DIAGNOSIS AND

TREATMENT OF
TRANSVERSE
DISCREPANCY

Preceptor- Dr. Shubhangi Jain

Presenter – Prithvi Raj Singh ( IInd year )
CONTENT
S
 Introduction
 Etiology
 Classification
 Diagnosis
 Treatment
INTRODUCT
ION
Crossbite is defined - ‘a transverse discrepancy in
tooth relationship’ – British Glossary of Dental Terms
ETIOLOGY
 Dental factors – faulty eruption pattern, insufficient arch
length, over retained primary teeth, ectopic eruption,
habits
 Skeletal factors – asymmetric growth of maxilla and
mandible, difference in basal width of maxilla and
mandible : constricted maxilla , cleft palate
 Functional factors – tooth interferences
CLASSIFICATION

Skeletal Dental

Functional

bilateral maxillary lingual

(or palatal) crossbite unilateral mandibular buccal
means that the upper crossbite would mean that the
molars are lingual to their mandibular molars are
normal position on both buccally positioned on one
sides, side
1. Dental transverse discrepancies: In one or both arches Lewis
et al stated that dental manifested transverse discrepancies
are caused due to local factors.

• congenitally missing tooth/teeth

• Early loss of deciduous teeth
• habits like thumb sucking or tongue thrusting
2. Skeletal transverse discrepancies :

The skeletal type of transverse discrepancy involves maxilla or

mandible or a mixture of both.

• The maxillary problems result from symmetric or asymmetric

basal arch constriction and varies depending upon severity of
condition.
• Rotational changes of maxilla/mandible - asymmetric occlusal
relationship and asymmetric positioning of glenoid fossa.
• Severe skeletal problems - trauma, infection or congenital
anomalies, like facial clefts.
3. Functional related transverse problem:

Deflection of the mandible due to occlusal interferences are

often caused. The abnormal tooth contact especially in centric
relation leads to consequent lateral or antero-posterior
mandibular displacement, resulting in an asymmetric
maxillomandibular relationship
 hollowing of the paranasal region,

excessive width of the buccal corridors,

MANIFESTATI nasolabial fold deepening, or narrowing of

the alar bases
ONS severe crowding, rotation, or
INDICATING buccal/palatal displacement of the teeth,
crossbite (uni- or bilateral),
TRANSVERSE high palatal vault, and hourglass- or V-
DEFICIENCY shaped occlusions are considered among
the main manifestations.
IN MAXILLA Mouth breathing

Model analysis - Pont, Linder-Harth, and

Korkhaus
Arch symmetry and transverse tooth inclination variability -
study cast.

Examination of patient study casts is again required in order to

determine whether the transverse deficiency is absolute or
relative.

If the proper transverse cusp fossa relationships in centric

relation are not exhibited by the posterior teeth, then the
transverse discrepancy is said to be relative when the posterior
teeth will properly occlude (if tooth alignment were correct)
when the canines are placed in Class I occlusion in this case.

However, if after a Class I canine relationship is articulated in

the casts, a crossbite is still present, the transverse discrepancy is
classified as absolute
A gross estimation or a measurement using the American
Board of Orthodontics (ABO) measuring gauge will suffice.
Placing an ABO gauge across left and right first molars
defines a transverse occlusal plane. The gauge should contact
both the buccal and lingual cusps if the molar being
investigated has a transverse axial inclination perpendicular
to said plane.
Ashley Howe's analysis
proposed by Ashley Howe (1947) which is based on the
relationship of the tooth position with its apical base. Howe
believed that the crowding of the teeth is usually due to a lack of
width at the apical base rather than the arch length.

1.Premolar diameter (PMD) refers to the distance between the

buccal cusp tips of the first maxillary premolars (arch width)

2.Premolar basal arch width (PMBAW) refers to the distance

between the right and left canine fossae at the apical base
3. Total tooth material (TTM) refers to the sum of the
mesiodistal width of the teeth from the first molar on
one side to the first molar on the opposite side.

4. PMD% is calculated as PMD X 100 /TTM

5. PMBAW% is calculated as PMBAW X 100 /TTM

MAXILLOMDIBULAR
DIFFERENTIAL
 The Rocky Mountain analysis, developed by Ricketts , to establish
relative norms between specific radiographic landmarks with
further measurements required for analysis of
maxillary/mandibular transverse discrepancy.
 The frontolateral facial lines and the effective mandibular and
maxillary widths can be determined using said landmarks.
 maxillary width is the width between the points jugale left (JL)
and jugale right (JR), while mandibular width is the width between
the right antegonial tubercle (AG) and the left antegonial tubercle
(GA) .
 A maxillomandibular transverse differential index greater than
5mm in an adult patient indicates transverse deficiency.
YONSAI INDEX
 Kee –Joon Lee et al, sem in ortho 2018
 An estimated centre of resistance was used to represent the
transverse position of the posterior segment from the
CBCT
 The transverse width of the crown or estimated COR were
measured and compared
 The average difference between the max and mand widths
at COR was -0.39+1.87mm
WALA RIDGE
 Andrew in 2015 suggested a primary landmark for
assessing mandibular arch width and shape.
 WALA is an acronym for Will Andrews and Larry
Andrews, who collaborated in the discovery. The ridge is
the most prominent portion of a mandible’s mucogingival
junction.
DIAGNOSIS
 The width of the maxillary skeletal base can be seen by the
width of the palatal vault on the casts.
 If the base of the palatal vault is wide, but the dentoalveolar
processes lean inward, the crossbite is DENTAL in the sense
that it is caused by a distortion of the dental arch.
 If the palatal vault is narrow and the maxillary teeth lean
outward but are in crossbite, the problem is SKELETAL in
that it basically results from the narrow width of the maxilla.
 Just as there are dental compensations for skeletal deformity in
the AP and vertical planes of space, the teeth can compensate
for transverse skeletal problems, tipping facially or lingually if
the skeletal base is narrow or wide respectively.
 posterior crossbite in a preadolescent child falls into the
moderate category if no other complicating factors (such as
severe crowding) are present.
 It should be treated early if the child shifts laterally from the
initial dental contact position (a centric relation–to–centric
occlusion [CR-CO] shift). If there is no shift but space in the
arch is borderline, early mixed dentition treatment sometimes is
recommended, but usually it is better to delay until the late
mixed dentition so that more teeth can be guided into position.
 If a skeletal posterior crossbite is treated in adolescence, it will
require heavier forces and more complex appliances.
WHY EARLY TREATMENT???
 The status of the primary occlusion affects the
development of the permanent occlusion. Thus, a posterior
crossbite is believed to be transferred from primary to
permanent dentition, and the posterior crossbite can have
long-term effects on the growth and development of the
teeth and jaws.
 The abnormal movement of the lower jaw (mandibular
shift) may place a special strain on the orofacial structures,
causing adverse effects on the temporomandibular joints
and masticatory system.
 EMG; electromyographic studies have shown that the
activity of the temporal and masseter muscles is disturbed in
children with unilateral crossbite.
 Studies of adolescents and adults have revealed that
patients with posterior crossbite have an increased risk to
develop craniomandibular disorders, showing more signs
and symptoms of these problems.
 Therefore, early treatment is often advised to normalize the
occlusion and create conditions for normal occlusal
development
 Correcting posterior crossbites in the mixed dentition
increases arch circumference and provides more room for
the permanent teeth.
 On an average, a 1-mm increase in the inter-premolar width
increases arch perimeter values by 0.7 mm
TREATMENT
Treatment of dental transverse discrepancies: Behrents et al
suggested that depending on severity and whether the
abnormality is skeletal or dental in nature, the treatment options
available are broadly divided into three major treatment
methods:

1. The early correction of transverse discrepancies and

orthopedic approach to correct developing imbalance – This
involves eliminating functional shifts

2. Camouflage through orthodontic treatment – This is to

address dental related problems

3. A combination of orthodontic and surgical treatment for

severe discrepancies
 There are three basic approaches to the treatment of moderate
posterior crossbites in children-

expansion of a repositioning of
equilibration to
constricted individual teeth to
eliminate
maxillary arch, deal with intra-
mandibular shift,
and arch asymmetries
Crossbite due to mandibular shift.
 A, Initial contact;
 B, shift into centric occlusion.

The slight lingual position of the primary canines

can lead to occlusal interferences and an apparent
posterior crossbite.

This cause of posterior

crossbite is infrequent
and is best treated by
occlusal adjustment of
the primary canines
Moderate bilateral maxillary
constriction.
 A, Initial contact;
 B, shift into centric occlusion.

Moderate bilateral maxillary constriction

often leads to posterior interferences
upon closure and a lateral shift of the
mandible into an apparent unilateral
posterior crossbite

. This problem also is

best treated by
bilateral maxillary
expansion
Marked bilateral maxillary
constriction.
 A, Initial contact;
 B, centric occlusion (no shift).

Severe constriction often produces no

interferences upon closure, and the patient
has a bilateral posterior crossbite in centric
relation.

This problem is best

treated by bilateral
maxillary expansion
W – ARCH
fixed appliance constructed of 36 mil steel
wire soldered to molar bands .

activated by opening the apices of the W

and is easily adjusted to provide more
anterior than posterior expansion, or vice
versa, if this is desired.

The appliance delivers proper force levels

when opened 4-5 mm wider than the
passive width and should be adjusted to
this dimension before being inserted.
QUAD
HELIX
more flexible version of the W-arch.
The helices in the anterior palate are bulky,
which can effectively serve as a reminder to
aid in stopping a finger habit.
The combination of a posterior crossbite and a
finger-sucking habit is the best indication for
this appliance.
The extra wire incorporated in this appliance
gives it slightly greater range of action than the
W-arch, but the forces are equivalent
 average palatal expansion of 3.9 mm and an average
intermolar expansion of 6.5 mm
 with rapid or slow expansion using a jackscrew device, the
skeletal change was about 50% of the total change.
Expansion should continue at the rate of
2 mm per month (1mm tooth movement
on each side) until the crossbite is
slightly overcorrected. (the lingual cusps
of the maxillary teeth should occlude on
the lingual inclines of the buccal cusps
of the mandibular molars at the end of
active treatment)

Most posterior crossbites require 2 to 3

months of active treatment and 3 months
of retention (during which the lingual
arch is left passively in place
True unilateral maxillary
posterior constriction
 due to unilateral maxillary
constriction of the upper arch
 In these cases the ideal treatment is
to move selected teeth on the
constricted side.
can be achieved by using
different length arms on
a W-arch

or quad helix but some

bilateral expansion must be
expected.
 An alternative is to use a
mandibular lingual arch to
stabilize the lower teeth and
attach crosselastics to the
maxillary teeth that are at
fault. This is more
complicated and requires
cooperation to be successful,
but is more unilateral in its
effect.

 a latex elastic (unless the

patient has a latex allergy,
which is an indication for
polymer elastics) with a 3/ 16-
inch (5-mm) lumen
generating 6 ounces (170 gm)
of force
PALATAL EXPANSION IN PRIMARY
AND EARLY MIXED DENTITION
(1)a split removable plate with a jackscrew or heavy
midline spring;
(2) a lingual arch, often of the W-arch or quad-helix
design; or
(3) a fixed palatal expander with a jackscrew, which can
be either attached to bands or incorporated into a
bonded appliance. Removable plates and lingual
arches produce slow expansion. The fixed expander
can be activated for either rapid (0.5mm or more per
day), semi-rapid (0.25mm/day), or slow (lmm/week)
expansion
 a mix of skeletal and dental change that approximates one-
third skeletal and two-thirds dental change.
Out of 10mm expansion –
80% skeletal
20% dental
At 10 weeks – both skeletal
and dental are equal
Rate – 0.5mm / day
2 quarter turns of screw
 50% skeletal and 50% dental
from beginning
 1 turn / day or every other
day
 Rate – less than 2mm / week
PALATAL EXPANSION IN
PREADOLESCENT ( LATE MIXED
DENTITION )
 With increasing age, the midpalatal suture becomes more and
more tightly interdigitated.
 heavy force directed across the suture, which microfractures the
interdigitated bone spicules so that the halves of the maxilla can
be moved apart.
 A fixed jackscrew appliance
 functional appliances for Class II treatment on maxillary arch,
either intrinsic force-generating mechanisms such as springs and
jackscrews or buccal shields that reduce cheek pressure against
the dentition.
PALATAL EXPANSION IN ADOLESCENTS
(EARLY PERMANENT DENTITION)

 micro-implant assisted palatal expansion (MARPE) should

be used, with one activation of the screw (0.25 mm) per day,
rather than using heavy force against the teeth.
 This approach along with surgically assisted palatal
expansion (SARPE) and segmental osteotomy of the
maxilla are the possibilities for the more mature patients in
whom tooth supported expanders will not work
A Systematic Review Concerning Early Orthodontic Treatment of Unilateral Posterior Crossbite; Petre´n etal (Angle Orthod 2003;73:588–596.)
 The success rate was reported to be 100% or close to 100% for
treatment with QH and RME. For expansion plates, the success rate
reported was between 51% and 100% and for grinding, between
27% and 90%. Spontaneous correction was found to occur between
16% and 50% in the untreated control groups
 The treatment time for QH varied between one and 7.7 months and
that for expansion plate between four and 14 months. For RME, the
treatment time was 19 days

A Systematic Review Concerning Early Orthodontic Treatment of Unilateral Posterior Crossbite; Petre´n etal (Angle Orthod
2003;73:588–596.)
 Quad helix vs expansion plate - A greater increase in the maxillary
intermolar width was found in quad-helix group compared to the removable
expansion plate group, and the diference was statistically significant
 The treatment duration by quad-helix ranged from 3.36 to 7.7 months,
whereas the expansion by removable expansion plate took from 3.8 to
12.5 months
 The meta-analysis revealed that there was a non-signifcant diference
between the QH and EP patients in correcting mandibular midline deviation
Rme vs control
 It found a signifcant increase in the intercanine transversal width of the
maxillary arch (mean value: 3.6 mm) compared with the control group
(mean value: 1 mm)

Alsawaf et al. Progress in Orthodontics (2022) 23:5

Correction of Posterior Crossbites: Diagnosis and Treatment; Binder etal (Pediatr Dent. 2004;26:266-272
Correction of Posterior Crossbites: Diagnosis and Treatment; Binder etal (Pediatr Dent. 2004;26:266-272
Correction of Posterior Crossbites: Diagnosis and Treatment; Binder
etal (Pediatr Dent. 2004;26:266-272
 Effects of Palatal Expansion with Torque Activation using a
Transpalatal Arch: A Preliminary Single-Blind Randomized
Clinical Trial

Effects of Palatal Expansion with Torque Activation using a Transpalatal Arch: A Preliminary Single-Blind Randomized
Clinical Trial; Ghorbanyjavadpour etal; Hindawi International Journal of Dentistry Volume 2021
Effects of Palatal Expansion with Torque Activation using a Transpalatal Arch: A Preliminary Single-Blind
Randomized Clinical Trial; Ghorbanyjavadpour etal; Hindawi International Journal of Dentistry Volume 2021
REFERENCES
 Contemporary Orthodontics , William R. Proffit ,6th edition
 Orthodontics : diagnosis and management of malocclusion and dentofacial deformities .OP
Kharbanda
 A Systematic Review Concerning Early Orthodontic Treatment of Unilateral Posterior
Crossbite; Petre´n etal (Angle Orthod 2003;73:588–596.)
 Alsawaf et al. Progress in Orthodontics (2022) 23:5
 Correction of Posterior Crossbites: Diagnosis and Treatment; Binder etal (Pediatr Dent.
2004;26:266-272)
 Lippold et al. Trials 2013
 Functional changes after early treatment of unilateral posterior cross-bite associated with
mandibular shift: a systematic review; tsanidis etal Journal of Oral Rehabilitation 2016
 Effects of Palatal Expansion with Torque Activation using a Transpalatal Arch: A Preliminary
Single-Blind Randomized Clinical Trial; Ghorbanyjavadpour etal; Hindawi International
Journal of Dentistry Volume 2021
 Bin Dakhil N, Bin Salamah F (December 17, 2021) The Diagnosis Methods and Management
Modalities of Maxillary Transverse Discrepancy. Cureus 13(12): e20482
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