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INTERCEPTION OF SEVERE ANTERIOR TOOTH ROTATION AND CROSS
BITE IN THE MIXED DENTITION- A CASE REPORT.
Suresh K.S.*, Nagarathna J**.
ABSTRACT
This is a case report of an, 11 year old boy of mixed dentition age with class I
malocclusion presented with severe rotation of upper left central incisor and single tooth
anterior crossbite with inadequate space for their alignment. First premolar and retained
deciduous lateral incisor were extracted followed by fixed orthodontic treatment which
resulted in correction of single tooth cross bite and rapid correction of severly rotated
tooth within three months.
AOSR 2013; 3(1): 76- 83
Keywords: Dental cross bite, mixed dentition, fixed orthodontic treatment.
* Professor and Head of the department, Pedodontics & Preventive Dentistry,
Government Dental College & Research Institute, Bangalore – 560002, India.
** Lecturer, Department of Pedodontics & Preventive Dentistry, Government Dental
College & Research Institute, Bangalore – 560002, India.
and disturbances related to position.2
INTRODUCTION
Recognizing
conditions,
which
Tooth rotation is one among the eruption
predispose to malocclusion in young
disturbances related to position which
children, is an important part of any
poses greater difficulty for correction
comprehensive
dental
more so, if
Interceptive treatment is
compounded
1
assessment.
pediatric
the tooth in rotation is
with
adjacent
tooth
usually carried out in order to reduce the
malposition and inadequate space in the
severity of a developing malocclusion.
arch.
The period of mixed dentition offers the
Tooth rotation can be defined as
greatest
observable mesiolingual or distolingual
guidance
opportunity
and
for
occlusal
interception
of
intra alveolar displacement of the tooth
malocclusion.
around its longitudinal axis.3 A rotated
Eruption disturbances can be broadly
upper central incisor can be corrected by
classified as disturbances related to time
a removable orthodontic appliance with
76
Anterior tooth rotation & cross bite
minimal force but severe rotation with
inadequate arch length, a habit of biting
adjacent
the upper lip.
tooth
malposition
and
inadequate space within the arch for
Anterior cross bite may lead to abnormal
their alignment are difficult to correct.
enamel abrasion of the lower incisors,
Many rotations are associated with an
dental
element of apical displacement and will
incisors leading to thinning of labial
be difficult to correct with removable
alveolar plate, and/or gingival recession.
appliance.4
Anterior dental cross bite requires early
Anterior cross bites are commonly
and immediate treatment to prevent
encountered
malocclusion,
anterior
discrepancy
in
the
due
the
buccolingual
compensation
teeth
periodontal
of
mandibular
mobility,
fracture,
pathosis,
and
relationship of the upper and lower
temporomandibular joint disturbance. 6-12
teeth.5 Graber has defined cross bite as a
Lee13 outlined four factors to consider
condition, where one or more teeth may
before selecting a treatment approach
be abnormally malposed either lingually
1. Adequate space in the arch to
or labially with reference to opposing
reposition the tooth
teeth. Anterior dental cross bite has a
2. Suffcient overbite to hold tooth in
reported incidence of 4-5% and usually
position following correction
becomes evident during the early mixed-
3. An apical positioning of the tooth in
dentition phase.6-9
cross bite
The anterior cross bite may result from
4. A class I occlusion
variety of factors such as lingual
The main goal of treatment is to tip the
eruption path of the maxillary anterior
affected maxillary tooth or teeth labially
incisors, a repaired cleft lip, trauma to
to the point where a stable overbite
the primary incisor resulting in lingual
relationship exists.14 Relapse is usually
displacement of the permanent tooth
prevented by the normal overjet/overbite
germ, supernumerary anterior teeth, an
relationship that is achieved.15 Treatment
over-retained
pulpless
modalities for correction of anterior
deciduous tooth or root, odontomas,
cross bite are tongue blades, reversed
crowding
stainless steel crowns, fixed acrylic
in
necrotic
the
or
incisor
region,
inclined planes, bonded resin-composite
77
Suresh KS et al.
slopes, removable acrylic appliances
with
finger
springs,
and
Bruckl
appliance.10,12,16
Teeth which erupt in cross bite may be
corrected from the tipping forces that are
provided by removable appliances but in
cases of incisor root which are palatally
displaced, removable appliance offering
tipping force will not produce full
correction.
Fig 1: Pretreatment photograph showing
rotated 21& retained 62.
The aim of this case report was to
canine bilaterally and class I molar
describe
fixed
relation. The maxillary left central
appliance in correction of severely
incisor was mesiopalatally rotated and
rotated anterior tooth and anterior dental
maxillary
cross bite with inadequate space for their
palatally erupted was in cross bite
alignment in mixed dentition patient.
associated with retained primary lateral
the
advantages
of
left
lateral
incisor
was
incisor. (Fig-2)
CASE REPORT
An 11 year old male patient was
Total space analysis revealed inadequate
reported to Department of Pedodontics,
space for the mesiodistal alignment of
Government Dental College with the
rotated central incisor as well as
chief complaint of irregularly positioned
palatally erupted lateral incisor, hence it
upper front teeth. (Fig-1) The child’s
was decided to extract upper left first
Medical history was non contributory
premolar to create space for alignment of
and
examination
malpositioned teeth and also to provide
revealed late mixed dentition in the
sufficient space for the eruption of the
upper arch with uneruped permanent
permanent canine.
78
intraoral
clinical
Anterior tooth rotation & cross bite
correction of the cross bite; hence lower
bilateral removable bite plane was
removed. The same nickel titanium wire
was engaged with the rotated upper left
central incisor. Patient was seen for
routine orthodontic activation of the full
arch appliance once in 15 days. After 3
months of activation, the rotated upper
left central incisor was repositioned to its
Fig 2: Dental casts showing rotated 21,
normal position. (fig-3)
palatally erupted 22 & retained 62.
The parents were informed about the
malocclusion, and a written consent to
proceed with the treatment was taken
and aimed at correction of the cross bite
followed by rotation correction. In the
first appointment, retained deciduous left
lateral incisor was extracted and after the
correction of cross bite, in subsequent
appointment upper left first premolar
was extracted. Two molar bands were
cemented to the upper first molars and
preadjusted edgewise brackets of 0.18
Fig 3: Dental casts showing derotated 21
slot were bonded on the respected teeth
& correction of crossbite w.r.t 22.
15,14,11,21,22,24,25 and tooth in cross
bite was engaged with 0.16 round nickel
The
titanium wire and bilateral removable
retention was started by a modified
posterior bite plane was placed in the
Hawley
lower arch to open the bite in the
appliance removal, the childs intraoral
anterior
appearance was consistent with what one
79
region.
There
was
rapid
appliance
retainer.
was
At
removed
the
time
and
of
Suresh KS et al.
would normally find in a child of his
between 8 to 11 years during which the
age.
root is being formed and the tooth is in
the active stage of eruption. The
important role plays not only the age of
the child but also the motivation for
treatment, how he or she perceives the
problem.
There are different treatment approaches
Fig 4: Post treatment photograph
showing well aligned teeth.
for the correction of anterior dental cross
bite which can be used in early mixed
dentition period. These include tongue
blade therapy18, reverse stainless steel
DISCUSSION
crowns19, removable Hawley retainer
Several clinical treatments have been
proposed in the literature for correcting
malpositioned
removable
teeth
and
which
fixed
include
appliances.
Anterior cross bite is a condition which
seldom corrects by itself because the
maxillary incisor is locked behind the
mandibular incisors and continues to
progress leading to severe malocclusion,
thus early treatment can reestablish
proper muscle balance and a well
balanced occlusal development. Early
treatment
is
also
directed
towards
preventing dysplastic growth of both
skeletal
and
the
dentoalveolar
components.17 The ideal age for the
correction of anterior dental cross bite is
80
with anterior Z-springs14 and bonded
resin-composite slopes.16
The tongue
blade therapy is successful only with
patient cooperation, and there is no
precise control of the amount and
direction of force applied. The reverse
stainless steel crowns have been shown
to be successful but the two main
disadvantages of using reverse stainless
steel
crowns
are
the
unaesthetic
appearance of the crown form and the
limitations of working with an inclined
slope
that
removable
patient
is
already
appliance
cooperation
formed.
A
also
requires
and
parental
supervision.5 The Lower Inclined Bite
Plane is the traditional method used for
Anterior tooth rotation & cross bite
correcting
or
contour and may increase the chance of
multiple tooth dental cross bite. It has to
relapse. Hence decision was taken to
be used only if there is enough space in
choose fixed appliance as the right
dental arch for labial movement of the
approach in correction of malpositioned
upper incisors. Clinically it can be used
teeth in this case. A major goal of
in cases when upper incisors are in cross
extraction of maxillary left first premolar
bite with more than one half of vertical
in this patient was to make tooth mass
overbite. The movement of teeth occurs
compatible with the arch dimension,
from the resulting force of closing
thereby enhancing the stability of final
muscle and inclined plane interaction.
occlusion also the results of extraction
One of the shortcomings of early
therapy have been proven quite stable
treatment is the possibility of a two-
over the long term resulting in well
phase orthodontic therapy as often it is
alignment of the teeth with their
difficult to estimate the further growth of
adjacent. For a late mixed dentition child
the
anterior
mandible.20
crowding
in
single
The
tooth
presence
mandibular
of
with severe rotation and crossbite were
incisors,
efficiently managed using fixed full arch
tempromandibular joint problems, and
maxillary
considered
deficiency
before
has
to
suggesting
appliance.
be
this
CONCLUSION
appliance.
Timely intervention of malocclusion
One should be aware of limitations of
should be initiated as early as possible to
using removable appliances in correction
prevent existing problems from getting
of rotated tooth as one obtains point
worse and minimize or eliminate the
contact resulting in tipping movements
need for comprehensive orthodontic
which is less effective at derotation of
treatment at a later stage. Treatment of
tooth than fixed appliance. If the incisor
malpositioned teeth are relatively precise
root positioned palatally torquing the
if it is planned with fixed orthodontic
incisor root, with simple tipping force
appliance
will procline the tooth excessively
postoperative results without any relapse
leading to poor esthetics, poor gingival
resulted in rapid correction of single
81
in
attaining
of
desired
Suresh KS et al.
tooth dental cross bite & correction of
5. Skeggs RM, Sandler RM. Rapid
severely rotated upper left central incisor
correction of anterior crossbite
with good alignment of the erupting
using a fixed appliance. A case
canine.
report. Dent Update 2002; 29:
299-302.
Hence it can conclude that in magnitude
6. Major PW, Glover K. Treatment
of malpositioned teeth, fixed appliance
of anterior cross-bites in the early
by providing good anchorage, minimal
mixed dentition. J Can Dent
duration, should be considered as the
Assoc 1992; 58: 574–575.
treatment of choice.
7. Heikinheimo
K,
Myllarniemi
S.
evaluation
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CORRESPONDENCE
Dr. Suresh KS
Government Dental College & Research Institute,
Bangalore – 560002
Email – [email protected]
Phone - +919740159214
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Orthops 2002; 121: 582–583.
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83
Am