic reviews
indicated that more scientific evidence from well-
designed randomized controlled trials is needed to deter-
mine the most effective treatment for early correction of
unilateral posterior crossbite and effective cost analysis.17,18
We conducted a community-based trial to compare
the effectiveness of the QDH and removable plates for
treating unilateral dental and functional posterior cross-
bite. Our hypothesis was that the QDH and the remov-
able plate would have equal effectiveness, equal costs,
and equal numbers of complications, whereas the un-
treated group (control) would not show self-correction.
MATERIAL AND METHODS
This was a community-based trial designed to pro-
duce more evidence of the efficacy of the 2 most popular
techniques available to treat posterior crossbite in the
mixed dentition. We also focused on access to treatment
by evaluating the cost effectiveness of these orthodontic
appliances. The subjects in this study were from public
schools and the Santo Amaro Social Project, conducted
e45
e46
Fig 1. Occlusal views of the QDH and EP appliances.
by the University of Pernambuco, Recife, Pernambuco,
Brazil. The Santo Amaro Social project enrolls about
700 children aged between 7 and 17 years. It is a social
program aimed at supporting sports activities for a large
underprivileged community located in a poor area of
Recife known as the Santo Amaro favela. This commu-
nity project also provides primary health care for the
participants, including oral hygiene.
The trial was conducted in the small dental clinic of
the Santo Amaro area, a basic dental unit in the center
of the favela.
The sample comprised 99 children from that commu-
nity, a sample large enough to produce statistically
significant results.
The treatments were funded by the University of
Pernambuco and a research grant from the Ministry of
Education of Brazil (CAPES); the treatment was free
for the patients. The target children had both unilateral
posterior dental and functional crossbites in the mixed
dentition (all incisors and permanent first molars were
already present).
To meet the inclusion criteria, the patients had no
sucking habits, previous orthodontic treatment, or Class
III malocclusion; they all had skeletal posterior crossbite.
The skeletal posterior crossbite was diagnosed by exam-
ining the casts models and anteroposterior cephalomet-
ric radiographs.
The study was approved by the ethics committee of
the University of Pernambuco. The parents or guardians
were informed of the purpose of the study and signed
the informed consent document allowing their children
to be treated.
The 99 children were randomly divided into 3 groups:
QDH, expansion plate (EP), and untreated controls. For
randomization, numbers were randomly drawn from
a plastic bag. Each child received a number from 1 to 99.
One specialist orthodontist in practice for over 10 years
(F.G.) diagnosed, took impressions (made the molds),
placed the appliances, and followed the treatment plan.
January 2011
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Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Godoy, Godoy-Bezerra, and Rosenblatt
Fig 2. Activation of the QDH appliance.
Since both the QDH and the EP are recommended for
treating functional and dental posterior crossbites, we
chose these 2 appliances to be used in our trial.
The QDH appliances were made of 0.9-mm stain-
less steel wire with stainless steel bands attached
with glass ionomer cement to the maxillary first mo-
lars (Fig 1). The degree of activation of the appliance
was adjusted to allow for the retention of the band on
1 side to pass from the central fossa of the first per-
manent molar when the other band was placed on
the molar. To try to prevent or compensate for rota-
tion and buccal tipping, the arms of the QDH were
held parallel to each other when activated, and a crown
torque was incorporated into the appliance so that the
molar bands were kept parallel (Fig 2). The QDH was
activated once a month until the posterior crossbite
was corrected.
The EP had a midline 10-mm screw, 4 stainless steel
clasps on the deciduous and permanent first molars, and
an acrylic covering (Fig 1). It was recommended that the
screw be opened a quarter rotation every week until the
posterior crossbite was corrected. The patient and par-
ents or guardians were instructed to use the EP day
and night except for tooth brushing.
Godoy, Godoy-Bezerra, and Rosenblatt e47

Table I. Age and sex characteristics

Group

QDH EP Control Total group

Variable (n 5 33) (n 5 33) (n 5 33) (n 5 99) P value
Age: mean 6 SD 8.00 6 0.79 7.82 6 0.85 8.09 6 0.81 7.97 6 0.81 Py 5 0.387
Sex: n (%)
Male 7 (21.2) 15 (45.5) 19 (56.6) 41 (41.4) Pz5 0.009*
Female 26 (78.8) 18 (54.5) 14 (42.2) 58 (58.6)

*Significant difference between groups at 5.0%; yANOVA; zPearson chi-square test.

Table II. Length of treatment until posterior crossbite correction, number of visits, number of appliances, and final
results of the treatment according to type of appliance
Group

QDH EP Total

Prevalence ratio
Variable n % n % n % P value (CI at 95%)
Length of treatment until posterior crossbite correction
Up to 3 months 18 54.5 6 18.2 24 36.4 Py5 0.009* 2.00 (1.02-3.92)
4 to 6 months 9 27.3 17 51.5 26 39.4 0.92 (0.41-2.12)
7 or more 6 18.2 10 30.3 16 24.2 1.00
Number of visits
#10 18 54.5 16 48.5 34 51.5 Py5 0.622 1.13 (0.69-1.84)
.10 15 45.5 17 51.5 32 48.5 1.00
Number of appliances
One 28 84.8 24 72.7 52 78.8 Py5 0.228 1.51 (0.72-3.18)
Two 5 15.2 9 27.3 14 21.2 1.00
Final result
Success 33 100.0 30 90.9 63 95.5 Py5 0.238 z

Failure - - 3 9.1 3 4.5

*Significant difference at 5.0%; yPearson’s chi-square test; zNot possible to determine due to the low occurrence.

The patients and parents received both oral and
written information on the treatment, oral hygiene,
and maintenance of the appliance.
In this study, we evaluated the following: correction
of posterior crossbite, amounts of maxillary and man-
dibular intermolar and intercanine expansion, length
of treatment, cost-benefit (treatment time, number of
appliances used, and number of appointments) success
rate, and number of complications. Palatal expansion
and crossbite correction were measured on the study
casts by 1 masked investigator (J.G.) using a sliding
caliper (model I 395 24989 MFGIN, Rocky Mountain
Orthodontics, Denver, Colo) to the nearest 0.1 mm.
The investigator was unaware of the type of appliance
used by the patient and the length of treatment (pre-
treatment, after expansion, after 6 months of retention,
or 6 months after removal of the retention plate).
The following measurements were made on the study
casts: (1) maxillary and mandibular intermolar widths:
the width between the central fossae of the right and
left maxillary and mandibular first permanent molars;
and (2) maxillary and mandibular intercanine widths:
the width between the crown tips of the right and left
deciduous or permanent maxillary and mandibular
canines (Fig 3). The mandibular arch was measured to
verify the spontaneous expansion achieved after the
maxillary expansion.
However, as expected in the mixed dentition, some
children did not yet have their permanent canines
after exfoliation of the deciduous teeth; as a result,
those children could not have this measurement
taken.
Dropouts and treatments not completed within 12
months were classified as unsuccessful.
For both techniques, the patients were evaluated
every 4 weeks; no overcorrection was produced, and
each child with the desired crossbite correction had
a plate placed for retention of the treatment to be
used 24 hours a day for 3 months and, after the first 3
months, for 3 more months just at night.
The untreated group received no orthodontic
treatment during the trial period. According to the

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Table III. Relapses 12 months after posterior crossbite correction according to type of appliance
Group

QDH EP Total group

Relapse n % n % n % P value RR (CI at 95%)

Yes 3 9.1 3 9.1 6 9.1 P*5 1.000 1.00
No 30 90.9 30 90.9 60 90.9 1.00 (0.43-2.32)
TOTAL 33 100.0 33 100.0 66 100.0

RR, relative risk.

*Fisher exact test.

Table IV. Means and standard deviations of the length of treatment until crossbite correction, number of complica-
tions, number of appliances used, and number of visits according to group
Group

Variable Statistics QDH EP P value

Length of treatment until crossbite correction (mo) Mean 4.24 6.12 Py 5 0.007*
Median 3.00 5.00
SD 2.05 3.25
Minimum 2 2
Maximum 9 15
Number of complications Mean 2.15 1.67 Py 5 0.122
Median 2.00 2.00
SD 0.80 0.50
Minimum 1 1
Maximum 3 2
Number of appliances used (cost) Mean 17.27 19.09 Pz 5 0.235
Median 15.00 15.00
SD 5.46 6.78
Minimum 15 15
Maximum 30 30
Number of visits Mean 11.48 11.61 Py 5 0.869
Median 10.00 11.00
SD 3.01 2.93
Minimum 8 8
Maximum 20 18

*Significant difference at 5.0%; yt test with equal variances; zT test with different variances.

ethics committee’s guidelines, for all children in the
untreated group who had no self-correction, the treat-
ment would be provided at no cost as part of another
trial.
Statistical analysis
The sample size calculation established an error of
5% and a power of 95%. To detect any differences in
length of treatment between the 2 methods, the means
and standard deviations were calculated based on the
data from the study of Hermanson et al18 (8.00 6
3.00 for the QDH; 12.00 6 5.00 for the EP). The sample
should include 27 patients per group to show a statisti-
cally significant difference. To make up for possible
dropouts, we decided to add 20% to the number of
children, so we ended up with a total of 99 children,
33 in each group.
To test the examiner’s internal reproducibility, after
examining 45 sets of study casts, we randomly selected
20 to be reexamined after 1 week to ensure internal
agreement. The results of the paired t test for the re-
peated measurements of intermolar and intercanine
maxillary widths performed on 20 sets of study casts
showed high agreement of the correlation coefficients
of 0.98 (0.97-0.99) for the maxillary molars and 0.95
(0.88-0.98) for the maxillary canines.
We used SPSS software (version 15, Statistical Pack-
age for the Social Sciences, Chicago, Ill) to analyze the
data. The Pearson chi-square test and the Fisher exact
test were used for analysis of differences between the

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Godoy, Godoy-Bezerra, and Rosenblatt e49

Table V. Evaluation of the type of appliance according to complications

Group

QDH EP Total group

Variable n % n % n % P value PR (CI at 95%)ǁ

Complication
Yes 13 39.4 9 27.3 22 33.3 Pz 5 0.296 1.30 (0.81-2.09)
No 20 60.6 24 72.7 44 66.7 1.00
Loss of appliance
y
Yes - - 8 24.2 8 12.1 P§ 5 0.005*
No 33 100.0 25 75.8 58 87.9
Displacement of appliance
Yes 11 33.3 - - 11 16.7 Pz \0.001* y

No 22 66.7 33 100.0 55 83.3

Breakage of appliance
y
Yes 6 18.2 - - 6 9.1 P§ 5 0.024*
No 27 81.8 33 100.0 60 90.9
Missed appointments
Yes 11 33.3 7 21.2 18 27.3 Pz 5 0.269 1.00
No 22 66.7 26 78.8 48 72.7 1.33 (0.83-2.16)
Total 33 100.0 33 100.0 66 100.0

*Significant difference at 5.0%; yNot possible to determine due to null occurrence; zPearson chi-square test; §Fisher exact test; ǁPrevalence ratios of
the QDH group in relation to the EP group.

variables. The t test was used for continuous variables
with equal or different variances. Analysis of variance
(ANOVA) with the Tukey test were used to compare in-
dependent groups, the effects of the treatment, the
length of the treatment, the amount of expansion, and
the costs between groups.
RESULTS
The numbers, sexes, and ages of the patients are
shown in Table I.
All children treated in this trial with both appliances
had their crossbite corrected. However, 3 patients in the
EP group showed crossbite correction only after the 12
months of treatment (Table II); no self-correction was
observed in the untreated group (control). Relapses
occurred in 9.1% of the 2 experimental groups after 1
year of follow-up (Table III).
The average treatment length to correct the unilat-
eral posterior crossbite was higher with the EP (6.12
months 6 3.25) than with the QDH (4.24 months 6
2.05) (Table IV).
Our study design was a prospective cohort, and our
patients were followed for approximately 20 months af-
ter correction, since our mean correction time was 4.5
months, depending on the choice of appliance.
The average numbers for loss of appliance, displace-
ment of appliance, breakage of appliance, and missed
appointments in the QDH group were 12.1% higher
than in the EP group (39.4% for the QDH group,
27.3% for the EP group).
No appliances were lost in the QDH group, but 24.2%
were lost in the EP group; failure occurred in one third of
the QDH patients during the treatment, but there were
no failures in the EP group. Breakage of appliances oc-
curred in 18.2% of the QDH patients and in none of the
EP patients. For both experimental groups, the average
number of clinical visits and the number of teeth
involved in the crossbite were about the same.
Because the patients in the EP group could activate
the appliance at home, loss of appointments did not in-
terfere with the treatment, whereas those in the QDH
group could not miss appointments because it would
represent a delay in treatment. The number of missed
appointments was 12.1% higher in the QDH group
than in the EP group (33.3% 3 21.2%). The results of
all complications can be seen in Table V.
For the cost-benefit analysis, the average number of
appliances used was 1.82 higher in the EP group than in
the QDH group, and the length of treatment was also
longer in the EP group (Tables II and IV). The
laboratory costs were the same for both appliances.
Comparing the total treatment costs, the number of
clinical visits, the length of treatment, and the number
of appliances needed, the EP group cost 10.53% more
than QDH group (Table IV).
There were no significant differences between the
groups in regard to the initial intercanine and intermolar
distances (Tables VI and VII). We can see significantly
larger amounts of expansion in maxillary intermolar
and intercanine distances in the QDH and EP groups

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e50 Godoy, Godoy-Bezerra, and Rosenblatt

Table VI. Means and standard deviations of maxillary intermolar and intercanine distances by time evaluation and
group
Group

QDH EP Control
Distance Evaluation/difference Mean 6 SD Mean 6 SD Mean 6 SD P value
Intermolar Initial 37.45 6 2.02 (a) 38.09 6 3.31 (a) 37.61 6 2.36 (a) Py 5 0.590
Until crossbite correction 43.15 6 2.83 (A, b) 42.55 6 2.46 (A, b) 37.76 6 2.41 (B, a) P (Tukey)y \0.001*
After 6 months retention 42.70 6 2.71 (A, c) 41.88 6 2.57 (A, c) 38.21 6 2.25 (B, b) P (Tukey)y \0.001*
Six months after removal 41.76 6 2.44 (A, d) 41.18 6 2.67 (A, d) 38.45 6 2.28 (B, b) P (Tukey)y \0.001*
of retention plate
Comparison of P values between Pz \0.001* Pz \0.001* Pz \0.001*
the 4 evaluations
Differences (initial 3 6 months 4.31 6 2.40 (A) 3.09 6 2.40 (A) 0.84 6 1.03 (B) P (Tamhane)y \0.001*
after removal of
retention plate)
Differences (initial 3 until crossbite 5.70 6 2.31 (A) 4.46 6 2.22 (A) 0.15 6 0.76 (B) P (Tamhane)y \0.001*
correction)
Intercanine Initial 28.57 6 2.52 (A, a) 31.10 6 3.10 (B, a) 31.39 6 2.81 (B) P (Tukey)y \0.001*
Until crossbite correction 32.08 6 2.41 (AB, b) 32.96 6 2.68 (A, ab) 31.17 6 2.78 (B) P (Tukey)y 5 0.048*
After 6 months retention 31.58 6 2.08 (b) 32.71 6 2.29 (ab) 31.27 6 2.83 Py 5 0.094
Six months after removal of 31.50 6 2.52 (b) 32.62 6 2.54 (b) 32.04 6 2.66 Py 5 0.354
retention plate
Comparison of P values P \0.001* Pz 5 0.012* Pz 5 0.110
between the 4 evaluations
Differences (initial 3 6 months 2.96 6 2.48 (A) 1.43 6 1.78 (B) 0.36 6 1.68 (B) P (Tukey)y \0.001*
after removal of retention plate)§
Differences (initial 3 until 3.48 6 2.24 (A) 1.80 6 2.96 (A) 0.17 6 0.59 (B) P (Tamhane)y \0.001*
crossbite correction)§
Note: If all upper-case letters in parentheses are different, there are significant differences between the corresponding groups with paired compar-
isons of Tukey(a) or Tamhane T2(b).
Note: If all lower-case letters in parentheses are different, there are significant differences between the corresponding evaluations with paired com-
parisons of Bonferroni.
*Significant difference at 5.0%; yANOVA; zANOVA test for repeated measurements; §The discrepancy in the value of the mean of the variable dif-
ferences and the differences between the values of the means in the 2 corresponding evaluations was a result of differences in the numbers due to
the possible loss of teeth in the mixted dentition.

than in the control group. No significant differences
were found between the 2 experimental groups. In the
mandibular arch, however, the QDH group had greater
intermolar expansion than did the EP group and the
control group (Table VII).
DISCUSSION
Our study showed equal success for the QDH and re-
movable plates in the treatment of posterior crossbite;
this was also reported in earlier studies.13-16,19
Despite the large number of published studies, which
resulted in 2 systematic reviews on posterior crossbite
correction,17,20 only 1 recent randomized controlled
trial reported on the effectiveness of the QDH
compared with the EP and an untreated group.21 The re-
sults of this recent study21 showed a higher number of
unsuccessful treatments in the EP group than in QDH
group; this agrees with a previous longitudinal study,
which found that only 50% of the treatments with re-
movable EPs were successful, and compliance could be
a predictable limitation.6 In our study, both treatments
promoted correction, and the reason for this broad suc-
cess was the high compliance of the patients; because of
their low access to orthodontic care in this poor target
community, the chance to take advantage of free treat-
ment probably encouraged compliance. However, after
the 12-month period, within the 6-month retention pe-
riod, a few patients (3 in each group) did not cooperate,
and relapses did occur in both experimental groups.
These findings agree with an earlier report that evaluated
the long-term stability of the correction of posterior
crossbite and found that the QDH group had 3 times
more relapses than did the EP group.16
In our study, instead of using the same QDH appli-
ance for retention for the QDH group, we chose to use
removable plates for retention in both experimental

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Godoy, Godoy-Bezerra, and Rosenblatt e51

Table VII. Means and standard deviations of the mandibular intermolar and intercanine distances by time evaluation
and group
Group

QDH EP Control
Distance Evaluation/differences Mean 6 SD Mean 6 SD Mean 6 SD P value
Intermolar Initial 41.12 6 2.27 (a) 42.09 6 2.82 42.30 6 2.36 Py 5 0.128
Until crossbite correction 41.58 6 2.11 (ab) 41.97 6 2.24 42.21 6 2.16 Py 5 0.488
After 6 months retention 41.79 6 2.12 (b) 41.79 6 2.51 41.97 6 2.23 Py 5 0.933
Six months after removal of 41.58 6 2.05 (ab) 41.73 6 2.31 42.12 6 2.19 Py 5 0.580
retention plate
Comparison of P value between Pz 5 0.014* Pz 5 0.385 Pz 5 0.215
the 4 evaluations
Differences (initial 3 6 months after 0.46 6 1.23 (A) 0.36 6 1.71 (B) 0.18 6 1.10 (AB) Py 5 0.044*
removal of retention plate)
Differences (initial 3 until crossbite 0.46 6 1.20 0.12 6 1.36 0.09 6 0.38 Py 5 0.054
correction)
Intercanine Initial 26.68 6 1.56 27.18 6 1.91 27.00 6 1.79 Py 5 0.537
Until crossbite correction 26.50 6 1.60 27.44 6 2.36 27.13 6 1.69 Py 5 0.183
After 6 months retention 26.65 6 1.15 27.52 6 2.05 27.48 6 1.68 Py 5 0.135
Six months after removal of 26.90 6 1.45 27.56 6 2.02 27.71 6 1.68 Py 5 0.275
retention plate
Comparison of P value between Pz 5 0.568 Pz 5 0.371 Pz 5 0.062
the 4 evaluations
Differences (initial 3 6 months after 0.05 6 1.66 0.39 6 1.56 0.70 6 1.40 Py 5 0.383
removal of retention plate)
Differences (initial 3 until crossbite 0.21 6 0.92 0.28 6 1.51 0.13 6 0.43 Py 5 0.192
correction)
Note: If all upper-case letters in parentheses are different, there are significant differences between the corresponding groups with paired compar-
isons of Tukey(I).
Note: If all lower-case letters in parentheses are different, there are significant differences between the corresponding evaluations with paired com-
parisons of Bonferroni.
*Significant difference at 5.0 %; yANOVA; zANOVA test for repeated measurements.

groups for consistency. This might have been the cause
of similar results with regard to relapses in both groups.
Some authors prefer to use the QDH itself as a retainer
for 3 months after completing treatment. In our experi-
ence, breakage or displacement of the QDH during
the retention period could compromise the treatment,
because it needs an appointment for recementing and
replacement; on the other hand, the EP, if underused,
can also lose its effectiveness for stability.
In the current literature, only a few studies have
reported on self-correction of posterior crossbite in
the deciduous dentition, related to the discontinua-
tion of sucking habits and chronic respiratory child-
hood diseases.4,5 At the beginning of the trial, the
above-mentioned studies might have diagnosed chil-
dren with nonnutritive sucking habits with functional
crossbite; however, as the sucking habit ceased, the
occlusion might have stabilized, leading to a false im-
pression that self-correction had occurred. In our
study, self-correction was not seen in the untreated
group. This observation might be because our sample
children were in the mixed dentition, and, in this age
range, there is a remarkable decrease in nonnutritive
sucking habits and chronic respiratory conditions. It
is known that, once the nonnutritive habit has ceased,
the maxilla continues with its transversal growth
without interference from the nonnutritive habit. In
our study, all patients either had never had a nonnu-
tritive habit or had ceased to have it at least 6
months before the trial to avoid this confounding
variable.
The average length of treatment to correct unilateral
posterior crossbite was higher in the EP group—6.12
months (SD, 3.25)—than in the QDH group—4.24
months (SD, 2.05)—and the average length of treatment
in the EP group was shorter than in previous re-
ports.16,18,21 This difference might be explained by the
fact that our participants showed excellent compliance.
In our study, the number of complications was higher
in the QDH group (displacement and breakage of appli-
ances) than in the EP group (loss of appliance). One
might think that the reasons for this could be the num-
ber of missed appointments, which was 12.1% higher in
the QDH group than in the EP group.

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For the QDH group, besides activating the appliance,
the orthodontist must educate the patient on what to eat
and what not to chew, and also reinforce the need to use
the appliance correctly. However, some patients will
place the tongue between the QDH and the palate and
insist on eating hard and sticky foods. Even though
the number of complications in the QDH group was
higher than in the EP group, the average number of
appliances needed was 1.82 higher in the EP group;
this increased the cost of treatment by 10.54% and
was also reported in a retrospective study.18
Based on our findings, we suggest that children with
posterior crossbite could be treated in the mixed dentition
period with simple appliances that would enable expan-
sion of the palate. Our study showed that the treatment
can be performed in 12 months for posterior crossbite
correction and 6 months for retention. Patient compli-
ance could have been an issue, but, in this trial, because
the treatment was free of charge, the children were willing
to be treated. These results can be reproduced in clinical
and community settings anywhere across the world.
CONCLUSIONS
1. The QDH and the EP had equal success in correcting
posterior crossbites in the mixed dentition.
2. The greatest disadvantage of the QDH compared
with the EP was frequent breakage.
3. The greatest disadvantge of the EP was lost appli-
ances and subsequent laboratory costs.
4. Greater maxillary expansion and greater spontane-
ous mandibular expansion were achieved with the
QDH, but there was also greater relapse.
5. Since the average treatment time was significantly
shorter and 11% cheaper in the QDH group, we
can definitely say that this is the more cost-
effective choice for treatment.
6. Posterior crossbites did not spontaneously correct
during the transition into the permanent dentition.
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