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
malocclusion presented with se!ere rotation of upper left central incisor and single tooth
anterior crossbite with inade"uate space for their alignment. #irst premolar, retained
deciduous lateral incisor were extracted followed by fixed orthodontic treatment which
resulted in correction of single tooth crossbite and rapid correction of se!erly rotated
tooth within three months.
Keywords$ se!ere rotated tooth, dental cross bite, mixed dentition, fixed orthodontic
treatment.
* %rofessor and &ead of the department, %edodontics ' %re!enti!e (entistry,
)o!ernment (ental *ollege ' +esearch nstitute, ,angalore - ./0001, ndia.
** 2ecturer, (epartment of %edodontics ' %re!enti!e (entistry, )o!ernment (ental
*ollege ' +esearch nstitute, ,angalore - ./0001, ndia.
Introduction: +ecognising conditions, which predispose to malocclusion in young
children, is an important part of any comprehensi!e pediatric dental assessment.
1
ntercepti!e treatment is usually carried out in order to reduce

the se!erity of a de!eloping
malocclusion. The period of mixed dentition offers the greatest opportunity for occlusal
guidance and interception of malocclusion.
3ruption disturbances can be broadly classified as disturbances related to time and
disturbances related to position.
1
Tooth rotation is one among the eruption disturbances
1
related to position which poses greater difficulty for correction more so, if the tooth in
rotation is compounded with ad4acent tooth malposition and inade"uate space in the arch.
Tooth rotation can be defined as obser!able mesiolingual or distolingual intra al!eolar
displacement of the tooth around its longitudinal axis.
5
6 rotated upper central incisor can
be corrected by a remo!able orthodontic appliance with minimal force but se!ere rotation
with ad4acent tooth malposition and inade"uate space within the arch for their alignment
are difficult to correct. 7any rotations are associated with an element of apical
displacement and will be difficult to correct with remo!able appliance.
8
6nterior crossbites are commonly encountered malocclusion, is the discrepancy in the
buccolingual relationship of the upper and lower teeth.
.
)raber has defined crossbite as a
condition, where one or more teeth may be abnormally malposed either lingually or
labially with reference to opposing teeth. 6nterior dental crossbite has a reported
incidence of 89.: and usually becomes e!ident during the early mixed9dentition phase.
/9;
The anterior crossbite may result from !ariety of factors such as lingual eruption path of
the maxillary anterior incisors, a repaired cleft lip, trauma to the primary incisor resulting
in lingual displacement of the permanent tooth germ, supernumerary anterior teeth, an
o!er9retained necrotic or pulpless deciduous tooth or root, odontomas, crowding in the
incisor region, inade"uate arch length, a habit of biting the upper lip.
6nterior crossbite may lead to abnormal enamel abrasion of the lower incisors, dental
compensation of mandibular incisors leading to thinning of labial al!eolar plate, and<or
gingi!al recession. 6nterior dental crossbite re"uires early and immediate treatment to
pre!ent anterior teeth mobility, fracture, periodontal pathosis, and temporomandibular
4oint disturbance.
/911

2ee
15
outlined four factors to consider before selecting a treatment approach
1. 6de"uate space in the arch to reposition the tooth
1. Suffcient o!erbite to hold tooth in position following correction
5. 6n apical positioning of the tooth in cross bite
1
8. 6 class occlusion
The main goal of treatment is to tip the affected maxillary tooth or teeth labially to the
point where a stable o!erbite relationship exists
18
+elapse is usually pre!ented by the
normal o!er4et<o!erbite relationship that is achie!ed
1.
Treatment modalities for
correction of anterior crossbite are tongue blades, re!ersed stainless steel crowns, fixed
acrylic inclined planes, bonded resin9composite slopes, remo!able acrylic appliances
with finger springs, and ,ruc=l appliance.
10,11,1/
Teeth which may erupted in cross bite may be corrected from the tipping forces that are
pro!ided by remo!able appliances but in cases of incisor root palatally displaced
remo!able appliance offering tipping force will not produce full correction.
The aim of this case report was to describe the ad!antages of fixed appliance in
correction of se!erely rotated anterior tooth and anterior dental cross bite with inade"uate
space for their alignment in mixed dentition patient.
Case report: 6n 11 year old male patient was reported to (epartment of %edodontics,
)o!ernment (ental *ollege with the chief complaint of irregularly positioned upper front
teeth.>figure91? The child@s 7edical history was non contributory and intraoral clinical
examination re!ealed late mixed dentition in the upper arch with uneruped permanent
canine bilaterally and class molar relation. The maxillary left central incisor was
mesiopalatally rotated and maxillary left lateral incisor was palatally erupted was in
crossbite associated with retained primary lateral incisor. >#igure91?
#igure91
5
%retreatment photograph showing rotated 11' retained /1
#igure91

(ental casts showing rotated 11, palatally erupted 11 ' retained /1
8
Total space analysis re!ealed inade"uate space for the mesiodistal alignment of rotated
central incisor as well as palatally erupted lateral incisor, hence it was decided to extract
upper left first premolar to create space for alignment of malpositioned teeth and also to
pro!ide sufficient space for the eruption of the permanent canine.
The parents were informed about the malocclusion, and a written consent to proceed with
the treatment was ta=en and aimed at correction of the crossbite followed by rotation
correction. n the first appointment, retained deciduous left lateral incisor was extracted
and after the correction of crossbite, in subse"uent appointment upper left first premolar
was extracted. Two molar bands were cemented to the upper first molars and pread4usted
edgewise brac=ets of 0.1A slot were bonded on the respected teeth1.,18,11,11,11,18,1.
and tooth in crossbite was engaged with 0.1/ round nic=el titanium wire and bilateral
remo!able posterior bite plane was placed in the lower arch to open the bite in the
anterior region. There was rapid correction of the crossbite, hence lower bilateral
remo!able bite plane was remo!ed. The same nic=el titanium wire was engaged with the
rotated upper left central incisor. %atient was seen for routine orthodontic acti!ation of the
full arch appliance once in 1. days.6fter 5 months of acti!ation, the rotated upper left
central incisor was repositioned to its normal position.>figure95? The appliance was
remo!ed and retention was started by a modified &awley retainer. 6t the time of
appliance remo!al, the childs intraoral appearance was consistent with what one would
normally find in a child of his age.
#igure95

(ental casts showing derotated 11 ' correction of crossbite w.r.t 11
.
Figure-4

%ost treatment photograph showing well aligned teeth
iscussion:
Se!eral clinical treatments ha!e been proposed in the literature for correcting
malpositioned teeth which include remo!able and fixed appliances. 6nterior crossbite is a
condition which seldom corrects by itself because the maxillary incisor is loc=ed behind
the mandibular incisors and continues to progress leading to se!ere malocclusion, thus
early treatment can reestablish proper muscle balance and a well balanced occlusal
de!elopment. 3arly treatment is also directed towards pre!enting dysplastic growth of
both s=eletal and the dentoal!eolar components.
1B
The ideal age for the correction of
anterior dental crossbite is between A to 11 years during which the root is being formed
and the tooth is in the acti!e stage of eruption. The important role plays not only the age
of the child but also the moti!ation for treatment, how he or she percei!es the problem.
There are different treatment approaches for the correction of anterior dental crossbite
which can be used in early mixed dentition period. These include tongue blade therapy
1A
,
re!erse stainless steel crowns,
1;
remo!able &awley retainer with anterior C9springs
18
and
bonded resin9composite slopes.
1/
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 re!erse stainless steel crowns ha!e been shown to be successful but the two
main disad!antages of using re!erse stainless steel crowns are the unaesthetic appearance
/
of the crown form and the limitations of wor=ing with an inclined slope that is already
formed. 6 remo!able appliance also re"uires patient cooperation and parental
super!ision
..
The 2ower nclined ,ite %lane is the traditional method used for correcting
anterior single tooth or multiple tooth dental crossbite. t has to be used only if there is
enough space in dental arch for labial mo!ement of the upper incisors. *linically it can be
used in cases when upper incisors are in crossbite with more than one half of !ertical
o!erbite. The mo!ement of teeth occurs from the resulting force of closing muscle and
inclined plane interaction. Dne of the shortcomings of early treatment is the possibility of
a two9phase orthodontic therapy as often it is difficult to estimate the further growth of
the mandible.
10
The presence of crowding in mandibular incisors, tempromandibular
4oint problems, and maxillary deficiency has to be considered before suggesting this
appliance.
Dne should be aware of limitations of using remo!able appliances in correction of rotated
tooth as one obtains point contact resulting in tipping mo!ements which is less effecti!e
at derotation of tooth than fixed appliance. f the incisor root positioned palatally tor"uing
the incisor root, with simple tipping force will procline the tooth excessi!ely leading to
poor esthetics, poor gingi!al contour and may increase the chance of relapse. &ence
decision was ta=en to choose fixed appliance as the right approach in correction of
malpositioned teeth in this case.6 ma4or goal of extraction of maxillary left first premolar
in this patient was to ma=e tooth mass compatible with the arch dimension, thereby
enhancing the stability of final occlusion also the results of extraction therapy ha!e been
pro!en "uite stable o!er the long term resulting in well alignment of the teeth with their
ad4acents.#or a late mixed dentition child with se!ere rotation and crossbite were
efficiently managed using fixed full arch appliance.
Conc!usion:
Timely inter!ention of malocclusion should be initiated as early as possible to pre!ent
existing problems from getting worse and minimiEe or eliminate the need for
comprehensi!e orthodontic treatment at a later stage. Treatment of malpositioned teeth
B
are relati!ely precise if it is planned with fixed orthodontic appliance in attaining of
desired postoperati!e results without any relapse resulted in rapid correction of single
tooth dental cross bite ' correction of se!erely rotated upper left central incisor with
good alignment of the erupting canine.
&ence can conclude that in magnitude of malpositioned teeth, fixed appliance by
pro!iding good anchorage, minimal duration, should be considered as the treatment of
choice.
+eferences$
1. 7alandris 7,7ahoney 3K. 6etiology,diagnosis ' treatment of posterior crossbites in
the primary dentition. nternational Journal Df %aediatric (entistry 1008$18$1..91./.
1. &uber K2, Suri 2, Tane4a %. 3ruption disturbances of the maxillary incisors$ a
literature re!iew.J *lin %ediatr (ent. 100A SpringF 51>5?$111950.
5. ,acettiT.Tooth rotation associated with aplasia of nonad4acent teeth.6ngle
Drthodontuics.1;;A$/A,8B198B8.
8. saacson K), 7uir JJ(, +eetd,+T. +emo!able orthodontic appliances. 1nd edition
Grightlondon 1005$ 50958
.. S=eggs +7,Sandler +7.+apid correction of anterior crossbite using a fixed
appliance.6case report.(ental Hpdate1001F1;$1;;9501.
/. 7a4or %, )lo!er K. Treatment of anterior cross9bites in the early mixed dentition. J *an
(ent 6ssoc. 1;;1F .A$.B8-.B..
B. &ei=inheimo K, Salmi K, 7yllarniemi S. 2ong9term e!aluation of orthodontic
diagnosis ma=e at ages of B and 10 years. 3ur J Drthod. 1;ABF;$1.1-1.;.
A
A. &annu=sela 6, Iaananen 6. %redisposing factors for malocclusion in B9year9old
children with special reference to atopic diseases. 6m J Drthod (entofacial Drthop.
1;ABF;1$1;;-505.
;. &annu=sela 6, 2aurin 6, 2ehmus I, Kauri +. Treatment of cross9bite in the early
mixed dentition. %ron #inn (ent Soc. 1;AAFA8$1B.-1A1.
10. Dlsen *,. 6nterior crossbite correction in uncooperati!e or disabled children. *ase reports.
6ust (ent J. 1;;/F 81$508-50;.
11. 3streia #, 6lmerich J, )ascon #. ntercepti!e correction of anterior crossbite. J *lin %ediatr
(ent. 1;;1F 1.$1.B-1.;.
11. Ialentine #, &owitt JG. mplications of early anterior crossbite correction. J (ent *hild.
1;B0F 5B$810-81B.
15. 2ee ,($*orrection of crossbite.(ent *lin North 6m 11$/8B9/A,1;BA
18.Jacobs S). Teeth in cross9bite$ the role of remo!able appliances. 6ustralian (ental
Journal. 1;A;F58>1?$10-1A.
1.. *roll T%. #ixed inclined plane correction of anterior cross bite of the primary
dentition. Journal of %eriodontology. 1;A8F;>1?$A8-;8.
1/. ,ayra= S, Tunc 3S. Treatment of anterior dental crossbite using bonded resin9
composite slopes$ case reports. 3uropean Journal of (entistry. 100AF1$505-50B.
1B. Iadia=as ), IiaEis 6(. 6nterior crossbite correction in the early deciduous dentition.
6merican Journal of Drthodontics and (entofacial Drthopedics. 1;;1F101>1?$1/0-1/1.
1A.6sher +S, Kuster *), 3ric=son 2. 6nterior dental crossbite correction using a simple
fixed appliance$ case report. %ediatric (entistry. 1;A/FA>1?$.5-...
;
1;. *roll T%, 2ieberman G&. ,onded compomer slope for anterior tooth crossbite
correction. %ediatric (entistry. 1;;;F11>8?$1;5-1;8.
10. Ngan %. ,iomechanics of maxillary expansion and protraction in *lass patients.
6merican Journal of Drthodontics and (entofacial Drthopedics. 1001F111>/?$.A1-.A5.
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