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Spontaneous correction of anterior crossbite by RPE anchored on deciduous

teeth in the early mixed dentition

Article  in  European Journal of Paediatric Dentistry · September 2012

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 M. Rosa, P. Lucchi*, L. Mariani, A. Caprioglio
University of Insubria, Varese, Italy
* University of Cagliari, Italy
e-mail: marcorosa@specialistiortodonzia.it
Spontaneous
correction of anterior
crossbite by rpe
anchored on deciduous
teeth in the early
mixed dentition
abstract
Aim The purpose of this study was to evaluate the
effectiveness of Haas RPE anchored on deciduous
teeth in the early mixed dentition, for inducing
the spontaneous correction of permanent incisor’s
crossbite, without compliance, without post bite-plane
and no involvement of the permanent teeth.
Materials and methods The sample group
comprised 50 consecutive patients (mean age 8y 5m,
SD 2y 1m), 31 males, 19 females. They showed a cross-
bite affecting one or more permanent incisors, for a
total of 70 teeth. The patients were treated with Haas
RPE appliance anchored on second deciduous molars
and bonded on deciduous canines. No direct forces
were applied on the permanent teeth.
Results Anterior crossbite self-corrected
‘spontaneously’ in 84% of the cases. Lateral incisors
had a higher rate of self-correction than central incisors.
All hyper-divergent subjects showed a spontaneous
crossbite self-correction.
Conclusion The early maxillary expansion by Haas
RPE anchored on deciduous teeth is an efficient and
effective procedure to induce the anterior crossbite
self-correction in the early mixed dentition without the
need of a bite-plane, no involvement of the permanent
teeth and without compliance.
Keywords Anchorage on deciduous teeth; Anterior
crossbite; Early treatment; Mixed dentition; Rapid
Palatal Expansion (RPE).
176
Introduction
Anterior crossbite is commonly noticed in the early
mixed dentition and refers to a condition where, in
centric occlusion, one or more upper incisors are
palatally positioned in relationship to the mandibular
teeth [Graber, 1988]. The prevalence reported in the
literature ranges from 2.2% to 11.9%, depending on
the age of the children observed [Major and Glover,
1992; O’Brian, 1993; Karaiskos et al., 2005; Lux et al.,
2009].
Causes of anterior crossbite can be multiple and related
to many factors: anterior crowding, lingual eruption
path of upper incisors, sequelae of traumatic injuries
on the deciduous incisors, dental anomalies (such as
supernumerary, cysts or odontomas), inadequate arch
form and length, over-retained or decayed deciduous
teeth or bad habits such as biting the upper lip. The
anterior crossbite is often also associated with other
malocclusions such as crowding, posterior crossbite,
rotations, mandibular shifts and asymmetries and Class
III malocclusion.
It is a commonly held opinion, that anterior crossbite
should be corrected as soon as possible. Furthermore
many clinical reports concluded that early treatment
appears to be most effective, especially when the crossbite
is associated to occlusal trauma due to CO/CR discrepancy
[Popovich and Thompson, 1973; Kocadereli, 1998]. The
main goal of early treatment is to prevent dentoalveolar
compensation, enamel abrasion or crown fracture,
periodontal breakdown (mostly gingival recession
on proclined lower incisors), teeth mobility and TMJ
disorders [Jones and O’Neill, 1996; Rubio et al., 2002].
Furthermore, this situation also involves unfavourable
aesthetics, which usually is the parents’ main concern
[Lee, 1978].
Many different treatment options such as fixed and/
or removable appliances, which act directly on the
malpositioned teeth, have been used and suggested by
several authors. Borrie and Bearn, in 2011, published
the results of a systematic literature review and “…
highlighted the lack of high quality evidence for the
management of anterior cross-bites in children.
Although the level of evidence is low, there is similarity
in the length of time it took to successfully treat anterior
cross-bites using similar treatment modalities...”.
We believe that early treatment should involve simple
and non-invasive procedures, minimal chair-side time
and it should be predictably successful (i.e. it should
not require any compliance).
With this in mind the aim of this study was to evaluate
the effectiveness of HAAS Rapid Palatal Expansion
(RPE) anchored on deciduous teeth in the early mixed
dentition, for inducing the spontaneous correction
of permanent incisor’s crossbite with no involvement
of the permanent teeth and without relying on the
patient’s compliance.
European Journal of Paediatric Dentistry vol. 13/3-2012
 SPONTANEOUS CORRECTION OF ANTERIOR CROSSBITE DURING RPE treatment

Subjects and methods
This study was a retrospective clinical investigation. The
sample group consisted of 50 children (31 males and 19
females) consecutively treated by the same clinician (MR).
The mean age of the sample was 8y 5m (SD 2y 1m).
All patients showed crowding in the upper arch
associated with the crossbite of one or more permanent
incisors. There was a total of 70 teeth, divided into
10 upper right lateral incisors, 19 upper right central
incisors, 28 upper left central incisors and 13 upper left
lateral incisors. Twenty out of the 50 patients (40%) also
showed a posterior crossbite.
Crowding of upper permanent incisors was evaluated
on casts with space analysis from the upper right to the
upper left first molars, from mesial to mesial. All patients
were then classified into severely crowded (lack of space
>8 mm), mildly crowded (lack of space 4-8 mm) and
slightly crowded (lack of space <4 mm). The sample was
split into 6 severely crowed, 30 mildly crowed and 14
slightly crowded subjects.
The vertical pattern of growth of the subjects was
evaluated tracing lateral cephalograms using GoGn:SN
(mean normal value 30° ±2°). The study group was
divided into 20 hypo-divergent, 17 normal and 13 hyper-
divergent subjects.
The patients were all treated with the same appliance
using the same clinical procedure: a Haas RPE appliance
was anchored with second deciduous molars bands
and bonded onto the deciduous canines using acrylic
resin [Rosa and Cozzani, 1995]. Regarding the type of
appliances, 47 were manufactured using Leone screw
11mm ref. AO620 (Leone SpA, Sesto Fiorentino, Italy)
and 3 using Forestadent screw 10 mm ref. A167-1326
(Forestadent Gmbh, Pforzheim, Germany).
All appliances were manufactured by the same dental
lab (Orthocheck / Trento / Italy).
In the patients with posterior crossbite, all appliances
were activated twice a day during the first 2 weeks, then
once a day; in the patients with no posterior crossbite the
screw was activated once a day during the first 3 weeks,
and then every other day. Expansion was carried out until
posterior crossbite on permanent molars selfcorrected
and adequate space for upper incisors eruption and
alignment was achieved. The mean activation was 9.8
mm in the posterior crossbite cases and 8.2 mm in the
non-posterior crossbite cases. Patients were monitored
every week by the clinician during the active expansion
phase.
Transverse overcorrection was obtained in the maxillary
arch on deciduous molars (a scissor bite in some cases),
but not on the untouched permanent molars, whose
transverse relationship was within a normal range, at the
end of active phase.
The posterior crossbite (permanent molars) self-
corrected in all patients during the active phase.
No direct forces were applied on the permanent teeth:
first molars or incisors. No posterior bite plane was used
in any patient.
A descriptive statistical analysis was conducted.

fig. 1, 2, 3 Anterior crossbite on both permanent lateral incisors self-corrected during RPE anchored on deciduous canine and
second deciduous molars in the early mixed dentition. At the end of the transition, before the second phase of treatment, the
crossbite self-correction is stable without any retention strategy.

figg. 4-6 Before treatment the anterior crossbite is established on fully erupted permanent lateral incisors. Crowding is also evident
on maxillary permanent incisors with no posterior crossbite.

European Journal of Paediatric Dentistry vol. 13/3-2012 177

ROSA M. et al.

figg. 7-9 After 30 activations of the RPE, the vertical dimension slightly increased due to posterior overcorrection until cusp to
cusp occlusion, the diastema opened between upper incisors and crossbite of lateral permanent incisors is self-correcting (Fig. 2)
with no direct forces acting on them.

figg. 10-12 One year after the active expansion, with the passive RPE bonded on upper deciduous second molars and canines, the
relapse of the scissor bite and occlusal spontaneous adjustment on posterior teeth during the retention time are remarkable. The
permanent incisors also self-adjusted: the diastema is closed, the crowding on permanent incisors spontaneously improved. The
anterior cross-bite did not relapse (Fig. 3).

Results appliances (brackets bonded onto the incisors in

The results of dental crossbite correction are shown
in Table 1 and 2.
As shown in Table 1, the anterior crossbite self-
corrected in 84% of the cases: 42 patients (31 males,
19 females) out of 50.
Looking at the different teeth, the correct position
was obtained in 84%. For 11 teeth that did not self-
correct, other devices were used in order to correct
the crossbite. In 4 cases the clinician used Class I
elastics, 2 crossbites were solved using resin bite-
block bonded on deciduous molars and 5 with fixed
crossbite using, the RPE bonded on deciduous canines
and molars as anchorage).
The crossbite self-correction was achieved within
the first 6 weeks of treatment in all cases.
As reported in Table 1, both, right and left lateral
incisors, showed a higher rate of self-correction when
compared to central incisors. Only 2 lateral incisors
remained in crossbite at the end of RPE activation.
All hyper-divergent patients had a spontaneous
resolution of the anterior crossbite, whereas the
lowest success rate was observed in the hypo-
divergent group.

Crossbite tooth numbers success failure

n % n % n %
11 19 27.14% 16 84.21% 3 15.79%

21 28 40.00% 22 78.57% 6 21.43%

12 10 14.28% 9 90.00% 1 10.00%

22 13 18.58% 12 92.30% 1 7.70%

tabLE 1 Distribution of
11+21 47 67.14% 38 87.15% 9 12.85% success and failure rates
12+22 23 32.86% 21 97.15% 2 2.85%
for different type of upper
incisors.

178 European Journal of Paediatric Dentistry vol. 13/3-2012

 SPONTANEOUS CORRECTION OF ANTERIOR CROSSBITE DURING RPE treatment
Go-Gn:SN numbers success
n % n %
< 28° 20 40 % 14
28°-32° 17 34% 14
> 32° 13 26% 13
Discussion
All the patients of the sample were treated with RPE
in order to correct the crowding and/or the posterior
crossbite. The RPE-Haas appliance was anchored only
on the deciduous teeth (bands on deciduous second
molars and bonded with resin on the palatal surface
of the deciduous canines) without involving the
permanent molars and permanent incisors. The main
reasons for anchoring the RPE on deciduous teeth
[Rosa, 2011; Rosa and Cozzani, 2003] are:
› prevention of any damage and/or unwanted
side-effects to permanent teeth: enamel
demineralisation, periodontal attachment loss,
external root resorption;
› untouched permanent molars move spontaneously
not only during the active expansion, but also in the
following months and adjust spontaneously within
stable occlusion;
› spontaneous correction of the posterior crossbite on
untouched permanent molars with no dentoalveolar
compensation (i.e. buccal tip);
› no need of permanent molars anchorage: deciduous
teeth can effectively support the load of the RPE.
It has been stated in the literature that the posterior
crossbite on untouched permanent molars self-
corrected in all cases [Cozzani et al., 1999; Cozzani
et al., 2003], and this was also observed in our
sample. in all hyper-divergent cases could be explained (and
We also agree that anterior crossbite is an indication
for early treatment. Most of the appliances proposed
in the literature to solve anterior crossbite, require
patient’s cooperation in wearing appliances, mechanics
which acts directly on the incisors and sometimes
time-consuming chairside treatment. RPE anchored on
deciduous teeth in the mixed dentition is a procedure
that is easy to manage with short visits and does
not require any compliance. Furthermore it allows
increasing the perimeter of upper arch and inducing
the self-improvement of the crowding and permanent
incisors’ rotation [Rosa, 2003 a; Cozzani et al., 2003;
Rosa, 2003 b].
The mean time for anterior crossbite correction was
5 weeks (SD 2w 4d), according with those reported in
literature. When correction did not occur in the first
3-6 weeks of treatment, direct forces were applied on
incisors, having as an anchorage the RPE bonded on
European Journal of Paediatric Dentistry vol. 13/3-2012
failure
n %
70.00% 6 30.00%
tabLE 2 Distribution of
82.36% 3 17.64% success and failure rates in
100.00% 0 0% hypo-divergent, normal and
hyper-divergent subjects.
the deciduous teeth. Indeed, as shown by Borrie and
Bearn [2011], cemented appliances had a tendency to
work within 3-4 weeks and fixed appliances correcting
the crossbite within 6 weeks to 3 months.
The anterior crossbite corrected in 84% of the
consecutively treated patients without raising the bite by
mean of bite planes or bonded devices. Actually, during
the active expansion, posterior occlusion changed from
a cusp-fossa relationship to a cusp-to-cusp relationship.
As a consequence the vertical dimension increases,
the bite opens and a slight relocation of the condyles
could occur, which is the occlusal condition required
for the anterior crossbite’s ‘spontaneous’ correction. In
the months following the active expansion, permanent
molars will adjusts to a correct occlusion (sometimes
after selective grinding of the deciduous molars) and
the vertical dimension returns to the pre-treatment
values. This also helps the stabilisation of the anterior
crossbite self-correction.
No retention appliance or strategy was required after
active treatment. None of the self-corrected incisors
and permanent molars relapsed.
The crossbite of lateral incisors has a higher rate
of self-correction than central incisors. This could be
related to the smaller amount of overbite due to the
shorter crown or to the fact that the lateral incisors
were not yet fully erupted.
Also the higher amount of self-correction (100%)
expected) for the same reason. Furthermore, in this
type of subjects, the occlusal and muscle forces could
be lower than in the hypodivergent patients, promoting
a more rapid and easier movement of the teeth.
Lastly we want to underline that also a spontaneous
(total or partial) de-rotation of the permanent crossbite
and crowded incisors was observed in all rotated
incisors. The early spontaneous de-rotation is stable
with no need of retention or circumferential supracrestal
fiberotomy. This point is for crucial interest in the
smiling area and could represent itself an indication for
early maxillary expansion [Rosa, 2003 a; Cozzani et al.,
2003; Rosa, 2003 b].
Conclusion
According to our data, in the large majority of cases
179
 ROSA M. et al.
(84%), RPE anchored on deciduous teeth in the early
mixed dentition is, in itself, an effective procedure to
induce crossbite spontaneous correction of permanent
incisors (87,15% of central incisors and 97,15% of
lateral incisors), when it is associated to crowding and/
or posterior crossbite.
The main advantage is:
› predictability (no compliance required);
› prevention (spontaneous correction without
involving the permanent teeth);
› effectiveness (no dentoalveolar compensation and
the achievement of a spontaneously established,
stable occlusion);
› efficiency (little chairside time and high cost-benefit
ratio);
› long-term stability.
Further prospective investigations are needed to
confirm our findings and clarify other clinical points:
effectiveness in spontaneous de-rotation of crowded
incisors, stability of early de-rotation, regarding the
best treatment timing and the relationship between
dental crowding and success.
Acknowledgement
We would like to thank Dr. Vittoria Fortini and Dr.
Jonathan Sandler for the manuscript review.
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European Journal of Paediatric Dentistry vol. 13/3-2012