Adult transverse diagnosis and

treatment: A case-based review

Thomas E. Southard, Steven D. Marshall, Veerasathpurush Allareddy, and
Kyungsup Shin

Problems in the transverse dimension can be challenging to manage, espe-

cially in adult patients. The purpose of this article is to provide a review of
normal transverse jaw development, the etiology and diagnosis of trans-
verse discrepancies, goals of adult transverse treatment, and treatment
options for adult transverse discrepancies. Mirroring a seminar from your
orthodontic residency, this article is written in question and answer format.
We ask that you think through answers to the questions we present very
carefully and make the best decisions you can, before you refer to the
answers we provide. Like your orthodontic residency, you will find that cer-
tain principles are emphasized and applied time and time again to a spec-
trum of patients in this case-based article. These are the principles which
have served us well over many years of teaching and treating adults in the
transverse dimension. (Semin Orthod 2019; 25:69–108) © 2019 Elsevier Inc.
All rights reserved.

Q : Our knowledge of the transverse morpho-

logic changes which occur during growth
and development is far greater than our under-
standing of the biology underlying those changes.
That said, can you describe the pattern of trans-
verse bone changes which occur during maxillary
and mandibular growth and development?
A: A pattern of bony width change occurs as a
gradient in the vertical dimension.1 As illustrated
in Fig. 1, the greatest width change occurs more
superiorly (Jugal point), and the least width
change occurs inferiorly (mid-alveolar point of
the mandible). Divorced from this pattern are
the transverse mandibular basal bone changes,
measured as bi-gonion and bi-antegonion.
Q: Can you describe the transverse dental (per-
manent molar) movements which occur during
growth and development.
A: Maxillary molars erupt with buccal crown
torque and upright with age as the maxilla
widens. Mandibular molars erupt with lingual
Department of Orthodontics, The University of Iowa, Iowa City,
IA 52242, USA.
Corresponding author. E-mail: tom-southard@uiowa.edu
© 2019 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2019.02.008
crown torque and upright with age. These molar
crown torque changes are accompanied by con-
current increases in maxillary and mandibular
intermolar widths (Fig. 2). On average, the basal
bone of the maxilla increases in width by
5.4 mm; maxillary intermolar width increases by
3.0 mm; mandibular intermolar width increases
by 2.0 mm; and mandibular cross arch crest level
alveolar width increases by 1.6 mm.1,2
Q: What does the above finding mean in
terms of dental treatment goals?
A: The finding provides support for the Amer-
ican Board of Orthodontics’ requirement that
ideal finishing treatment include upright poste-
rior teeth.
Q: Can you list at least four etiologic factors
that cause adult transverse discrepancies?
A: Etiologic factors include3 13:
 Ectopic tooth eruption. Fig. 3A illustrates a
developing (left to right) buccal cross bite
resulting from ectopic first permanent molar
eruption.
 Soft tissue imbalance (example: prolonged
digit sucking). Fig. 3B shows the posterior
cross bite (and anterior open bite) resulting
from three decades of heavy thumb sucking.
 prolonged retention of primary teeth

Seminars in Orthodontics, Vol 25, No 1, 2019: pp 69 108 69

70 Southard et al

Figure 1. Mean transverse basilar, cross arch alveolar, and inter molar changes from age 7.5 years to 26.4 years: 1,
maxillary basilar width; 2, maxillary cross arch width mid-alveolar buccal; 3, maxillary cross arch width mid-alveolar
palatal; 4, maxillary cross arch width alveolar crest buccal; 5, maxillary cross arch width alveolar crest palatal; 6,
maxillary intermolar width; 7, mandibular intermolar width; 8, mandibular cross arch width alveolar crest buccal;
9, mandibular cross arch width alveolar crest lingual; 10, mandibular cross arch width mid-alveolar buccal; 11,
mandibular cross arch width mid-alveolar lingual; 12, mandibular basilar width (bi-gonion); 13, mandibular basilar
width (bi-antegonion). Horizontal bars indicate average change in width measured in millimeters from 7.5 years to
26.4 years.

 Asymmetric mandibular growth (Fig. 3C  Excess or deficient anteroposterior growth of

and D) note the right posterior cross bite the maxilla or mandible. Fig. 3F H illustrates
(and right chin deviation) that has resulted a 19-year-old male with complete lingual cross
from excess left mandibular growth. bite of the entire dentition due to maxillary
anteroposterior deficiency/mandibular ante-
roposterior excess.
 Some TMD issues. Temporomandibular joint
dysfunction has been associated with skeletal
asymmetries and cross bite occlusion.
 Excess or deficient maxillary or mandibular
transverse growth. Fig. 3I K illustrate a left
posterior cross bite developed in a cleft lip
and palate patient due to deficient maxillary
transverse growth.

Q: Can you discuss five factors that should be

considered when formulating a diagnosis and
treatment plan for adult patients with transverse
Figure 2. Average transverse molar movements from discrepancies?
ages 7 to 26 years. A: The following factors must be considered:
 Adult transverse diagnosis and treatment: A case-based review 71

Figure 3. Factors causing transverse problems: (A) ectopic eruption of posterior teeth; (B) prolonged digit suck-
ing; (C E) asymmetric mandibular jaw growth; (F H) deficient maxillary/excessive mandibular anteroposterior
growth resulting in complete maxillary lingual crossbite with relative transverse discrepancy; (I K) deficient max-
illary transverse growth associated with a palatal cleft.

 Magnitude of transverse discrepancy: This is the
single most important factor in your transverse
treatment planning decision. The magnitude
of the transverse apical base discrepancy will
determine the degree to which a posterior
cross bite is characterized as dental or skeletal;
it will, in most instances, dictate whether a skel-
etal cross bite can be corrected by masking or
must be corrected by surgery; and in cases of
surgical treatment, it may lead you to choose a
specific surgical modality.
As illustrated in Fig. 4, transverse dental com-
pensations (usually maxillary posterior buccal
crown torque and mandibular posterior lingual
crown torque) must be taken into consideration
when determining the magnitude of the trans-
verse discrepancy. Buccally-tipped maxillary
molars will tend to move lingually as they are
uprighted (unless a trans-palatal arch is used to
apply torque to upright their roots while main-
taining the intermolar distance). Likewise, lin-
gually-tipped mandibular molars will tend to
move buccally as they are uprighted (unless a
lower lingual holding arch is used to apply tor-
que to upright their roots while maintaining the
intermolar distance). Removal of these compen-
sations by uprighting the molars can dramatically
72 Southard et al
F G
I J
Figure 3. Continued
increase the transverse occlusal discrepancy and
worsen the cross bite relationship.
Finally, always remember that changes in the
sagittal and vertical relationships of the maxillary
and mandibular apical bases can affect transverse
occlusal relationships. If one plans to move the
maxilla or mandible relative to each other either
by orthopedics during growth or surgery after
completion of growth, then one must check how
the movements will affect the resulting posterior
transverse relationships (e.g. see absolute vs. rela-
tive transverse discrepancy below).
47 mm
47 mm
H
39 mm
42 mm
K
 Facial symmetry or asymmetry:
The first thing to do when compiling a prob-
lem list in the transverse dimension is to exam-
ine the patient’s face in the frontal view. Unlike
problems in either the anteroposterior or verti-
cal dimensions, problems in the transverse
dimension are frequently camouflaged by the
overlying soft tissue. However, asymmetries can
usually be spotted during clinical examination.
The use of CBCT scan can also be of value in
assessing skeletal asymmetries and transverse
 Adult transverse diagnosis and treatment: A case-based review 73

Figure 4. (A) The magnitude of a transverse discrepancy is not simply the (linear) difference between maxillary
first molar intermolar width (lingual cusp to lingual cusp) and mandibular first molar intermolar width (central
fossa to central fossa). (B) Instead, the magnitude of the transverse discrepancy must consider compensations
which will be removed by uprighting posterior teeth. (C) Uprighting posterior teeth increases the transverse dis-
crepancy magnitude and can worsen, or create, a posterior cross bite.

skeletal discrepancies between the maxilla and
mandible.
We do not recommend using 2-D posteroante-
rior cephalometric radiographs to determine
transverse skeletal discrepancies between the
maxilla and mandible because the alveolar pro-
cess bone of the jaws, the bone that houses the
roots of the teeth and is the bone of interest in
diagnosing transverse skeletal discrepancies, is
obscured in posteroanterior cephalometric films.
 Presence of a lateral CR-CO shift:
One should always check for a CR-CO shift in
every patient at every appointment. If one detects an
asymmetry, especially a deviation of the chin in
the presence of a unilateral cross bite, one
should try to establish whether the asymmetry is
a result of the shift. In addition, one should
check for lateral deviation upon opening. One
should ask the patient to touch their tongue to
the roof or back of their mouth while they open
and close slowly until their teeth just touch to
help seat the condyles. Then, ask the patient to
close into maximal intercuspation to check for a
CR-CO shift. If there is any doubt on the pres-
ence of a functional shift, one can place the
patient on a flat-plane bite plate for a week or
two to disarticulate the occlusion and deprogram
them. However, compliance with a removable
appliance is not always forthcoming. We prefer
to deprogram using either a fixed expansion
appliance (in the presence of a constricted max-
illa while attempting orthopedics, masking, or
SARME) or leveling and aligning with fixed
orthodontic appliances. Whenever possible,
remove the need for compliance.
Principle of CR-CO shifts and treatment plan-
ning: if you detect a sizable CR-CO shift, then
inform the patient that you cannot establish your
final treatment plan until the shift has been elim-
inated. It is only when the shift is eliminated that
one can understand the true relationship
between the jaws and develop a rational treat-
ment plan.
 Whether the transverse discrepancy is relative or
absolute:
Haas14 introduced the terms relative and abso-
lute transverse discrepancy. A relative transverse
discrepancy exists when the posterior teeth do
not coordinate in centric relation, but do coordi-
nate when the canines of the models are placed
in Class I occlusion. For instance, Fig. 5A shows
the models of an adult patient with a severe Class
II malocclusion. Note the significant transverse
discrepancy in CR. The patient was treatment
planned for mandibular advancement. Fig. 5B
shows the same models advanced to a Class I
canine relationship. Note that the transverse dis-
crepancy has disappeared. This patient had a rel-
ative transverse discrepancy.
On the other hand, an absolute discrepancy
exists when the posterior teeth still do not coor-
dinate even when the canines are placed into a
Class I relationship. For instance, Fig. 5C shows
the models of a patient with a severe Class III
74 Southard et al

Figure 5. Transverse discrepancies: (A and B) patient with relative transverse discrepancy; (C E) patient with
absolute transverse discrepancy.

malocclusion in centric relationship. Note the
significant transverse discrepancy. The patient
was treatment planned for a mandibular setback.
Fig. 5D shows the same models setback to Class I
canines. Note that the transverse discrepancy is
still present. In fact, the discrepancy will be even
worse when the mandibular molars are
uprighted (Fig. 5E, dental compensations
removed). This patient had, therefore, an abso-
lute transverse discrepancy.
 Magnitude of buccal corridors:
In terms of esthetics, the transverse dimen-
sion is probably the least studied. When a
patient smiles, the buccal corridors are spaces
existing between the lateral surfaces of the pos-
terior teeth and the inner commissures of the
lips or cheeks. Usually, a patient with a con-
stricted maxilla and narrow maxillary arch will
have large buccal corridors. Conversely, a
patient with a wide maxilla, and a broad maxil-
lary arch, will have small buccal corridors.
Moore and colleagues studied the effect of buc-
cal corridor size on smile esthetics15 and found
that large buccal corridors are considered unaes-
thetic (Fig. 6).
When examining a patient, we recommend
recording the presence and magnitude of buccal
corridors during a natural smile.
 Adult transverse diagnosis and treatment: A case-based review 75

Figure 6. Effect of buccal corridors on smile esthetics. (A) Broad smiles, with small buccal corridors, are preferred
by lay persons; (B) Very narrow smiles, usually resulting from maxillary transverse skeletal deficiency, and large
buccal corridors are considered less attractive.

 Whether the posterior cross bite (transverse discrep- Q: Why not?

ancy) is dental or skeletal: this factor will be con-
sidered in detail in the following series of
questions.
Q: Let’s assume that a patient presents to you
with a posterior cross bite (Fig. 7). Further,
assume that the patient is Class I without a func-
tional shift. Is the cross bite of dental or skeletal
origin? Can dental cross bites be differentiated
from skeletal cross bites simply by counting the
number of teeth in cross bite?16
A: No. We cannot conclude that when only
1 2 posterior teeth are in cross bite that it is a
dental cross bite, and we cannot conclude that
when more teeth are in cross bite that it is a skele-
tal cross bite.
A: Differentiation between dental and skeletal
cross bites is not that simple. As recently
reported,17 there is a large variation in transverse
skeletal widths (and transverse compensations)
in the absence of cross bites ranging from:
 Small maxillary skeletal width compared to a
large mandibular skeletal width (Fig. 8A), to
 Comparable maxillary and mandibular skele-
tal widths (Fig. 8B), to
 Large maxillary skeletal width compared to a
small mandibular skeletal width (Fig. 8C).
In other words, a large transverse skeletal dis-
crepancy can exist in the absence of a cross bite,
in the presence of only a few teeth in cross bite,

Figure 7. Patient presenting with only mandibular right permanent molars in cross bite. Transverse dental dis-
crepancies cannot be differentiated from skeletal discrepancies simply by counting the number of teeth in cross
bite.
76 Southard et al

Figure 8. Variation in transverse skeletal widths in the absence of cross bites: (A) small maxillary skeletal width
compared to a large mandibular skeletal width (maxillary buccal crown torque and mandibular lingual crown tor-
que compensations); (B) comparable maxillary and mandibular skeletal widths (relatively upright molars); (C)
large maxillary skeletal width compared to a small mandibular skeletal width (maxillary lingual crown torque and
mandibular buccal crown torque compensations).

or in the presence of a large number of teeth in
cross bite. Counting teeth to determine the presence or
absence of a transverse skeletal discrepancy is ill
advised. You must consider the presence and
magnitude of dental compensations in order to
determine whether a transverse skeletal apical
base discrepancy exists.
Q: How do transverse dental compensations
develop?
A: Transverse dental compensations develop
in the same way, and for the same reasons, that
anteroposterior dental compensations develop.
Teeth tend to erupt throughout life until suffi-
cient occlusal, or soft tissue, load prevents fur-
ther eruption. They erupt along their long axes,
but their buccal-lingual direction is influenced
by the soft tissue envelope (tongue-cheeks-lips)
in order to bring them into occlusion with teeth
from the opposing jaw. In the presence of a
hypoplastic maxilla, the tongue will tend to tip
the maxillary incisors forward, and the mandib-
ular lip will tend to tip the mandibular incisors
lingually (anteroposterior compensations). In
that way, the incisors will be brought into occlu-
sion. In a similar fashion, in the presence of a
hypoplastic maxilla, the tongue will tend to tip
the maxillary molars buccally, and the cheeks
will tend to tip the mandibular molars lingually
(transverse compensations). In that way, the
molars will erupt into occlusion.
 Adult transverse diagnosis and treatment: A case-based review 77

Q: So, if we cannot simply count the number
of posterior teeth in cross bite, then how do we
differentiate between a dental and skeletal cross
bite?
A: By visualizing what happens in the trans-
verse dimension when we upright the molars
(eliminate transverse compensations). For
instance, since maxillary and mandibular skele-
tal bases relate well in a dental cross bite,
uprighting molars will improve (eliminate) a
dental cross bite (Fig. 9A). On the other hand,
since maxillary and mandibular skeletal bases
do not relate well in a skeletal cross bite, then
uprighting molars will worsen a skeletal cross
bite (Fig. 9B).
Q: List the goals of adult transverse treatment.
A: Goals of adult transverse treatment include:
 Correcting posterior cross bites, lateral CR-
CO shifts, and skeletal asymmetries
 Uprighting posterior teeth (eliminating trans-
verse dental compensations)
 Creating a stable and coordinated posterior
occlusion
 Reducing large buccal corridors
 Maintaining a healthy periodontium
 Increasing chewing efficiency (for example,
in patients with scissor or Brodie bites)
Q: An adult presents to you with a posterior
lingual cross bite. Can you list the options for
dealing with this problem?

Figure 9. Determining whether a posterior cross bite is dental or skeletal: (A) uprighting molars will improve a
dental cross bite because the maxillary and mandibular skeletal bases relate well; (B) uprighting molars (removing
transverse compensations) will worsen a skeletal cross bite because the maxillary and mandibular bases do not
relate well.
78
A: The options may include:
 No treatment leave the patient in posterior
cross bite
 Dental cross bite upright the involved teeth,
thus improving/correcting the cross bite
 Skeletal cross bite the same three general
options are available for dealing with transverse
skeletal discrepancies as for dealing with antero-
posteriorly, or vertical, skeletal discrepancies:
- Orthopedics (attempt maxillary skeletal
expansion)
- Masking (camouflage, increasing trans-
verse compensations)
- Orthognathic surgery
The challenge is deciding which the best
option is. You must consider all the factors dis-
cussed earlier: magnitude of the transverse dis-
crepancy, presence of an asymmetry and/or CR-
CO shift, whether the cross bite is of dental or
Figure 10. Class III patient treated with mandiblar first premolar extractions but left in posterior cross bite.
Southard et al
skeletal origin, whether the transverse discrep-
ancy is relative or absolute, the presence and
degree of dental compensations (torques),
which jaw is at fault, the presence of large buccal
corridors, the patient’s age, the condition of the
periodontal tissues, and the patient’s desires.
Q: When is the option of no transverse treatment
reasonable?
A: When we treat children, we almost always
correct cross bites, eliminate posterior transverse
compensations (upright posterior teeth), and cor-
rect lateral CR-CO shifts. However, in adults we
may choose to leave these problems. As the pres-
ence of posterior cross bite is not thought to
increase the incidence of TMD,18 22 the decision
to improve posterior crossbite will depending
upon the patient’s desires, transverse discrepancy
magnitude, absence of a CR-CO shift, and peri-
odontal biotype.
For example, the Class III patient in
Fig. 10A C stated that he wanted the “easiest,
 Adult transverse diagnosis and treatment: A case-based review 79

fastest, treatment without surgery.” Since he
currently had no problems with his posterior
cross bite, and since his posterior teeth were
relatively upright, we chose to treat him with
mandibular first premolar extractions but to
leave him in cross bite (Fig. 10D F). This
option was appealing because we were at least
able to provide him with canine rise disclusion
(Fig. 10G H).
Q: A 35-year-old female presents with a right
posterior buccal cross bite of her first and second
molars (Fig. 11). CR = CO. Does the patient have

Figure 11. Intraoral records of a 35-year-old female, Class I malocclusion with a unilateral right posterior cross
bite. CR = CO.
80
a skeletal, or dental, posterior cross bite and
Why?
A: The patient’s right posterior cross bite is a
dental cross bite. Why? Clearly, the mandibular
right molars have erupted with significant lingual
crown torque (Fig. 11E). The maxillary right sec-
ond molar exhibits buccal crown torque
(Fig. 11F). Since uprighting these teeth will
improve, or correct the cross bite, we can con-
clude that the patient has a dental cross bite.
Q: In general terms, how would you correct
the cross bite?
A: Since uprighting posterior teeth improves a
dental cross bite and the skeletal bases relate
well, one can move the right maxillary second
molar crown lingually and the mandibular right
molar crowns buccally (Fig. 12).
Q: What specific problems would you antici-
pate when uprighting the right molars?
A: One major problem is the amount of right
molar overbite. In other words, the right molars
have erupted so far past each other (Fig. 11H
and I) that the vertical dimension may be signif-
icantly opened as the right molars are
uprighted and brought into occlusion. The
patient’s right molars may become the only
teeth in contact, and the patient may not be
able to tolerate this increase in vertical dimen-
sion. Furthermore, the patient may require sig-
nificant occlusal adjustment (enameloplasty),
molar endodontics, or even molar crowns on
her right side to finish with a reasonable occlu-
sion. The patient must be informed of these
possibilities.
Q: How would you proceed?
A: We placed comprehensive fixed orthodontic
appliances, and asked the patient to wear cross
Figure 12. A 35-year- old female shown in Fig. 11. To correct the right dental cross bite, upright the right molars
by moving the maxillary right second molar crowns lingually and mandibular right molar crowns buccally.
Southard et al
bite elastics from right mandibular molar lingual
buttons to right maxillary molar buccal brackets.
Surprisingly, no other treatment was necessary,
not even an anterior biteplate to allow the right
molars to pass across each other. The post-treat-
ment deband photographs are shown in Fig. 13.
Q: A 19-year-old woman presents (Fig. 14)
with a chief complaint of “I want my top teeth
straightend.” The patient has a straight profile,
but dentally the premolars appeared to have a
Class II relationship by about 2 mm. The incisors
contacted edge-to-edge. The patient has a bilat-
eral posterior lingual cross bite and large buccal
corridors. Does this patient have a posterior den-
tal or skeletal cross bite?
A: There are no intra-oral frontal views of the
maxillary and mandibular arches (teeth sepa-
rated) to clearly ascertain posterior crown tor-
ques (compensations). However, in Fig. 14E it
appears that the maxillary premolars and first
molars have lingual crown torque, and the man-
dibular molars have lingual crown torque.
Therefore, if the patient’s maxillary posterior
teeth are upright, they will tend to move buccally,
and the cross bite should improve. This would
suggest that the patient has a dental cross bite.
On the other hand, if the mandibular posterior
teeth are upright, they should also tend to move
buccally, and her cross bite would worsen. This
would suggest that the patient has a skeletal cross
bite. Fig. 14B shows that the patient has large
buccal corridors, suggesting that a relatively
small maxilla. In summary, the patient’s poste-
rior cross bite has features of both a dental and
skeletal cross bite.
Q: How can this 19-year-old patient have an
edge-to-edge incisor relationship when the patient
 Adult transverse diagnosis and treatment: A case-based review
Figure 13. Post-treatment records of a 35-year-old female shown in Fig. 11. Note the large mandibular buccal wear
facets in Figure 13D.
only has a mild Class II malocclusion? In other
words, most patients with edge-to-edge incisors
have a Class III malocclusion.
A: Although we are speculating, the patient’s
maxillary premolars may have erupted, or drifted
forward from the ideal position leaving the max-
illary canines with inadequate room to erupt.
Conversely, her maxillary incisors may have
drifted posteriorly into an edge-to-edge relation-
ship with her mandiublar incisors.
Q: What are the options for dealing with her
bilateral posterior cross bite? Why would, or why
would you not choose the following options?
A: The options include:
 No treatment leaving the patient in poste-
rior cross bite. This option is not recom-
mended. If comprehensive treatment is to be
pursued, then it would be negligent to leave
the patient in posterior cross bite.
 Attempting orthopedic treatment with a rapid
maxillary expansion appliance (RME). If the
maxillary mid-palatal suture were to separate,
and if one were to get significant maxillary
skeletal widening, then this could be an ideal
option.
 Attempt to mask or camouflage the malocclu-
sion by increasing transverse compensations
may be a viable option since, as we previously
stated, uprighting the maxillary posterior teeth
will bring them buccally improving the cross
bites. We would then only need to increase the
81
mandibular posterior teeth lingual crown tor-
que to correct the cross bites.
 Surgically-Assisted RME (SARME) would
guarantee correction of the bilateral posterior
cross bites, skeletally. The drawbacks of this
option are the surgical risks.
 Multiple Piece Maxillary Osteotomy (MPMO)
to widen the maxillary skeleton would not
be a better choice than SARME since the sur-
gery would be more complex (requiring a
maxillary down fracture) and the amount of
expansion achievable with MPMO would be
limited compared to SARME.
Q: What are the potential problems in
attempting RME expansion in a 19-year-old
woman?
A: The maturity of the maxillary sutures at the
patient’s age. Sutural separation can be obtained
most effectively before/during pubertal growth spurt.
Maxillary expansion after the pubertal growth
spurt results in mainly dentoalveolar (not ortho-
pedic/skeletal) effects.23 27 At 19 years of age,
this young woman’s facial skeleton may be too
mature, and offer too much skeletal resistance,
to permit separation of her mid-palatal suture.
However, one could attempt RME at the rate of
0.25 mm per day, or 0.25 mm every other day,
and monitor patient to see if the mid-palatal
suture separates.
Q: Is the mid-palatal suture the major site of
skeletal resistance to RME?
82
Figure 14. Initial records of a 19-year-old female with a bilateral posterior lingual cross bite.
A: No. If the mid-palatal suture was the major
site of skeletal resistance to RME, then once the
suture was opened, the skeletal resistance would
drop dramatically. However, Isaacson and
Ingram28 reported no significant change in the
RME opening force during the time the mid-pal-
atal suture opened. Instead, it has been sug-
gested that the zygomatic buttress is the major
site of skeletal resistance to RME.29
Q: If you attempt to treat this patient with
RME, how would you know if the mid-palatal
suture has separated or has not separated?
A: The most obvious sign of mid-palatal suture
separation is the development of a maxillary
Southard et al
midline diastema. However, if a midline diastema
does not form, then look for other signs that
indicate the suture is not separating such as:
 The absence of a clear bony radiographic
mid-palatal split on an occlusal radiograph.
 The impingement of the RME appliance’s
metal arms on the palatal soft tissue (indicat-
ing lateral dental movement and not lateral
hemi-maxillae bone movement).
 A sensation of expansion pressure from the
screw more than 5 or 10 min beyond expan-
sion screw activation.
 Patient complaints of pain.
 Adult transverse diagnosis and treatment: A case-based review
Q: What is the first principle of attempting
maxillary skeletal expansion (maxillary trans-
verse orthopedics) in an adult? How does this
principle apply to this patient?
A: First principle: when attempting maxillary skele-
tal expansion (orthopedics) in an adult patient, you
must have a “fallback” plan if the mid-palatal suture
does not split.
 With this 19-year-old woman, we recommend
first activating the RME appliance screw once
a day, or once every other day, for 1 or 2
weeks. If the mid-palatal suture does not sepa-
rate, you are achieving only dental movement.
 If the dental expansion achieved is large com-
pared to what you need to correct the cross
bites, if the maxillary posterior buccal perio-
dontium is robust (thick buccal bone, thick
keratinized attached tissue, thick biotype), and
if you believe you can correct her cross bites by
increasing posterior compensations, then your
fallback plan could be continuing dental
expansion slowly with the RME appliance (at
the rate of 0.25 mm or 0.5 mm per week.)
 If the dental expansion achieved is small com-
pared to what you need to correct the cross
bites, or if the posterior buccal periodontium
is a thin biotype, then your fallback plan could
be either surgical intervention (i.e. SARME)
or leaving her in cross bite.
Q: Which of the above options have you
decided to use and treat this patient?
Figure 15. Progress records of a 19-year-old female shown in Fig. 14. RME resulted in a mid-palatal split (A and
B). Patient following deband (C).
83
A: Following discussions with the patient, we
decided to attempt orthopedics using RME
(0.25 mm expansion per day, patient returning
to clinic for a follow-up in 1 week). Our fallback
plan, if a mid-palatal split was not achieved,
would be a referral for SARME.
Fortunately, a mid-palatal split was achieved
(Fig. 15A and B). Following spontaneous maxil-
lary midline diastema closure, fixed orthodontic
appliances were placed, arches were leveled and
aligned, Class II elastics were worn to correct
molars and canines to Class I, and Fig. 15C shows
the post-treatment facial photograph of the
patient. Note the reduction in buccal corridors.
Q: How long should an adult orthopedic
transverse correction be retained?
A: The longer we are in practice, the longer
we keep expansion patients in an RME appli-
ance. One can convert the RME appliance into
a transpalatal arch (TPA) and maintain the
molar expansion for another 9 12 months.
Removing the metal RME appliance arms to the
first premolar bands (see Fig. 15B), and remov-
ing the premolar bands, permits the maxillary
arch to be bonded, leveled, and aligned while
the TPA is in place.
Q: A 42-year-old female (Fig. 16A L) presents
with a chief complaint of “My teeth are crooked.”
From her examination and records, the follow-
ing diagnosis and problem list was obtained:
1. straight profile
2. mild mandibular skeletal protrusion
84 Southard et al

Figure 16. Initial photographs of a 42-year-old female with bilateral posterior cross bite.
 Adult transverse diagnosis and treatment: A case-based review
3. long lower anterior face height (3 mm inter-
labial gap)
4. Angle Class III molar relationship
5. Iowa Classification of III (4 mm) I III(4 mm)
III(5 mm)
6. no CR/CO discrepancy
7. missing mandibular right second premolar
8. mandibular first molar aymmetry - right
ahead of left
9. mandibular canine asymmetry - left ahead of
right
10. maxillary/mandibular intercanine widths =
29 mm/21 mm
11. maxillary 1st molar inter-lingual cusp width
41 mm
12. mandibular 1st molar inter-fossa width 45 mm
13. maxillary molar transverse dental compensa-
tions (buccal crown torque)
14. mandibular molar transvese dental compen-
sations (lingual crown torque)
15. right posterior lingual cross bite of premo-
lars and second molars
16. left posterior lingual cross bite of molars and
premolars.
Does the patient has a dental or skeletal poste-
rior cross bite?
A: If the posterior transverse compensations
were removed (molars uprighted), then the max-
illary molars would tend to tip lingually, the man-
dibular molars would tip buccally, and the
posterior cross bites would worsen. The patient
has a skeletal posterior cross bite.
Q: In addition to providing the patient with
the proper Angle Classification, one should also
provide the patient with the proper Iowa Classifi-
cation. What is the Iowa Classification?
A: The Iowa Classification quantifies the
patient’s anteroposterior relationship. For
instance, the patient’s Iowa Classification was:
III(4 mm, right first molars) I(right canines)
III(4 mm, left canines) III(5 mm, left first molars)
A shortcoming of the Angle Classifcation is
that it is qualitative, not quantitative. When I tell
you that a patient presents with an Angle Class II
relationship, you have no idea how severe that
Class II relationship is. The patient could be min-
imally Class II, say by 1 mm, or the patient could
be severely Class II, say by 6 mm. But, if I tell you
85
that the patient is Class II by 6 mm on the right
and 2 mm on the left, then you have a better
sense of the Class II severity. The need for quan-
tification was the reason that we instituted the
Iowa Classification.
Q: What are your options for dealing with the
patient’s bilateral posterior cross bite? Why would,
or why would you not, choose each option?
A: The options include:
 No treatment leaving her in cross bite.
Depending upon the patient's desires, this is a
viable alternative especially since the patient
is not biting her cheek. If the patient pursues
comprehensive orthodontic treatment, then
we would at least recommend achieving
canine disclusion - even if we leave her in pos-
terior cross bite.
 Attempting RME (orthopedics) we do not
recommend this option due to the patient’s
age.
 Masking (camouflage, Fig. 17) would con-
sist of increasing buccal crown torque for all
maxillary posterior teeth (except the right
first molar which is not in cross bite) and
increasing mandibular lingual crown torque
for all posterior teeth (except the right first
molar which is not in cross bite).
 Surgically-assisted RME (SARME) would
provide a guarantee of correcting her bilateral
posterior cross bites.
 Multiple piece maxillary osteotomy (MPMO)
to widen the maxillary skeleton. Since the lin-
ear discrepancy between the maxillary first
molar lingual cusp tips and the mandibular
first molar central fossa is 4 mm, even with
some molar uprighting the required final
maxillary molar expansion may be within the
MPMO surgical limit of 8 10 mm. So, this
option warrants some consideration if a LeFort
osteotomy is being considered for some other maxil-
lary movement (e.g. maxillary advancement). If
surgical movement of the maxilla in some
other direction is not being considered, then
the maxillary expansion surgery of choice
would be SARME, not MPMO.
Q: Let’s discuss the masking option further.
Since the patient’s posterior teeth already pre-
sented with transverse compensations, would it
be wise to increase the compensations?
86 Southard et al
Figure 17. Masking (camoflauge) to correct a lingual skeletal cross bite consists of increasing maxillary buccal
crown torque and increasing mandibular lingual crown torque.
A: We know that patients without cross bites
have been shown to exhibit a wide range of com-
pensations,17 without apparent ill effect. So,
there does not appear to be a scientific reason to
prevent us from increasing posterior teeth com-
pensations. However, upright molars should
always be a transverse treatment goal,2 so increas-
ing maxillary molar buccal torque (and mandib-
ular molar lingual torque) is not ideal.
Q: Of the transverse options considered, how
do you recommend proceeding with her bilat-
eral posterior cross bite?
A: SARME was recommended, but was denied
by her insurance company. The patient opted for
orthodontic treatment to camouflage the skeletal
malocclusion. The mandibular left first premolar
was extracted, fixed orthodontic appliances were
placed, and the mandibular left canine was
retracted into a Class I relationship with the maxil-
lary left canine. An attempt was made to correct
the patient’s bilateral posterior cross bites by plac-
ing the patient on cross bite elastics and increas-
ing the right (and left) maxillary transverse
compensations (buccal crown torques).
The post-treatment records are shown in
Fig. 18A J. Note the increase in the right and
left maxillary transverse compensations (buccal
crown torque) by comparing Figs. 16K and 18I.
Despite the increase in compensation, only the
patient’s canines and right first premolars are
out of cross bite. All the remaining posterior
teeth were finished in cross bite.
Q: Was the patient’s transverse treatment ideal?
A: No. The result was a compromised finish.
Q: Can you justify the patient’s transverse
treatment and result?
A: Yes. As with any skeletal discrepancy,
whether in the anteroposterior, vertical, or trans-
verse dimension, you must decide whether mask-
ing (camoflauge) is a reasonable alternative to
surgery (or orthopedics). In the transverse
dimension, the decision to mask (increase com-
pensations) is predicated upon the magnitude of
the skeletal discrepancy, the presence and mag-
nitude of compensations already present, the
periodontal biotype, and the patient’s desires.
The patient’s treatment was adequate. The
patient’s smile esthetics were improved, the
occlusion has good function, and the periodon-
tium was healthy. The result was reasonable
given the fact that patient could not undergo
SARME treatment.
Q: Masking the patient’s cross bite could also
include translating her maxillary posterior teeth
buccally with slow expansion (0.25 mm, or possi-
bly 0.5 mm, expansion per week using an RME
appliance or TPA). Can you suggest guidelines
for such maxillary buccal translation?
A: The guidelines include:
 A range of 3 5 mm would be a reasonable
amount of transverse maxillary first molar
dental expansion
 A robust buccal periodontium must exist (thick
biotype - thick bone, thick keratinized tissue)
 Short posterior roots, thin periodontal bio-
type, or larger expansion magnitudes are indi-
cations for SARME, not masking
 Non-SARME adult maxillary expansion can
result in significant buccal teeth tipping, buccal
alveolus tipping, translation of roots through
cortical bone, periodontal defects (fenestration
 Adult transverse diagnosis and treatment: A case-based review 87

Figure 18. Post-treatment records of the patient shown in Fig. 16.

88
and dehiscence), osseous defects, and signifi-
cant expansion relapse.6,30 34
 Other transverse translatory movements
(maxillary molar lingual translation, mandib-
ular molar buccal translation, mandibular
molar lingual translation) may also be consid-
ered in correcting cross bites. All molar trans-
verse translatory movements are likely a
combination of translation and tipping.
Q: A 42-yeard-old woman (Fig. 19A M)
presents with a chief complaint of “My teeth are
crooked.” From her examination and records, the
following diagnosis and problem list was obtained:
Figure 19. Initial records of a 42-year-old female with bilateral posterior cross bites.
Southard et al
1. convex profile
2. Angle Class I molar relationship
3. Iowa Classification: I II(1 2 mm) II(2 mm) I
4. no CR/CO discrepancy
5. large buccal corridors
6. mild maxillary and mandibular anterior
crowding
7. bilateral posterior lingual cross bite (right 1st
molars and 2nd premolars; left 1st molars
and both premolars)
8. maxillary premolars exhibit lingual crown
torque (Fig. 16H)
9. maxillary right second molar, left second
molar, and left first molar exhibit buccal
 Adult transverse diagnosis and treatment: A case-based review 89

Figure 19. Continued

crown torque, maxillary right first perma-
nent molar is upright
10. “hour-glass” maxillary arch shape
11. mandibular posterior teeth appear to have
normal bucco-lingual inclination5
Does the patient has a bilateral posterior den-
tal or skeletal cross bite?
A: The patient’s cross bite is a combination of
both a skeletal cross bite and a dental cross bite.
In other words, if we were to remove transverse
90
dental compensations existing for the patient’s
posterior teeth, the transverse premolar relation-
ship would improve (premolar cross bite poten-
tially corrected) but the transverse molar
relationship would worsen at the left first molar
and second molars.
Q: What are your options for dealing with the
patient’s bilateral posterior cross bite? Why would,
or why would you not, choose each option?
A: Options include:
 No treatment leave her in cross bite. This is
a viable alternative depending upon the
patient’s desires especially since her canines
are coordinated. If a broad maxillary arch
form is used during leveling and aligning,
maxillary premolars will tend to upright, and
move buccally, with improvement of the bilat-
eral premolar transverse relationship.
 Attempting RME (orthopedics) - is not recom-
mended due to her age.
 Masking (camouflage) would consist of
increasing buccal crown torque for the max-
illary first molars, translating maxillary
molars buccally, increasing lingual crown
torque for the mandibular posterior teeth,
and possibly translating mandibular poste-
rior teeth lingually. Each of these move-
ments would tend to correct the cross bites.
Masking could include dental expansion
using an RME appliance (0.25 or 0.5 mm expan-
sion per week). This approach is appealing
since the patient’s maxillary periodontium is
very thick lateral to the maxillary first molars
(Fig. 20).
 SARME would guarantee enough posterior
overjet to correct cross bites and permit
uprighting of posterior teeth.
 Multiple piece maxillary osteotomy (MPMO)
to widen the maxilla would not be consid-
ered unless a need existed for some other
maxillary movement (impaction, down graft,
advancement, or setback) which is not indi-
cated here.
Q: Of these options, which would you recom-
mend?
A: Based upon conversations with the patient,
a decision was made to attempt non-surgical,
non-extraction treatment (masking). An RME
Southard et al
Figure 20. Masking (camoflauge) to correct the
patient’s first molar cross bites could be considered
since the buccal periodontium covering her maxillary
first molars is robust.
appliance, with bands to maxillary first premolars
and first molars, was placed and opened at the
rate of 0.25 mm every 4 days. Expansion ended
after the first molar cross bites were corrected
(maxillary first molar roots became palpable on
the buccal). The RME appliance was converted
to a TPA by removing the first premolar bands
and associated metal arms. Fixed appliances
were placed, arches leveled and aligned, Class II
elastics worn. The patient was debanded
(Fig. 21A H).
Q: What transverse changes do you observe
from the patient’s initial records to deband? Can
you offer any “take-home pearls”?
A: Transverse changes:
 Maxillary arch shape has been altered from an
hour-glass shape to a broad arch form.
 Deband maxillary posterior buccal periodon-
tium remains thick and healthy
 Posterior teeth in both arches appear reason-
ably upright
 The patient’s buccal corridors have been
reduced
Take-home pearls include:
 A demonstration of our First Principle of Mask-
ing whether in the anteroposterior, vertical,
or transverse dimensions, success with mask-
ing increases when the skeletal apical base
 Adult transverse diagnosis and treatment: A case-based review 91

Figure 21. Post-treatment records of a 42-year-old female shown in Fig. 19.

discrepancy is small, when the patient looks
normal, and when the dental compensations
are small. The patient’s initial transverse skele-
tal apical base discrepancy was small, she
looked normal, and she exhibited only mild
transverse compensations.
 Successful transverse masking is predicated
upon having a robust, thick periodontal bio-
type (wide zone of attached tissue and thick
facial-lingual gingival dimension).
Q: A patient presents with a left scissors bite and
with CR = CO (Fig. 22A C). Can you suggest non-
surgical options for correcting this scissors bite?
A: Options include:
 Because the mandibular arch has an hour-
glass shape on the left, by aligning the man-
dibular arch with a broad arch form the man-
dibular left posterior teeth should move
buccally - tending to improve the left cross
92 Southard et al
Figure 22. Initial records of a patient with left scissors bite (photographs courtesy of Dr. Mike Callan).
bite and upright the lingually-torqued man-
dibular left first molar.
 Left cross bite elastics could be worn between
fixed appliances from the maxillary left buccal
to the mandibular left lingual.
 Instead, TADs were placed in the palate
(Fig. 23) as anchors to tranlate the maxillary
left posterior teeth lingually.
Q: Let’s now consider maxillary transverse sur-
geries. In terms of the surgery itself, what is the
principle difference between SARME and an
MPMO?
Figure 23. Progress record of the patient in Fig. 22,
showing palatal TADs used as anchors to move maxil-
lary left posterior teeth lingually (note movement of
maxillary left first molar lingually in relation to the
maxillary left second molar which was not bonded).
Photos courtesy of Dr. Michael Callan.
A: Downfracture of the maxilla. Both surgeries
include a horizontal osteotomy of the lateral
maxillary wall, separation of the lateral nasal
wall, nasal septum disarticulation, and palatal
osteotomy. But, the maxilla is downfractured in
MPMO and not downfractured with SARME.
Q: Can you suggest guidelines for SARME ver-
sus MPMO?
A: Recommended guidelines include:
 SARME is chosen for expansions of 10 mm or
more because tissue is being grown with a
SARME (histiogenesis). The limit of expansion
with MPMO is 8 10 mm due to soft tissue
stretch, depending on the height of the palate.
 SARME is chosen when only transverse widen-
ing is needed. MPMO is chosen when the
maxilla will also be moved in other directions
(impaction, downgraft, advancement, set-
back)
 SARME is chosen (Fig. 24) if significant maxil-
lary intercanine width widening is needed35,36
(e.g. in patients with significant maxillary arch
anterior narrow tapering).
 SARME is chosen in cases of low palatal vault
(where palatal tissue can only be minimally
stretched). MPMO can be considered in cases
of a high palatal vault where soft tissue stretch
may be less limiting.
 Adult transverse diagnosis and treatment: A case-based review
Figure 24. Maxillary expansion with SARME can pro-
duce significant anterior widening.
 MPMO is chosen in patients with significant
steps in the anterior - where the maxillary
arch must be leveled, and surgically-treated,
in two planes. Research indicates that leveling
an anterior step up to 2 mm is stable,32 but
research is lacking for leveling anterior occlu-
sal steps greater than 2 mm. Certainly, a maxil-
lary anterior occlusal step of 6 mm or more
could warrant leveling, and surgically-treating,
in two planes.
 MPMO is chosen in cases of maxillary antero-
posterior excess - where maxillary first premo-
lars are extracted and the anterior maxilla is set
back; and in cases of maxillary transverse skele-
tal excess - where a wedge of maxillary bone is
removed in order to narrow the maxilla.
 SARME exhibits minimal relapse and overcor-
rection is generally unnecessary. MPMO can be
unstable. Surgical expansion with an MPMO
should include: surgical over-expansion by
20%; a fixed occlusal splint placed at the time
of surgery to hold the transverse correction for
six weeks post-surgically; and the use of a palatal
splint, TPA, or heavy overlay wire to hold the
transverse correction for as long as possible
when the occlusal splint is removed.6,32 36
 MPMO the orthodontist should remove
transverse compensations (upright posterior
teeth) before surgery.
 MPMO - the more pieces, the more problems. Try to
keep the number of bony cuts to a minimum -
to ensure an adequate soft-tissue pedicle and
blood supply.
Q: Describe the difference between a two-
piece and a three-piece MPMO.
93
A: In a two-piece MPMO (Fig. 25A and B), an
osteotomy cut is made para-sagittally, and the
maxilla is widened by opening (rotating) the
hemi-maxillae around the central incisors.
Therefore, the intercanine width increases but
less than the intermolar width increases. Two-
piece MPMOs can also be designed with osteot-
omy cuts involving only one posterior segment.
In a three-piece MPMO (Fig. 25C and D),
the intercanine width is maintained because
osteotomy cuts are made distal to the canines.
Depending upon the surgical goals, three-
piece MPMOs can even be designed with
osteotomy cuts distal to premolars or without
widening the posterior at all and only correct-
ing a significant anterior occlusal step.
Q: A 19-year-old male (Fig. 26A M) presents
to you with the chief complaint, “My front teeth
don't touch and my jaw sits back.” You note the
following:
1. convex profile
2. retrusive chin
3. Angle Class II relationship
4. Iowa Classification II(2 mm) II(2 mm) II
(3 mm) II(3 mm)
5. CR = CO
6. minimal buccal corridors in posed smile
7. mild maxillary and mandibular anterior
crowding
8. anterior open bite
9. maxillary and mandibular anterior teeth are
stepped up relative to the posterior teeth by
2 3 mm
10. constricted (anteriorly tapering) maxillary arch
11. recession of maxillary first permanent
molars buccal periodontium
12. maxillary premolar lingual crown torque
13. maxillary second molar buccal crown torque
14. mandibular premolar and molar lingual
crown torque
The patient does not have a posterior cross
bite. However, in order to address his chief com-
plaint, your treatment plan calls for mandibular
premolar extractions, mandibular canine retrac-
tion through the extraction spaces, and a bilat-
eral sagittal split osteotomy (BSSO) mandibular
advancement. In terms of this treatment plan,
how do you assess the patient’s future transverse
relationship?
94 Southard et al
Figure 25. A two-piece (A and B) and three-piece (C and D) MPMO.
A: To assess his future transverse relationship,
advance the patient’s mandibular model into the
anticipated anteroposterior position (relative to
his maxillary model) following premolar extrac-
tions, canine retractions, and BSSO mandibular
advancement surgery.
Q: Fig. 27A and B illustrate the patient's initial
mandibular model advanced to where it should be
following mandibular first premolar extractions,
canine retraction, and surgery. In terms of the
resulting transverse relationship, what do you note?
A: His models now exhibit a bilateral posterior
cross bite. The interdental width of the patient's
maxillary arch is inadequate by approximately
3 4 mm on each side (6 8 mm total), especially
in the canine area.
Q: What are your options for dealing with his
anticipated post-surgical bilateral posterior cross
bite? Why would, or why would you not, choose
each option?
A: Options include:
 No treatment leaving him in cross bite. This
option is, in our opinion, unacceptable. If the
patient is willing to undergo major surgery to
improve his appearance/bite, then not
addressing the anticipated cross bites would
be inexcusable.
 Attempting RME (orthopedics) - is not recom-
mended due to the gingival recession buccal to
his maxillary first molars (Fig. 26D F). Even
if those sites were grafted, the risk of further
recession during RME is significant.
 Masking (camouflage; increasing buccal
crown torque of the maxillary canines and
maxillary posterior teeth plus increasing lin-
gual crown torque of the mandibular poste-
rior teeth) is not recommended due to the
magnitude of his anticipated transverse dis-
crepancy, the presence of maxillary buccal
gingival recession, the significant mandibular
lingual compensations already present, and
the fact that our goal is an ideal outcome.
 Adult transverse diagnosis and treatment: A case-based review 95

Figure 26. Initial records of a 19-year-old male with the chief complaint, “My front teeth don't touch and my jaw
sits back.”
96 Southard et al

Figure 27. Patient depicted in Fig. 26. Relationship of the patient's models with his initial mandibular model
advanced to the anticipted, postsurgical, position.

 SARME would guarantee enough posterior
overjet to correct the cross bites and upright
his posterior teeth without taxing the maxil-
lary buccal gingiva. Another advantage of
SARME is that it would provide significant
anterior expansion, which the patient's anteri-
orly-tapered maxilla needs. A drawback of
SARME is that the patient will need to go
through two major surgeries. Some patients
refuse mandibular surgery after SARME.
Some insurance companies deny payment for
two separate maxillary surgeries.
 Multiple piece maxillary osteotomy (MPMO)
is not recommended. Why? The amount
of maxillary intercanine widening we could
achieve with a two-piece MPMO is inadequate.
With a three-piece MPMO, the maxillary
intercanine width would be left unchanged.
Q: How do you recommend proceeding?
A: Options for dealing with his (post-surgical)
transverse relationship were presented to the
patient. He elected to undergo a SARME
(Fig. 28A and B). Subsequently, fixed orthodon-
tic appliances were placed, mandibular posterior
teeth were uprighted using cross bite elastics
worn from the lingual of the mandibular poste-
rior teeth to the buccal of the RME appliance,
mandibular first premolars were extracted, man-
dibular canines were retracted reciprocally until

Figure 28. Progress (A E) and deband (F M) records of the patient depicted in Fig. 26.
 Adult transverse diagnosis and treatment: A case-based review 97

Figure 28. Continued

mandibular spaces were closed (Fig. 28C E),
and a BSSO mandibular advancement was per-
formed. TADs were never placed for anchorage
during mandibular space closure, but his maxil-
lary incisors were advanced before surgery (Iowa
spaces placed) to permit Class I canine seating
during surgery without incisor interference.
These spaces were closed, post-surgically.
Deband records are shown in Fig. 28F M. Note
the excellent posterior interdigitation and
uprightness of the patient’s posterior teeth.
Q: For the patient, when would the ideal time
be to remove mandibular transverse compensa-
tions?
A: Ideally, mandibular compensations would
be removed before SARME. Why? Uprighting the
mandibular posterior teeth first would allow you
to more accurately judge the amount of maxil-
lary expansion you needed with SARME.
Q: An adult presents to you with a unilateral
right posterior cross bite (Fig. 29A) without a
CR-CO shift. You decide to treat with a right uni-
lateral SARME (right side only osteotomies). But,
as the maxilla is expanded, you notice that the
expansion is proceeding bilaterally, not unlater-
ally (Fig. 29B). Why? Do you have any recom-
mendations for achieving a true unilateral
SARME expansion?
98 Southard et al
Figure 29. Unilateral cross bite in an adult (A) before and (B) after unilateral SARME (bony cuts made only on
the patient's right side).
A: The reason a bilateral maxillary arch
expansion resulted is because the maxilla was
not disarticulated from the pterygoid plates. To
achieve only right unilateral expansion, the right
hemi-maxilla should be disarticulated from the right
pterygoid plates but leaving the left hemi-maxilla
attached to the pterygoid plates. The result is
that the right hemi-maxilla is held only by the
RME appliance and soft tissue and a true right
unilateral expansion can be achieved.
Q: A 19-year-old female (Fig. 30A P) presents
to you with the chief complaint, “I want my teeth
straight and do not like the way my gums show
when I smile.” She presents with:
1. convex profile
2. mandibular skeletal anteroposterior deficiency
3. long lower anterior face height (3 mm inter-
labial gap)
4. VME (vertical maxillary excess)
5. Angle Class II relationship
6. Iowa Classification II(4 mm) II(3 4 mm) II
(4 mm) II(5 mm) (Fig. 30L and M)
7. CR = CO
8. stepped up maxillary (»2 mm) and mandib-
ular incisors
9. anteriorly tapering maxillary arch
10. right posterior cross bite
11. “hourglass” shape to right maxillary arch
(not unusual in unilateral cross bites)
12. maxillary first molar lingual cusp intermolar
width = 45 mm (Fig. 30N)
13. mandibular first molar central fossa intermo-
lar width = 51 mm
14. maxillary second molar transverse dental
compensations (buccal crown torque,
Fig. 30O)
15. mandibular posterior teeth dental compen-
sations (lingual crown torque, Fig. 30P)
Is her right posterior cross bite a dental, or
skeletal, cross bite?
A: The patient’s cross bite is a skeletal cross bite
due to a maxillary skeletal transverse deficiency.
We can state that it is a skeletal cross bite because
uprighting her maxillary second molars and man-
dibular posterior teeth (removing dental compen-
sations) will worsen her right posterior cross bite
and could even put her in left posterior cross bite.
Q: If we attempt correction of the patient’s
unilateral posterior crossbite, can you estimate
the amount of maxillary intermolar width
increase that will be needed?
A: Assume for a moment that the patient will
be treated non-extraction. In that case, she will
finish with Class I molars. For her maxillary first
molar lingual cusps to seat in her mandibular
first molar central fossae, 6 mm of maxillary first
molar intermolar width increase is needed
(45 mm to 51 mm). In addition, uprighting her
lingually-inclinded mandibular first molars will
tend to move them buccally - adding to the
amount of maxillary intermolar width increase
needed. Looking at Fig. 30P, we can estimate
that this buccal movement will require an addi-
tional 2 mm per side. Therefore, we can estimate
that we need at least 10 mm of maxillary intermolar
expansion to properly interdigitate the posterior
occlusion at the end of her treatment.
If we were to consider an extraction scheme
that would result in a final molar occlusion other
than class I, the amount of maxillary intermolar
expansion would depend on the final bucco-lin-
gual position of the mandibular molars, and the
final occlusal position of the maxillary molars
with the mandibular arch.
Q: The patient’s non-extraction treatment
plan includes placing fixed orthodontic applian-
ces, leveling/aligning both arches, a LeFort I
 Adult transverse diagnosis and treatment: A case-based review 99

Figure 30. Initial records of a 19-year-old female presenting with the chief complaint, “I want my teeth straight
and do not like the way my gums show when I smile.”
100 Southard et al

Figure 30. Continued

maxillary differential impaction surgery (5 mm options for dealing with the unilateral posterior
posterior impaction, 3 mm anterior impaction), cross bite? Why would, or why would you not,
and a possible mandibular BSSO surgery. In choose each option?
terms of this treatment plan, what are your A: Options include:
 Adult transverse diagnosis and treatment: A case-based review
 No treatment This option is, in our opinion,
unacceptable. If the patient is willing to
undergo major surgery to improve her
appearance/bite, then not addressing her
cross bite would be unfortunate.
 Attempting RME (orthopedics) - is reasonable
for a 19-year-old woman, but a mid-palatal
split is certainly not guaranteed. Further:
a. Her posterior buccal periodontium appears
robust (Fig. 30D and F, thick biotype
thick bone, thick keratinized tissue).
b. We recommend activating the RME appli-
ance screw once a day, or once every other
day, for 1 or 2 weeks. If the mid-palatal
suture does not separate, assume that you
are achieving dental movement only.
c. If you Attempt RME, you must have a “fall-
back” plan if the mid-palatal suture does
not split.
d. An SARME would be an excellent fallback
option. With SARME, adequate maxillary
expansion would be guaranteed. However,
if you first attempted RME, then it would
be prudent to allow posterior teeth mobility
to decrease first for 2 3 months before
using them as anchors for SARME.
e. MPMO would not be a good fallback
option. Why? The recommended limit of
MPMO expansion is 8 10 mm, but we
would also request 20% over-expansion for
stability. Therefore, depending upon the
amount of dental expansion initially
achieved, if we do not get a mid-palatal
suture split, then we should consider
SARME.
 Masking (camouflage) would consist of
increasing maxillary molar buccal crown tor-
que and increasing mandibular posterior
teeth lingual crown torque. We do not recom-
mend masking to correct her right cross bite:
a. The patient requires at least 10 mm of
transverse maxillary first molar expansion
more than the maximum recommended
masking range of 3 5 mm. The balance
between the amount needed and amount
recommended would come from rolling
the mandibular posterior teeth lingually by
3 mm per side. This would be significant,
and a compromise.
b. Although the patient exhibits robust maxil-
lary buccal periodontium, non-SARME
adult maxillary expansion can result in
101
significant buccal teeth tipping, buccal alve-
olus tipping, translation of roots through
cortical bone, periodontal defects, osseous
defects, and significant expansion
relapse.6,37 41 She would need to accept
these risks.
 SARME would guarantee enough posterior
overjet to correct her cross bite and permit
uprighting of posterior teeth. However, this
would require two maxillary surgeries since a
LeFort I impaction is also planned.
 MPMO to expand the maxillary skeleton is
not recommend since the required maxillary
expansion (including the 20% overcorrection
for stability) exceeds the recommended
MPMO limit of 8 10 mm.
Q: How do you recommend proceeding?
A: RME was attempted with 0.25 mm expan-
sion once per day for two weeks (3.5 mm total
screw expansion). A diastema did not form, and
a mid-palatal split was not observed on an occlu-
sal radiograph. Based upon the expansion
already achieved, a decision was made to pro-
ceed with leveling/aligning both arches, fol-
lowed by a LeFort I MPMO to impact and
expand the maxilla. Pre-surgical progress records
are shown in Fig. 31A E.
Q: How do you choose which MPMO to use to
address the patient’s transverse relationship dur-
ing the LeFort I maxillary impaction surgery?
A: Make a set of progress models, either algi-
nate/plaster or virtually from a CBCT scan. Posi-
tion the models into a Class I canine relationship
with a best fit transverse relationship (Fig. 32A
and B). Determine where the transverse expan-
sion is needed.
Next, exhaustively consider all possible maxil-
lary expansion sugeries. We considered a two-
piece MPMO (Fig. 32C), a three-piece MPMO
with bony cuts made between the premolars
(Fig. 32D), and a three-piece MPMO with second
premolar extractions and bony cuts made
between the first premolars and first molars
(Fig. 32E). This latter option would permit the
two proximal maxillary segments to be moved
away from the pterygoid plates. Of these options,
the two-piece MPMO was selected because some
inter-canine expansion was desirable.
Q: Significant difficulties occurred during sur-
gery including excessive bleeding from the ptery-
goid plexus. The occlusal splint broke and less
102 Southard et al

Figure 31. Pre-surgical progress records of a 19-year-old patient depicted in Fig. 30.

Figure 32. Progress models of the patient depicted in Fig. 30. (A and B) unaltered models with canines advanced
into a Class I relationship and best fit posterior occlusion; (C) two-piece MPMO; (D) three-piece MPMO with lat-
eral bony cuts made between maxillary premolars; (E) three-piece MPMO with extraction of maxillary second pre-
molars and bony cuts made between first premolars and first molars.
 Adult transverse diagnosis and treatment: A case-based review 103

maxillary expansion was achieved than hoped
for. The patient returned one week post-surgery
(Fig. 33). How will you deal with the inadequate
maxillary transverse expansion once the occlusal
splint is removed in five weeks?
A: Following discussions with the surgeon and
the patient, a decision was made to proceed by
placing posterior transverse compensations. At six
weeks post-surgery, the occlusal splint was removed,
and a palatal splint was fabricated and worn. Some
months later, the patient began wearing cross bite
elastics from the lingual of the maxillary first
molars to the buccal of the mandibular first molars.
In addition, and in consultation with the surgeon,
the patient was placed on a high-pull headgear to
address her post-surgical Class II relationship. Post-
surgical orthodontic treatment was completed.
Deband photographs are shown in Fig. 34.
Q: Can you describe a recently introduced
non-surgical technique to help overcome skeletal
resistance to maxillary expansion in young
adults?
A: Yes, in addition to including both maxillary
first premolars and first permanent molars as

Figure 33. Post-surgical photographs of the patient shown in Fig. 30.

Figure 34. Deband photos of the patient shown in Fig. 30.

104 Southard et al
anchors, TADs can be inserted into palatal bone
and attached to the Hyrax appliance (Fig. 35A and
B). It has been suggested that such TAD-supported
RME helps overcome skeletal resistance to RME,
protects anchor teeth, and reduces buccal tipping
of the posterior dentoalveolar segment.42 44
Q: Can you describe at least four mandibular
surgeries which are used in treating posterior
cross bites?
A: Possible mandibular surgeries include:
 Mandibular BSSO advancements which can
improve/correct a posterior buccal cross bite
by advancing a wider part of the mandibular
arch into a narrower part of the maxillary
arch (Fig. 36A C). In a similar fashion, a
mandibular BSSO setback can improve/cor-
rect a posterior lingual cross bite by moving a
narrower part of the mandibular arch into a
wider part of the maxillary arch.
 Asymmetric mandibular BSSO advancements
(or setbacks) can be used to advance (or set-
back) one side of an asymmetric mandible and
improve/correct transverse relationships.
Fig. 36D and F illustrate a Class III subdivision
left patient with excessive left mandibular
growth and resulting right posterior cross bite.
An asymmetric mandibular setback osteotomy
corrected her left Class III relationship and
her right posterior cross bite (Fig. 36E and G).
 To reduce mandibular intermolar width, a
mandibular midline osteotomy combined with
a “lingual roll” of the two hemi-mandibles
(Fig. 36H) has been suggested.45,46 Further, it
has been suggested that this procedure avoids
Figure 35. (A and B). Mini-screws inserted into palatal bone, and included in the Hyrax appliance, provide addi-
tional anchorage for overcoming maxillary skeletal resistance to expansion (photos courtesy of Drs. Michael
Callan and Kirsten Frazier).
the need for maxillary expansion with some
mandibular advancements. However, our sur-
geons at the University of Iowa are not enthusi-
astic about this technique because it sections
the mandible into four pieces.
 The mandible arch can be constricted by
extracting a mandibular central incisor, per-
forming a mandibular midline osteotomy,
removing bone at the extraction site, and fix-
ating the two hemi-mandibles in contact at
the symphysis.
 The mandible arch can be widened by per-
forming a mandibular midline osteotomy,
separating the two hemi-mandibles at the mid-
line, bridging the symphyseal defect with a
bone graft, then fixating the two hemi-mandi-
bles and bone graft.
 In cases of mandibular transverse deficiency,
the mandible can be widened by sympyseal
distraction47 49 using either a tooth-born, or
bone-born, distraction device. A mid-symphy-
seal osteotomy cut is made, a 4-5-day latency
period is allowed, and then activation of
0.75 mm per day (midline opening) is fol-
lowed until the desired mandibular expansion
is achieved (Fig. 36I). Overexpansion is not
performed, and the expansion device is left in
place for a minimum of three months for sta-
bility. Prior studies have shown that osseous
expansion achieved by mandibular symphy-
seal distraction osteogenesis is stable in the
long term.50,51 During distraction osteogene-
sis, there is progressive bone generation and
expansion of the soft tissue envelope which
contributes to long term stability.
 Adult transverse diagnosis and treatment: A case-based review 105

Figure 36. Mandibular surgeries used in correcting posterior cross bites: (A C) a BSSO advancement osteotomy
will generally improve the transverse relationship in cases of buccal cross bite; (D,F) patient with right posterior
cross bite and deviation of chin to the right caused by excessive left condylar growth successfully treated (E,G)
with asymmetric left mandibular setback osteotomy; (H) midline osteotomy combined with “lingual roll” of hemi-
mandibles to reduce mandibular inter-canine and inter-molar widths; (I L) symphyseal distraction to widen man-
dibular inter-canine and inter-molar widths.

We wish to emphasize that when widening the
mandible using either this technique or a mid-
line osteotomy with bone graft, widening of the
entire mandibular arch takes place, not just widening
of the intercanine width (Fig. 36J). As an
example, the patient whose models are shown in
Fig. 36K required mandibular expansion from
the canines to the second molars. Symphyseal
distraction was appropriate and resulted in cor-
rection of his transverse relationship (Fig. 36L).
106 Southard et al

Figure 36. Continued

 Adult transverse diagnosis and treatment: A case-based review 107

Figure 36. Continued

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