6 Orthodontics January 2019

Enhanced CPD DO C

Felicity Borrie David Bearn

Anterior Crossbite
Correction with a Lower
Removable Appliance
Abstract: This case demonstrates the use of a novel design of lower removable appliance to correct an anterior crossbite, by retracting the
lower incisors.
CPD/Clinical Relevance: Patients usually do not tolerate lower removable appliances; however, this case highlights how a simple
modification to a lower removable appliance can make it patient friendly and a useful appliance in the management of anterior crossbites
in those cases where an upper appliance is not appropriate.
Ortho Update 2019; 12: 6–7

Anterior crossbites are usually present
in the mixed dentition. The prevalence
can vary depending on the age of the
child examined and his/her country
of origin. From a UK perspective,
the prevalence has been reported
to be between 7% and 10%.1 The
orthodontic literature has numerous
publications relating to the correction
of single tooth anterior crossbites;
the evidence in support of the most
effective appliance is weak. This has
been highlighted by a recent review
of the literature in this area.2 Lower
removable appliances are rarely used
in orthodontics in the UK, usually
due to poor compliance associated
with discomfort from the appliance.
However, there appears to be some
reconsideration of this appliance and
its versatility as articles have appeared
in the literature regarding its use in
the management of ectopic lower
permanent canines.3,4 This case report
focuses on the use of a lower removable
appliance to correct an anterior crossbite
in a child in the early mixed dentition.
Case report
An eight-year-old female
was referred to the Paediatric Dentistry
department at Dundee Dental Hospital
in 2011 with hypodontia. Clinical and
radiographic examination revealed the
patient to be in the early mixed dentition,
with delayed eruption of the upper first
permanent molar, a peg-shaped UR2
and severe hypodontia, missing UR3,7,8,
UL2,3,7,8, LL7,8 and LR7,8. There was no
reported family history of hypodontia.
The patient had a mild skeletal III pattern
with Class III incisors, a right side buccal
crossbite and associated displacement
(Figures 1 and 2).
Despite the patient presenting
with a large median diastema, her
complaint was directed only towards the
anterior crossbite, and both the patient
and her mother were keen to have this
corrected.
As the upper first permanent
molars were partially erupted, and
the rest of the upper buccal segment
comprised primary molars, the potential
available undercuts for retention of
an upper removable appliance were
poor. The upper incisors were already
proclined and the only suitable
undercuts were lingually in the lower
arch, so it was decided to make a
lower removable appliance (LRA). The
design consisted of occlusal coverage
buccally, bilaterally with a connecting
lingual bar, and the active component
was a modified Robert’s retractor. The
occlusal coverage was constructed in
Durasoft® 1.8 mm, which is a bilaminate,
with the hard layer on the outside of
the appliance allowing any bonding
of acrylic to the material. The Robert’s
retractor was constructed in 0.5 mm
stainless steel, and the lingual bar was a

Felicity Borrie, BDS, PhD, MFDS, MOrth, FDS(Orth) RCS(Ed), Consultant Orthodontist, Dr Gray’s Hospital, Elgin and David Bearn, BDS, MSc,
PhD, F(Orth)DS RCS, MOrth RCS, FHEA, Professor of Orthodontics, University of Dundee Dental School, Park Place, Dundee DD1 4HR, UK.

Downloaded from magonlinelibrary.com by 130.237.122.245 on February 13, 2019.

January 2019
Figure 1. Pre-treatment presentation: anterior
view.
Figure 2. Pre-treatment: right lateral view.
Figure 3. Appliance in situ: occlusal view.
Figure 4. Appliance in situ: right lateral view.
standard stainless steel lingual arch as used
in the construction of a lower partial denture
(Figures 3 and 4). Not only did the Durasoft®
engage in the lingual undercuts and provide
retention of the appliance, it also provided
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Figure 5. Crossbite corrected, bilateral open
bites present.
occlusal capping to disclude the
anterior teeth.
The appliance was fitted
and appropriate instruction for care
given. The patient was reviewed
approximately every six to eight weeks
to have the appliance reactivated. After
four months of wear, the patient had
worn down the occlusal capping, so the
decision to add some glass ionomer
cement (GIC) to the upper primary
molar teeth and to add some acrylic to
the appliance, was taken rather than
make a new appliance. The patient was
reviewed for a further six months by
which time the crossbite was corrected;
however, the patient had bilateral open
bites (Figure 5). The decision was made
to leave the remaining GIC on the
deciduous teeth as these were close to
exfoliation. The patient was instructed
to wear the appliance at night only to
maintain crossbite correction and allow
the posterior occlusion to settle. Three
months later the patient was reviewed
and the lateral open bites were closed.
The patient has since been reviewed
one year since stopping appliance wear
and the crossbite correction remains
stable. She still has no concerns
regarding her upper anterior spacing
but will be reviewed by the hypodontia
team in due course.
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Orthodontics 7
Discussion
Following fitting of the LRA,
the patient adapted well and did not
complain of any irritation buccally or
lingually. She also had no temporary
speech issues. Due to the retention system
(Durasoft® buccal capping), the appliance
did not become less retentive between
appointments. The only drawback was
the wear to the occlusal capping which
could be managed by either bonding
acrylic, where the wear had occurred, or
by adding GIC to the opposing primary
molars.
Conclusion
A lower removable appliance
is an acceptable alternative to an upper
removable appliance when there are
limitations with retention during the
mixed dentition and further proclination
of the upper incisors is not possible. This
novel design was well tolerated by the
patient, easy to adjust and facilitated
correction of the crossbite.
References
1. O’Brian M. Children’s Dental Health in
the United Kingdom. London: Office
of Population Censuses and Surveys,
1993: pp67−68.
2. Borrie F, Bearn D. Early correction
of anterior crossbites: a systematic
review. J Orthod 2011; 38: 175−184.
3. Sabuncuoglu FA, Karacay S,
Erkan M. Orthodontic treatment
of transposition of permanent
mandibular lateral incisor and left
canine in mixed dentition: a case
report. Pediatr Dent 2012; 34: E40–
E43.
4. Altan B, Doruk C. The treatment of an
impacted mandibular canine: case
report. Int J Orthod 2011; 22: 17−20.
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