KOREKSI CROSSBITE ANTERIOR DINI MELALUI

PEMBUKAAN GIGITAN POSTERIOR : STUDI KOHORT

PROSPEKTIF SUPERIMPOSISI GAMBAR 3D

Disadur dari:
Vasilakos G, Koniaris A, Wolf M, Halazonetis D, Gkantidis N. Early anterior
crossbite correction throughposterior bite opening: a 3D superimposition
prospective cohort study. European Journal of Orthodontics, 2018; 40(4): 364–71

PERIODE: 18 Juli – 09 September 2022

Penyaji:
1. Shabrina Alifah Siregar (210631267)
2. Dinda Tryana Sembiring (210631268)

Dosen Pembimbing:
Tanti Deriaty, drg., Sp.Ort., MDSc
NIP. 198608182019032011

DEPARTEMEN ORTODONSIA
FAKULTAS KEDOKTERAN GIGI
UNIVERSITAS SUMATERA UTARA
MEDAN 2022
DEPARTEMEN ORTODONSIA
FAKULTAS KEDOKTERAN GIGI
UNIVERSITAS SUMATERA UTARA

KOREKSI CROSSBITE ANTERIOR DINI MELALUI

PEMBUKAAN GIGITAN POSTERIOR : STUDI KOHORT
PROSPEKTIF SUPERIMPOSISI GAMBAR 3D

Disadur dari:
Vasilakos G, Koniaris A, Wolf M, Halazonetis D, Gkantidis N. Early anterior
crossbite correction throughposterior bite opening: a 3D superimposition
prospective cohort study. European Journal of Orthodontics, 2018; 40(4): 364–71
Jumat, 29 Juli 2022

Dosen Pembimbing : Mahasiswa Penyaji :

Tanti Deriaty, drg., Sp.Ort., MDSc Shabrina Alifah Siregar (210631267)

NIP. 198608182019032011 Dinda Tryana Sembiring (210631268)
 KOREKSI CROSSBITE ANTERIOR DINI MELALUI
PEMBUKAAN GIGITAN POSTERIOR : STUDI KOHORT
PROSPEKTIF SUPERIMPOSISI GAMBAR 3D
Disadur dari: Vasilakos G, Koniaris A, Wolf M, Halazonetis D, Gkantidis N.
Early anterior crossbite correction throughposterior bite opening: a 3D
superimposition prospective cohort study. European Journal of Orthodontics,
2018; 40(4): 364–71

Abstrak
Tujuan: Untuk menilai efektivitas, kinerja klinis, dan potensi efek samping dari
koreksi crossbite anterior dini melalui pembukaan gigitan.
Subjek dan metode: Sampel terdiri dari 16 pasien (kisaran usia 6,2– 9,3 tahun)
dengan crossbite anterior pada periode gigi bercampur yang dirawat melalui
pwmbukaan gigitan posterior. Pasien secara prospektif di follow up sampai minimal
6 bulan pasca perawatan dan tidak ada drop-out.
Hasil: Pada 14 pasien (87,5 %), crossbite anterior telah terkoreksi. Perawatan aktif
dari kasus yang berhasil dikoreksi berlangsung 2,5 bulan (kisaran: 0,6-8,9).
Koreksi crossbite anterior pada gigi insisivus sentral dicapai dengan bergeraknya
gigi ke labial 2,05 mm (kisaran: 0,97-5,45) dan inklinasi mahkota bukal 9,25°
(kisaran: 2,32-14,52°) (P <0,05). Gigi antagonis menunjukkan adaptasi spontan
dari posisi dalam arah yang berlawanan (P <0,05). Tidak ada efek samping penting
yang dicatat.
Keterbatasan: Ini adalah studi terkontrol non-komparatif, pada sampel terbatas.
Kesimpulan: Pembukaan gigitan adalah pendekatan yang menjanjikan,
sederhana, dan membutuhkan kepatuhan yang minim untuk koreksi crossbite
anterior dini. Teknik superimposisi 3D dan analisis model digital yang digunakan,
memungkinkan evaluasi yang tepat dari pergerakan satu gigi di ketiga bidang
ruang.
1. Pendahuluan

Crossbite anterior mengacu pada maloklusi akibat posisi lingual gigi

anterior rahang atas dalam hubungannya dengan gigi anterior rahang bawah.
Prevalensi crossbite anterior yang dilaporkan pada gigi bercampur bervariasi
antara 1,6 % dan 7,9 %.1,4 Menurut asalnya, dapat dibedakan menjadi crossbite
skeletal dan dental.5,6 Crossbite skeletal dikaitkan dengan profil skeletal yang
konkaf dan jaringan lunak dan biasanya memerlukan intervensi yang lebih
ekstensif untuk dikelola.7 Sedangkan crossbite anterior gigi atau dentoalveolar
adalah masalah yang lebih terlokalisir dan lebih mudah ditangani karena hal ini
mungkin hasil dari retensi gigi desidui yang berlebihan, pola erupsi yang tidak
teratur, atau malposisi sederhana dari gigi permanen.
Koreksi dini crossbite, bahkan pada awal periode gigi bercampur,
diindikasikan untuk mencegah potensi gangguan pada pertumbuhan normal
rahang dan gangguan fungsi neuromuskular atau sendi tempororahang bawahr,
terutama bila ada asimetri yang berhubungan dengan pergeseran fungsional
rahang bawah. Jika tidak dirawat, dapat menyebabkan disharmoni gigi
permanen, tulang, atau jaringan lunak atau meningkatkan risiko
ketidakseimbangan tempororahang bawahr atau neuromuskular pada tahap
selanjutnya8-10.
Intervensi dini pada gigi desidui mungkin tidak dianjurkan karena
masalahnya dapat terkoreksi sendiri pada kira-kira setengah dari kasus yang ada,
dan pasien tidak diharapkan mendapatkan manfaat yang signifikan dari koreksi dini
tersebut. Beberapa metode telah digunakan untuk koreksi crossbite anterior periode
gigi bercampur, termasuk piranti lepasan dan cekat11. Namun, kepatuhan pasien
sangat penting untuk keberhasilan perawatan dengan piranti lepasan12. Sedangkan
penggunaan piranti cekat tidak menuntut tingkat kepatuhan yang tinggi tetapi
terkait dengan efek samping yang bergantung pada waktu, seperti bintik putih dan
resorpsi akar, dan mungkin berdampak negatif pada kualitas hidup terkait kesehatan
mulut pasien.13
Untuk alasan ini, metode yang lebih sederhana, tanpa penggunaan piranti
ortodontik apa pun, telah disarankan untuk mengoreksi crossbite anterior selama
periode gigi bercampur14,15. Yaitu, pembuatan oklusal bite plane pada oklusal
molar kedua gigi desidui atau molar pertama gigi permanen pada rahang bawah
pada bagian kanan dan kiri, dan hal ini memungkinkan koreksi crossbite anterior
secara spontan. Pendekatan ini bisa sangat menjanjikan, terutama untuk anak-anak
yang tidak kooperatif atau berkebutuhan khusus. Namun, baru disajikan dalam
beberapa laporan kasus14,15 dan belum diuji secara komprehensif.
Dengan demikian, tujuan dari studi kohort prospektif ini adalah untuk
menilai efektivitas, kinerja klinis, dan potensi efek samping dari metode sederhana
koreksi crossbite anterior dini ini.

2. Bahan dan Metode

Penelitian ini dilakukan sesuai dengan prinsip etik yang dijelaskan dalam
Deklarasi Helsinki (versi 2013). Informed consent tertulis diperoleh dari pasien dan
orang tua mereka sebelum pendaftaran untuk memungkinkan penggunaan catatan
klinis standar dan cetakan gigi untuk tujuan penelitian.

2.1 Sampel

Enam belas pasien berturut-turut (11 laki-laki dan 5 perempuan; usia rata-rata
saat memulai perawatan: 8,0 ± 0,9, kisaran usia: 6,2-9,3 tahun) dimasukkan dalam
penelitian sesuai dengan kriteria kelayakan berikut: tidak ada karies aktif, gigi
bercampur, crossbite anterior (pada setidaknya satu gigi insisivus permanen
rahang atas), adanya ruang yang cukup untuk pergerakan labial gigi pada crossbite,
tidak ada pergeseran fungsional yang ekstrim (>4 mm), tidak ada crossbite
posterior, tidak ada bukti pola skeletal Kelas III (sebagaimana dinilai melalui
evaluasi klinis), tidak ada perawatan ortodontik sebelumnya, dan tidak ada
intervensi ortodontik lainnya sampai kunjungan tindak lanjut, dilakukan minimal
6 bulan pasca perawatan. Semua pasien dirawat di sebuah praktik pribadi di
Cologne (Jerman), yang dirawat oleh tiga ahli ortodontik, sesuai dengan protokol
praktik. Rekrutmen pasien dimulai pada bulan Februari 2013 dan berakhir pada
bulan Maret 2015 berdasarkan kehadiran peneliti utama dalam praktik. Empat
pasien telah dilakukan perawatan aktif pada awal penelitian dan data pra-
perawatan mereka diperiksa secara retrospektif untuk kelayakan. 12 pasien lainnya
terdaftar secara prospektif.
2.2 Prosedur Perawatan

Riwayat pasien, pemeriksaan klinis, foto ekstraoral dan intraoral, cetakan gigi
pada oklusi sentrik, dan radiografi panoramik diperoleh sebelum perawatan
dimulai (T0) sesuai dengan protokol praktik.
Pada awal perawatan, permukaan oklusal gigi molar kedua desidui bagian
kanan dan kiri pada rahang bawah atau molar pertama gigi permanen (bila geraham
desidui tidak ada atau mobiliti) dibersihkan, dikeringkan, dan dietsa dengan asam
fosfat 37% selama 20 detik, kemudian dicuci dan dikeringkan. Lapisan pertama
diaplikasikan (Orthosolo Universal Bond Enhanser, Ormco, CA, USA) dan semen
ionomer kaca yang dimodifikasi resin (Ultra Band-Lok Blue, Reliance Orthodontic
Products, 1540 West Thorndale Ave, Itasca, IL 60143) ditempatkan untuk
menaikkan bidang oklusal dan lakukan light-cured selama 30 detik. Prosedur ini
bertujuan untuk menaikkan gigitan kira-kira 1-2 mm lebih dari hubungan oklusal
anterior edge-to-edge untuk memungkinkan pergerakan labial gigi/gigi pada
crossbite (Gambar 1A dan 1B).
Pasien dan orang tua diinstruksikan bila ada oklusal bite plane yang hilang,
mereka harus membuat janji untuk menggantinya. Pemeriksaan kembali pasien
dijadwalkan setiap 4-5 minggu. Pasien tetap dianjurkan untuk menyikat gigi dan
menjaga kebersihan mulut. Selama kunjungan berkala, oklusal bite plane
dinaikkan seperti pada awal pembuatan oklusal bite plane dimana dalam kasus
overbite positif tidak memungkinkan pergerakan labial gigi/gigi pada crossbite.
Setelah crossbite anterior dan overjet positif dikoreksi, oklusal bite plane segera
dihilangkan.(Gambar 1C)

2.3 Follow up
Kunjungan berkala dijadwalkan setiap 6-8 minggu, tanpa melakukan intervensi
ortodontik atau prosedur retensi, sampai perawatan ortodontik lebih lanjut
direncanakan dan dilaksanakan untuk merawat masalah lain. Penilaian follow up
(T1) termasuk pemeriksaan klinis, foto ekstraoral dan intraoral, dan cetakan gigi
oklusi sentrik dilakukan pada 6-17 bulan setelah perawatan aktif. Enam bulan
ditetapkan sebagai periode tindak lanjut minimum dan diperpanjang sebanyak
mungkin berdasarkan kehadiran peneliti utama dalam praktik. Selain itu, di T1,
semua pasien mengisi kuesioner secara retrospektif menilai rasa sakit dan
ketidaknyamanan selama pengunyahan dan berbicara, dan nyeri sendi
tempororahang bawahr (TMJ) selama minggu pertama dan pada minggu-minggu
perawatan berikutnya. Jawaban- jawaban ini dicatat pada skala 0–10, dengan 0
ditandai sebagai 'tidak sama sekali' dan 10 ditandai sebagai 'ekstrim'.
Selanjutnya, pertanyaan terbuka memungkinkan pasien untuk melaporkan
masalah lain yang mereka anggap penting dalam setiap periode.

Gambar 1. Foto intraoral pasien yang dirawat karena gigitan silang anterior dengan pembukaan
gigitan. (A) Kondisi pra-perawatan; (B) Pembukaan gigitan untuk koreksi crossbite spontan
(bantalan oklusal berwarna biru); dan (C) Hasil akhir setelah 2,6 bulan.

Setelah pengumpulan data selesai, cetakan gigi dipindai di Kedokteran

Gigi Universitas Bern, menggunakan pemindai permukaan 3D (lampu
garis/iluminasi LED; akurasi < 20 µm; Pemindai laboratorium D104a,
Cendres+Métaux SA, Rue de Boujean 122, CH-2501 Biel/Bienne) untuk
mendapatkan model 3D Standard Tessellation Language (STL) yang
digunakan dalam penelitian. Setiap hubungan 3D rahang atas terdiri dari sekitar
325.000 simpul, dan setiap rahang bawah terdiri dari 300.000 simpul. Cetakan
gigi diperoleh sesuai dengan protokol reguler praktik, melalui cetakan alginat
(Tetrachrom Alginat, KANIEDENTA GmbH & Co.KG, Herford, Jerman),
yang dituang dengan gips (Alabaster Klasse 3, Wiegelmann Dental GmbH,
Bonn, Jerman) pada hari pembuatan cetakan.

2.4 Pengumpulan Data

Data berikut dikumpulkan pada T0 dan T1: usia, tanda dan gejala TMJ
(nyeri dan kebisingan saat istirahat dan selama gerakan rahang), gigi pada
crossbite, overjet dan overbite dari semua gigi insisivus permanen atas yang
telah erupsi penuh, gigi berjejal pada rahang atas. dan rahang bawah, kelas
Angel (molar), durasi perawatan aktif, kepatuhan pasien terhadap kunjungan,
gigi di mana oklusal bite plane ditempatkan, penambahan oklusal oklusal bite
plane yang lepas atau ketinggian yang tidak memadai, dan lamanya masa
follow up.
Data kuesioner menilai nyeri dan ketidaknyamanan selama pengunyahan
dan bicara, dan nyeri TMJ dikumpulkan di T1.
Berdasarkan hasil penelitian sebelumnya16, model gigi 3D dipindai pada
T0 dan T1 ditumpang tindihkan pada area kecil pada palatum yaitu dua pertiga
medial rugae ketiga dan 5 mm bagian paling dorsal ( Gambar 2), menggunakan
software Viewbox 4 (versi 4.1.0.1 BETA, Perangkat Lunak dHAL, Kifissia,
Yunani. Kesesuaian maksimum dari kedua model diharapkan pada area
referensi spesifik karena stabilitas bentuk anatominya17-22, yang juga tidak
terpengaruhi secara langsung oleh perawatan16.
Algoritma titik terdekat iteratif perangkat lunak (ICP)23
diimplementasikan menggunakan pengaturan berikut: 100% estimasi hubungan
tumpang tindih, pencocokan titik ke bidang, pencarian tetangga terdekat yang
tepat, pengambilan sampel titik 100%, dan 50 iterasi. Selanjutnya, pada model
T0, mahkota klinis gigi yang diinginkan dipilih untuk menilai pergerakan gigi
yang terjadi akibat perawatan dan pertumbuhan dari T0 ke T116. Ini adalah gigi
insisivus sentral permanen crossbite pada T0 dan setiap gigi kontralateral yang
tersedia di kedua model, yang berfungsi sebagai kontrol. Gigi yang dijadikan
kontrol terdapat pada 11 pasien, sedangkan 5 pasien lagi tidak terdapat gigi
yang dijadikan kontrol pada kedua cetakan. Jadi, setelah setiap cetakan
superimposisi, mahkota gigi yang dipilih sebelumnya pada T0 ditumpang
tindihkan secara individual pada masing-masing mahkota gigi di T1,
menggunakan pengaturan yang sama. Dengan sumbu referensi yang sama
digunakan untuk merekam pergerakan gigi yang diposisikan pada pusat
mahkota dari setiap gigi yang diinginkan pada model T024. Dua dari sumbu
ditempatkan pada bidang oklusal, sejajar dan tegak lurus terhadap garis tengah
palatal, dan sumbu ketiga tegak lurus terhadap keduanya (Gambar 3). Dengan
cara ini, translasi dan rotasi gigi (inklinasi, tip, dan rotasi) dari T0 ke T1 relatif
tercatat terhadap sistem referensi tiga sumbu.
 Potensi pergerakan (adaptasi) dari gigi insisivus bawah diikuti koreksi
crossbite juga diuji pada kasus dimana satu gigi insisivus sentral rahang bawah
mengalami crossbite pada T0, sedangkan gigi kontralateral tidak, dan gigi
tersebut berkontak dengan gigi atas pada interkuspasi maksimal. (n = 11, 10 di
antaranya crossbite telah terkoreksi; 2 dikeluarkan karena ketidaksempurnaan
cetakan pada daerah insisivus rahang bawah). Karena tidak ada area yang stabil
secara morfologis yang diketahui pada cetakan rahang bawah pasien yang
sedang tumbuh, untuk digunakan sebagai referensi superimposisi,
superimposisi pada rahang bawah dilakukan pada semua gigi posterior yang ada
yang tidak direposisi secara signifikan selama periode T0-T1, seperti yang
dinilai melalui inspeksi visual. Mahkota klinis gigi ini digunakan untuk
superimposisi; tekniknya, termasuk pengaturan software dan asal dan orientasi
dari sumbu referensi dimana pergerakan gigi dicatat, sama dengan yang
digunakan untuk lengkung rahang atas. Dalam delapan kasus, gigi molar
pertama permanen dan gigi molar pertama dan kedua desidui digunakan,
sedangkan dalam tiga kasus lainnya, hanya molar pertama permanen yang
digunakan. Hasil superimposisi rahang bawah ini diperiksa secara visual oleh
dua peneliti (GV & NG) dan dinilai memuaskan.

Gambar 2. Area palatal yang digunakan sebagai referensi untuk

superimposisi model serial (merah).
2.5 Analisis Statistik
Analisis statistik dilakukan dengan menggunakan SPSS (v.20.0, SPSS Inc.,
USA). Dilakukan uji normalitas pada data mentah dengan uji Shapiro-Wilk;
karena bukti non-normalitas dalam beberapa variabel, statistik parametrik dan
non-parametrik diterapkan, sesuai kebutuhan.

Untuk mengevaluasi kesalahan pengukuran pada evaluasi overbite,

overjet, dan crowding, 30 pengukuran diulangi dengan pemeriksa yang sama
setelah 2 minggu. Kesepakatan antar pemeriksa diuji dengan uji-t berpasangan
dan koefisien korelasi antar kelas (ICC); kesepakatan mutlak, model tetap dua
arah]. Perbedaan rata-rata antara pengukuran berulang juga dihitung.

3. Hasil

Uji-t berpasangan tidak menunjukkan perbedaan yang signifikan secara

statistik antara pengukuran berulang (P > 0,05). ICC menunjukkan
kesepakatan yang sempurna untuk pengukuran overjet (rata-rata: 0,95; interval
kepercayaan 95%: 0,86-0,98), pengukuran overbite (rata-rata: 0,96; interval
kepercayaan 95%: 0,88-0,99), dan pengukuran crowding (rata-rata: 0,99; 95%;
interval kepercayaan: 0.98-0.99). Perbedaan rata- rata antara pengukuran
berulang adalah 0,03 mm (interval kepercayaan 95%: 0,27-0,33) untuk overjet,
0,11 mm (interval kepercayaan 95%: 0,05-0,26) untuk overbite, dan -0,05 mm
(interval kepercayaan 95%; 0,18-0,08) untuk crowding.
Secara total, 16 pasien dengan anterior crossbite, yang memenuhi kriteria
inklusi, dimasukkan dalam penelitian dan tidak ada drop out. Pada tujuh
pasien, oklusal oklusal bite plane ditempatkan pada gigi molar kedua desidui,
sedangkan pada sembilan pasien pada gigi molar pertama permanen rahang
bawah. Pada dua pasien, oklusal oklusal bite plane hilang dua kali dan harus
diganti dan pada empat pasien lainnya hal ini terjadi sekali. Kepatuhan
terhadap kunjungan berkala dari 16 pasien baik. Pada 14 pasien dari
keseluruhan pasien crossbite anterior telah terkoreksi (87,5%). Hasil dari
perawatan tetap stabil selama masa follow up. Pasien di follow up selama rata-
rata 9,6 bulan (kisaran: 6,0-19,9 bulan) setelah akhir dari perawatan aktif, yang
berlangsung 2,5 bulan (kisaran: 0,6-8,9 bulan) mengenai 14 kasus yang
berhasil terkoreksi sepenuhnya. Karakteristik sampel pasien secara rinci dan
hasil perawatan disajikan pada Tabel 1.
Pada dua kasus, perawatan tidak berhasil, dan crossbite direncanakan
untuk dikoreksi pada tahap selanjutnya menggunakan piranti cekat, karena
tidak ada perubahan fungsi yang signifikan. Keduanya memiliki dua gigi
anterior crossbite, sedangkan satu kasus memiliki hubungan Kelas III ringan
(1/4 cusp) baik pada T0 dan T1. Sebaliknya, sebagian besar kasus yang berhasil
dirawat memiliki satu gigi yang mengalami crossbite, dan tidak ada kasus
berhasil yang memiliki hubungan Kelas III (Tabel 1).
Superimposisi gambar 3D dari cetakan gigi seri menunjukkan bahwa
koreksi crossbite anterior pada gigi insisivus sentral dicapai dengan pergerakan
ke arah labial 2,05 mm (kisaran: 0,97–5,45) dan inklinasi bukal dari mahkota
sebesar 9,25° (kisaran:2,32-14,52°). Nilai-nilai ini secara signifikan berbeda
dari gigi kontrol kontralateral yang tidak mengalami crossbite (Tabel 2)
(Gambar 3). Dalam satu kasus, dua gigi insisivus lateral yang dikoreksi
menunjukkan koreksi yang sama (rata-rata pergerakan ke arah labial 2,01 mm
dan inklinasi bukal dari mahkota 12,50 °). Pola perubahan posisi gigi yang
sama diamati pada gigi insisivus sentral dari dua kasus di mana perawatan
gagal. Pergerakan ke arah labial 1,72 mm (kisaran: 1,24-2,20) dan inklinasi
bukal dari mahkota telah diamati 6,31° (kisaran: 5,52-7,09°). Namun, ini tidak
cukup untuk mencapai koreksi.
Insisivus sentral rahang bawah yang merupakan antagonis gigi pada
crossbite, bergerak -0,93 mm ke posterior (kisaran: -2,39–(-0,16)) dan
menunjukkan inklinasi mahkota lingual 4,15 ° (kisaran: 3,04–8,76°). Nilai-
nilai ini secara signifikan berbeda dari gigi kontrol kontralateral yang
merupakan antagonis gigi, yang tidak crossbite (Tabel 3) (Gambar 4).
Selain 7 pasien yang melaporkan ketidaknyamanan sedang hingga berat
selama pengunyahan (5-8 dari 10) pada minggu pertama pengobatan, tidak ada
efek samping penting lainnya yang dilaporkan oleh pasien (Tabel 4).
 Gambar 3. Model rahang atas pra-perawatan (hijau muda) dan tindak lanjut (ungu).
Sumbu di mana gerakan dicatat sejajar dengan garis tengah jahitan palatal (Y: hijau, gerakan
antero-posterior; positif: anterior), tegak lurus terhadap garis tengah (X: merah, gerakan lateral;
positif: kanan), dan tegak lurus terhadap oklusal bidang (Z: biru, gerakan vertikal; positif: naik).
Rotasi setiap gigi di sekitar X (merah; inklinasi, positif: mahkota bukal untuk rahang atas dan
mahkota lingual untuk rahang bawah), Y (hijau; ujung, positif: kiri untuk rahang atas dan kanan
untuk rahang bawah), dan Z (biru sumbu rotasi, positif: bukal kanan) juga dicatat

4. DISKUSI
Penelitian ini merupakan penelitian pertama yang melakukan evaluasi
prospektif dari pendekatan yang cukup sederhana untuk merawat crossbite anterior
pada masa gigi bercampur. Dengan pembukaan gigitan sederhana menggunakan
oklusal bite plane pada gigi posterior. Dengan demikian, perawatan ini diharapkan
dapat menjadi alternatif dengan harga yang jauh lebih murah dibandingkan
perawatan konvensional berupa piranti cekat maupun lepasan.25 Hasil dari
perawatan pada penelitian ini cukup menjanjikan karena crossbite dapat dikoreksi
pada 14 pasien dari total 16 pasien, dalam waktu yang relatif singkat, hal ini
sebanding dengan waktu yang dibutuhkan dalam perawatan konvensional.26 Tidak
ada efek samping yang begitu penting yang yang dilaprkan pasien selain rasa tidak
nyaman saat mengunyah pada minggu pertama perawatan, hal tersebut juga terjadi
pada perawatan crossbite anterior dengan piranti cekat.27 Hasil setelah perawatan
tetap stabil, hal ini juga sejalan dengan hasil setelah perawatan konvensional.28
Selanjutnya, penelitian ini juga menggunakan teknik superimposisi gambar 3D dan
analisis model 3D yang memungkinkan untuk mengevaluasi pergerakan satu gigi
dalam ketiga bidang, teknik ini disarankan sebagai alat yang ampuh untuk
mempelajari pertanyaan klinis dan penelitian.
 Peningkatan gigitan untuk mengoreksi crossbite anterior telah dilaporkan
sebelumnya dalam kasus gigi desidui.29 Laporan kasus lainnya14,15 juga telah
menunjukkan hasil yang menguntungkan dari teknik ini yang dilakukan pada masa
gigi bercampur. Namun, sejauh ini belum ada yang meletiti kasus seperti ini dengan
studi cohort. Pada penelitian ini, peneliti secara prospektif mengikuti sekelompok
pasien untuk menilai kinerja perawatan ini.
Berdasarkan hasil penelitian, perawatan ini dapat disarankan untuk
mengoreksi crossbite anterior selama awal dan juga pertengahan fase gigi
bercampur pada pasien dengan maloklusi klas I atau klas II dan pola skeletal yang
sesuai. Syarat pada perawatan ini sudah terpenuhi semua pada penelitian ini, yaitu
ketersediaan ruang yang memadai untuk pergerakan gigi insisivus kearah labial.
Semua kasus dengan crossbite pada satu gigi berhasil dikoreksi (n=11), sedangkan
dua dari lima kasus dengan crossbite lebih dari satu gigi gagal. Dengan demikian,
perawatan ini sangat efektif dalam kasus dengan crossbite pada satu gigi.
Sayangnya, kasus yang gagal terlalu sedikit untuk menarik kesimpulan yang valid.
Namun, dari data yang tersedia, peneliti dapat menyarankan bahwa melalui metode
ini, dalam kebanyakan kasus, koreksi crossbite dapat dicapai dalam waktu tiga
bulan dan dalam kasus dimana tidak terjadi perubahan yang signifikan atau tidak
terkoreksi, maka tidak boleh bersikeras untuk melakukan perawatan dalam jangka
waktu lebih dari sembilan bulan.
Superimposisi gambar 3D dari dental gips mengungkapkan pola pergerakan
gigi dari crossbite ke posisi non-crossbite dan gerakan adaptif dari antagonis pada
rahang bawah. Rincian lebih teknis dari teknik ini telah disajikan sebelumnya.16
Dalam penelitian ini, gigi kontralateral yang tidak crossbite digunakan sebagai
kontrol. Hasil penelitian menunjukkan bahwa koreksi dicapai dengan gerakan ke
depan dan inklinasi mahkota bukal gigi rahang atas pada crossbite, sedangkan gigi
pada rahang bawah yang berlawanan menunjukkan reposisi posterior adaptif dan
inklinasi mahkota ke lingual.
 Tabel 1. Karateristik sampel. Mengenai variabel kontinu, disajikan dalam nilai median.
Umur Durasi Follow Gigi Tipe gigi Klasifikasi Overjet Overjet Overbite Overbite Crowding Crowding Crowding Crowding
pada peraw -up crossbite crossbite angel pada T0b pada T1b pada T0b pada T1b maksila maksila rahang rahang
T0 atan (Tf-T1) pada T0 pada T0 pada T0a (mm) (mm) (mm) (mm) pada T0 pada T1 bawah pada bawah pada
(tahun) (T0-Tf) (bulan) (mm) (mm) T0 (mm) T1 (mm)
(bulan)
Perawa- - #21 (n=6) Klas 1 Crossbite: Crossbite: Crossbite: Crossbite: Anterior: Anterior: Anterior: Anterior:
tan - #11 (n=5) (n=11, 1/4) -1,5 1,7 1,4 2,2 0,3 0,3 0,5 -0,3
berhasil - #11, #21 Klas 2 Kontrol: Kontrol: Kontrol: Kontrol: Total: Total: Total: Total:
7,9 2,5 9,6 1
n= 14 (n=1) (n=2, 1/2) 1,9 2 1,4 3,2 0.3 0,3 0,1 -0,3
(9 L, 5 P) - #12 - #22 Klas 2
(n=1) (n=1)
Perawa- - #11, #21 Klas I Crossbite: Crossbite: Crossbite: Crossbite: Anterior: Anterior: Anterior: Anterior:
tan gagal (n=1) (n= 1,1/4) -2,4 -1,6 2,5 0,9 -0,3 -5,2 -1,4 -1,4
8,5 10,3 14,5 2
n= 2 - #11, #12 Klas III Kontrol: Kontrol: Kontrol: Kontrol: Total : Total : Total : Total :
(2 L) (n=1) (n=1) - - - - -0,3 -0,7 -1,3 -1,3
Total Crossbite: Crossbite: Crossbite: Crossbite: Anterior: Anterior: Anterior: Anterior:
n= 16 -1,7 1,6 1,5 2,2 -0,4 -0,3 0,1 -0,4
8 2,6 9,6 1
(11 L, 5P) Kontrol: Kontrol: Kontrol Kontrol: Total: Total: Total: Total:
1,9 2,0 1,4 3,2 -0,4 0,3 0,1 -0,3

Keterangan:
Gigi kontralateral digunakan sebagai kontrol
L: laki-laki, P: Perempuan, Tf: Perawatan selesai (Treatment finished)
a
Tidak ada perubahan pada T1
b
Diukur pada gigi insisivus sentral yang crossbite pada T0
Tabel 2. Median pergerakan gigi crossbite pada maksila yang dikoreksi
dibandingkan dengan gigi kontrol kontralateral dari 14 kasus yang berhasil di
rawat .
X Y(mm) Z X- Y- Z-
(mm) (mm) rotation( ) rotation( ) rotation(o)
o o

Perawatan Gigi
berhasil insisivus
(n=14) sentral
yang
-0,09 2,05 -0,38 9,25 1,84 -0,12
berhasil
dikoreksi
(n=14)a

Gigi
insisivus
sentral
sebagai -0,18 0,29 -0,31 -1,31 1,79 -0,13
kontrol
(n=10)

P-valueb

0,639 0,000* 0,815 0,000* 0,815 0,682

Keterangan :
X = Pergerakan lateral (positif:kanan), Y = pergerakan antero-posterior (positif;anterior), Z =
pergerakan vertical (positif:apikal)
X-rotation = inklinasi (positif:mahkota bukal), Y-rotasi = tip (positif:kiri), Z-rotasi = rotasi
(positif:bukal kanan)
a
Pada tiga kasus, pengukuran dua gigi dirata-ratakan
b
Mann-Whitney U-test
*P<0,05
Tabel 3. Rerata pergerakan gigi antagonis crossbite maksila
X Y(mm Z (mm) X- Y- Z-
(mm ) rotation(o rotation(o rotation(o
) ) ) )
Gigi
insisivus
sentral
yang
0,09 -0,93 0,50 4,15 -1,77 0,18
berhasil
dikoreks
i (n=11)a

Gigi
insisivus
sentral
sebagai -0,19 -0,26 0,39 -0,77 -1,85 -1,40
kontrol
(n=9)b

P-valuec

0,025 0,73
0,342 0,002* 0,849 0,239
* 2

Keterangan:
Antagonis dari gigi kontralateral yang tidak mengalami crossbite, atau gigi dimana crossbite tidak
dikoreksi, digunakan sebagai kontrol. Semua gigi adalah gigi insisivus sentral rahang bawah.
X = Pergerakan lateral (positif:kanan), Y = pergerakan antero-posterior (positif;anterior), Z =
pergerakan vertical (positif:apikal)
X-rotation = inklinasi (positif:mahkota bukal), Y-rotasi = tip (positif:kanan), Z-rotasi = rotasi
(positif:bukal kanan)
a
Pada tiga kasus, pengukuran dua gigi dirata-ratakan
b
Pada satu kasus, pengukuran daua gigi dirata-ratakan. ini adalah satu-satunya kasus yang
menggunakan gigi antagonis dari crossbite yang tidak di koreksi.
c
Mann-Whitney U-test
*P<0,05
Gambar 4. Model rahang bawah sebelum perawatan (hijau muda) dan setelah follow-up (ungu)
pada molar pertama permanen dan molar 2 desidui, menunjukkan reposisi lingual pada gigi 41 dan
42, setelah koreksi gigi antagonis pada crossbite. Perhatikan bahwa pada gigi kontralateral hanya
terjadi pergerakan gigi minor.

Peneliti berasumsi bahwa pergerakan gigi pada rahang atas diinduksi oleh
tekanan dari lidah, yang diberikan kepada gigi yang crossbite selama berfungsi,
seperti berbicara, menelan, serta saat istirahat. Pergerakan gigi rahang bawah juga
dapat terjadi sebagai adaptasi terhadap keseimbangan baru yang dibentuk oleh
pembukaan gigitan (opening bite) dan posisi yang baru pada gigi maksila.30
Kemungkinan lain adalah kekuatan yang diberikan selama penyembuhan dari
kemungkinan trauma oklusal dari insisivus bawah menyebabkan reaksi ini, seperti
yang telah ditunjukkan sebelumnya untuk gigi yang bermigrasi secara patologis
setelah perawatan periodontal.31 Terlepas dari manfaat langsung yang diperoleh
dari koreksi crossbite anterior yang telah dijelaskan sebelumnya, reposisi gigi
rahang bawah di dalam lengkung rahang juga dapat bermanfaat dalam hal
mengurangi risiko resesi.32 Memang pada penelitian sebelumnya33 melaporkan
bahwa satu tahun setelah koreksi crossbite anterior, terjadi pengurangan sekitar 1
mm dari resesi vestibular pada gigi ini, penurunan mobilitas dan penebalan jaringan
periodontal, dibandingkan dengan kondisis sebelum perawatan dan pada gigi
kontralateral yang tidak mengalami crossbite. Normalisasi kekuatan pengunyahan
mungkin dapat menstabilkan gigi pada periodonsium dan menyebabkan
peningkatan status periodontal. Namun, dalam penelitian ini, kami menunjukkan
reposisi spontan ke lingual dari gigi insisivus bawah dalam lengkung rahang setelah
koreksi crossbite. dengan demikian, kami menyarankan bahwa peningkatan status
periodontal dapat dikaitkan dengan reposisi gigi dalam poisi yang lebih
menguntungkan dalam tulang alveolar.32 Selama koreksi dan terutama setelah
melepas oklusal bite plane, trauma oklusal sementara dapat terjadi sampai gigi
anterior mencapai hubungan oklusal yang lebih stabil. Namun, hal ini juga terjadi
pada perawatan dengan piranti ortodonto cekat dan lepasan.32

Tabel 4. Rerata tanggapan pasien yang menilai efek samping pengobatan (0= tidak
sama sekali, dan 10=ekstrim)
Nyeri Ketidaknya- Sakit Ketidakny Saki Komenta
pengunyaha manan saat saat a-manan t r lainnya
n pengunyaha bicar saat bicara TMJ
n a
Minggu 0 3 0 0 0 -
pertama
Minggu 0 0 0 0 0 -
selanjutny
a

Overerupsi gigi yang tidak menggigit dengan antagonis selama perawatan tidak
diharapkan karena lamanya perawatan. Memang, perubahan vertical yang minimal
terlihat jelas pada gigi insisivus selama periode pengamatan. Dengan alasan yang
sama, pengaruh yang signifikan pada perubahan vertikasl dimensi dari wajah juga
tidak diharapkan. Penelitian sebelumnya menunjukkan bahwa bahkan dengan
pendekatan yang lebih ekstensif, sulit untuk mengubah dimensi vertikal dari wajah
menggunakan pendekatan ortodontik konvensional.34 Di sisi lain overbite
meningkat selama masa pengamatan, seperti yang diharapkan pada kelompok usia
ini pada subjek yang tidak diobati.35,36 Peningkatan overbite ini juga dapat
berkontribusi pada hasil yang stabil.
Keuntungan utama dari perawatan ini adalah hanya memerlukan
sedikit/minimum kekooperatifan pasien. Pasien hanya harus menghadiri janji
pertemuan dengan dokter dan menginformasikan kepata dokter gigi jika oklusal
bite plane nya lepas, sehingga dapat diganti tepat waktu. Studi terbaru menunjukkan
bahwa pasien tidak mematuhi waktu pemakaian yang ditentukan bahkan ketika
mereka tahu bahwa kepatuhan mereka dilakukan pencatatan.12 Kepatuhan pasien
dengan piranti lepasan, yang akan menjadi alternatif yang valid dari perawatan ini,
telah terbukti cukup, secara umum dari tujuan retensi, tetapi tidak memadai untuk
pergerakan gigi aktif.12 Mengenai alternatif kedua untuk koreksi gigi crossbite
anterior, yaitu perawatan ortodonti cekat, akan bermanfaat dalam hal efek samping,
kepatuhan pasien, dan kepuasan pasien, jika ortodontis dapat mengurangi waktu
perawatannya.37,38 Bagaimanapun, kebanyakan pasien pasti akan menerima piranti
cekat setelah semua gigi telah berganti menjadi gigi permanen untuk mengoreksi
masalah gigi lainnya. Penyedia perawatan juga mendapat keuntungan dari
perawatan yang lebih efisien.39

4.1 Keterbatasan

Penelitian ini merupakan studi prospektif yang mengikuti pasien secara

berurutan. Namun, meskipun terdapat perbedaan yang signifikan antara gigi yang
diuji dan kontrol, ukuran sampel masih dapat dianggap terbatas, terutama pada
kasus dimana perawatan gagal. Ini tidak memungkinkan untuk menarik kesimpulan
yang aman mengenai alasan yang dapat menyebabkan kegagalan. Selanjutnya,
bagian kuesioner yang digunakan untuk menilai efek samping mengacu pada masa
lalu, dan dengan demikian hasil dapat ditafsirkan dengan tepat. Akhirnya,
perbandingan perubahan posisi gigi yang disebabkan oleh perawatan dilakukan
dengan gigi kontralateral dari pasien yang sama. Tidak ada pendekatan pengobatan
alternatif yang diuji. Studi banding diperlukan untuk lebih memahami kinerja
pendekatan ini, berbeda juga dengan pendekatan lain

5. Kesimpulan

Pembukaan gigitan adalah perawatan sederhana yang menjanjikan untuk

mengoreksi crossbite anterior pada gigi bercampur, yang memiliki tingkat
keberhasilan tinggi dan membutuhkan tingkat kepatuhan yang minimum. Koreksi
dicapai dengan gerakan ke depan dan inklinasi mahkota bukal gigi rahang atas pada
crossbite, sedangkan gigi pada rahang bawah yang berlawanan menunjukkan
reposisi posterior adaptif dan inklinasi mahkota ke lingual. Studi perbandingan
dimasa depan harus menguji pendekatan ini dalam hal efektivitas, efisiensi, efek
samping, biaya, dan stabilitas jangka panjang, jika dibandingkan dengan alternatif
lain seperti piranti ortodonti lepasan Hawley dengan pegas atau sekrup ekspansi.
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doi:10.1093/ejo/cjx074
Advance Access publication 20 October 2017

Original Article

Early anterior crossbite correction through

posterior bite opening: a 3D superimposition
prospective cohort study

Downloaded from https://academic.oup.com/ejo/article/40/4/364/4558651 by guest on 24 July 2022

Georgios Vasilakos1,2,3, Athanasios Koniaris3, Michael Wolf2,
Demetrios Halazonetis4 and Nikolaos Gkantidis1
Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Switzerland, 2Department of
1

Orthodontics and Dentofacial Orthopedics, Friedrich Schiller University of Jena, Germany, 3Private practice, Cologne,
Germany, 4Department of Orthodontics, School of Dentistry, National and Kapodistrian University of Athens, Greece

Correspondence to: Nikolaos Gkantidis, Department of Orthodontics and Dentofacial Orthopedics, University of Bern,
­CH-3010, Freiburgstrasse 7, Bern, Switzerland. E-mail: nikolaos.gkantidis@zmk.unibe.ch; nikosgant@yahoo.gr

Summary
Objectives: To assess the effectiveness, clinical performance, and potential adverse effects of
early anterior crossbite correction through opening of the bite.
Subjects and methods: The sample consisted of 16 consecutive patients (8.0 ± 0.9, range: 6.2–
9.3 years) with dental anterior crossbite in the mixed dentition who were treated through posterior
bite opening. Patients were prospectively followed until a minimum of 6 months post-treatment
and there were no drop-outs.
Results: In 14 patients (87.5 per cent), the anterior crossbite was corrected. Results remained stable
without any retention regime. Active treatment of the successfully treated cases lasted 2.5 months
(range: 0.6–8.9). Crossbite correction of central incisors was achieved by a 2.05 mm (range: 0.97–
5.45) forward movement and 9.25° (range: 2.32–14.52°) buccal inclination of the crowns (P < 0.05).
The antagonists showed spontaneous adaptation of their position in the opposite direction
(P < 0.05). No important adverse effects were recorded.
Limitations: This was a non-comparative controlled study, on a limited sample.
Conclusions: Bite opening is a promising, simple, and non-compliance approach for early dental
anterior crossbite correction. The technique of 3D superimposition and analysis of digital models
used here, allowed precise evaluation of single tooth movement in all three planes of space.

Introduction It may result from over-retention of deciduous teeth, irregular erup-

Anterior crossbite refers to malocclusion resulting from lingual pos-
ition of maxillary anterior teeth in relationship to the mandibular
anterior teeth. The reported prevalence of anterior crossbite in the
mixed dentition varies between 1.6 per cent and 7.9 per cent (1–4).
According to its origin, it can be differentiated into skeletal and
dental crossbite (5, 6). Skeletal crossbite is associated with a concave
skeletal and soft tissue profile and usually requires more extensive
interventions to be managed (7). Dental (or dentoalveolar) anter-
ior crossbite is a more localized problem and more easily managed.
tion pattern, or simple malposition of permanent teeth.
Early correction of crossbite, even in early mixed dentition, is
indicated to prevent potential interferences with normal growth of
the jaws and disturbances of neuromuscular or temporomandibular
joint function, especially when there is asymmetry associated with
functional shift of the mandible. If left untreated, it can cause per-
manent dental, skeletal, or soft tissue disharmonies or increase the
risk of temporomandibular or neuromuscular imbalances at a later
stage (8–10). Earlier intervention in the primary dentition may not

© The Author(s) 2017. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
364
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G. Vasilakos et al.
be advisable since the problem is self-corrected in approximately
half of the cases, and the patient is not expected to have significant
benefits from such an early correction (2).
Several methods have been used for anterior crossbite correc-
tion in the mixed dentition, including removable and fixed appli-
ances (11). However, patient compliance is essential for successful
treatment with removable appliances (12). Fixed appliances do not
demand such a high level of compliance but are associated with
time-dependent adverse effects, such as white spots and root resorp-
tion, and may have a negative impact on patients’ oral health-related
quality of life (13).
For these reasons, simpler methods, without the use of any ortho-
dontic appliance, have been suggested to correct anterior crossbite
during mixed dentition (14, 15). Namely, bilateral occlusal build-ups
were bonded on the mandibular second primary or first permanent
molars, and this allowed for spontaneous anterior crossbite correc-
tion. This approach can be quite promising, especially for unco-
operative or disabled children. However, it has only been presented
in a few case reports (14, 15) and has not been comprehensively
tested yet.
Thus, the aim of the present prospective cohort study was to
assess the effectiveness, clinical performance, and potential adverse
effects of this simple method of early anterior crossbite correction.
Materials and methods
The present study was conducted according to the ethical princi-
ples described in the Declaration of Helsinki (version 2013). Written
informed consents were obtained from the patients and their parents
prior to enrolment in the study, to allow the use of their standard
clinical records and dental casts for research purposes.
Sample
Sixteen consecutive patients (11 males and 5 females; mean age at
treatment start: 8.0 ± 0.9, range: 6.2–9.3 years) were included in the
study according to the following eligibility criteria: no active caries,
mixed dentition, anterior crossbite (at least one permanent maxillary
incisor), adequate space for labial movement of the teeth in cross-
bite, no extreme functional shift (>4 mm), no posterior crossbite,
no evidence of Class III skeletal pattern (as assessed through clin-
ical evaluation), no previous orthodontic treatment, and no other
orthodontic intervention until the follow-up visit, performed at a
minimum of 6 months post-treatment. All patients were treated at a
private practice in Cologne (Germany), operated by three orthodon-
tists, according to the practice protocol. Patient recruitment started
at February 2013 and ended at March 2015 based on the presence of
the primary investigator in the practice. Four subjects were already
Figure 1. Intraoral photos of a patient treated for anterior crossbite with opening of the bite. (A) Pre-treatment condition; (B) Opening of the bite for spontaneous
crossbite correction (blue-coloured occlusal pads); and (C) End result after 2.6 months.
365
in active treatment at the start of the study and their pre-treatment
files were retrospectively examined for eligibility. The other 12 sub-
jects were prospectively enrolled.
Treatment process
Patient history, clinical examination, extraoral and intraoral photos,
dental casts with construction bite (centric occlusion), and pano-
ramic radiographs were obtained before treatment start (T0) accord-
ing to the practice protocol.
At the start of the treatment, the occlusal surfaces of the lower
right and left mandibular second primary molars or first perman-
ent molars (if the primary molars were not present or were mobile)
were cleaned, dried, and acid etched with 37 per cent phosphoric
acid for 20 seconds. The etched surfaces were then washed and
carefully dried. A layer of primer was applied (Orthosolo Universal
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Bond Enhanser, Ormco, CA, USA) and resin-modified glass ionomer
cement (Ultra Band-Lok Blue, Reliance Orthodontic Products, 1540
West Thorndale Ave, Itasca, IL 60143) was placed to build up an
occlusal plane and light cured for 30 seconds. This procedure aimed
to raise the bite approximately 1–2 mm more than that of an edge-
to-edge anterior occlusal relationship in order to permit labial move-
ment of the tooth/teeth in crossbite (Figure 1A and 1B).
Patients and parents were instructed that if any of the occlusal
build-up was lost, they should make an appointment to replace it.
Patient recalls were scheduled every 4-5 weeks. Brushing and proper
oral hygiene were encouraged. During recall visits, the resin occlusal
plane was raised to the initial level in cases where the positive over-
bite did not permit labial movement of the tooth/teeth in crossbite.
Immediately after correction of anterior crossbite and attainment of
positive overjet, the occlusal build-ups were removed (Figure 1C).
Follow-up
Recall controls were scheduled every 6–8 weeks, without performing
any orthodontic intervention or retention procedure, until further ortho-
dontic treatment for other problems was planned and implemented.
Follow-up assessments (T1) including clinical examination, extraoral
and intraoral photos, and dental casts with construction bite (centric
occlusion) were performed at 6–17 months after active treatment. Six
months was set as the minimum follow-up period and was extended
as much as possible based on the presence of the primary investigator
in the practice. Additionally, at T1, all patients filled in a questionnaire
retrospectively assessing pain and discomfort during mastication and
speech, and temporomandibular joint (TMJ) pain during the first week
and at the next weeks of treatment. These answers were recorded on a
0–10 scale, with 0 marked as ‘not at all’ and 10 marked as ‘extreme’.
Furthermore, an open question allowed patients to report any other
issues that they considered important in each period.
366
After the completion of the data collection, the dental casts were
scanned in the Dental School of the University of Bern, using a 3D
surface scanner (stripe light/LED illumination; accuracy < 20 μm;
Laboratory scanner D104a, Cendres+Métaux SA, Rue de Boujean
122, CH-2501 Biel/Bienne) to obtain the 3D Standard Tessellation
Language (STL) models used in the study. Each maxillary 3D mesh
consisted of approximately 325 000 vertices, and each mandibu-
lar consisted of 300 000 vertices. The dental casts were obtained
according to the regular protocol of the practice, through alginate
impressions (Tetrachrom Alginat, KANIEDENTA GmbH & Co.
KG, Herford, Germany), which were poured with plaster (Alabaster
Klasse 3, Wiegelmann Dental GmbH, Bonn, Germany) within the
day when the impression was taken.
Data collection
The following data were collected at T0 and at T1: age, TMJ signs
and symptoms (pain and noise at rest and during jaw movement),
teeth in crossbite, overjet and overbite of all permanent upper
incisors that were fully erupted, anterior and total maxillary and
mandibular crowding, Angle Class (molars), duration of active treat-
ment, patient compliance to appointments, teeth where the resin was
placed, additions of occlusal bite plane performed due to losses or
inadequate height, and length of follow-up.
Questionnaire data assessing pain and discomfort during masti-
cation and speech, and TMJ pain were collected at T1.
Based on the results of a previous study (16), serial scanned
3D dental models obtained at T0 and T1 were superimposed on a
small area of the palate including the medial two-third of the third
rugae and the area 5 mm dorsal to them (Figure 2), using Viewbox
4 software (version 4.1.0.1 BETA, dHAL Software, Kifissia, Greece).
Maximum congruence of the two models is expected in the specific
reference area due to its anatomical form stability (17–22), which
was also not directly affected by treatment (16).
The software’s iterative closest point algorithm (ICP) (23) was
implemented using the following settings: 100 per cent estimated
overlap of meshes, matching point to plane, exact nearest neighbour
search, 100 per cent point sampling, and 50 iterations. Furthermore,
in the T0 model, the clinical crowns of the teeth of interest were
selected to assess tooth movement that occurred due to treatment
and growth from T0 to T1 (16). These were the permanent central
Figure 2. The palatal area used as reference for superimposition of serial
models (red).
European Journal of Orthodontics, 2018, Vol. 40, No. 4
incisors in crossbite at T0 and any contralateral tooth available in
both models, which served as control. A control tooth was avail-
able in 11 patients, whereas in the rest 5 patients no such tooth was
present in both casts. Thus, following each cast superimposition,
the pre-selected teeth crowns of interest at T0 were superimposed
individually on the respective teeth crowns at T1, using the same
settings. The origin of the reference axes for recording tooth move-
ment was positioned at the crown centroid of each tooth of interest
on the T0 model (24). Two of the axes were placed on the occlusal
plane, parallel and perpendicular to the midline palatal suture, and
the third axis was perpendicular to these two (Figure 3). In this way,
tooth translation and rotation (inclination, tip, and rotation) from
T0 to T1 were recorded relative to a three-axis reference system.
The potential movement (adaptation) of lower incisors follow-
ing the crossbite correction was also tested in cases where one man-
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dibular central incisor was in crossbite at T0, while the contralateral
tooth was not, and these teeth had contact with the upper teeth in
maximal intercuspation (n = 11, in 10 of them the crossbite was cor-
rected; 2 were excluded due to cast imperfections in the mandibular
incisor area). Since no morphologically stable areas are known in the
mandibular casts of growing patients, to be used as superimposition
references, superimpositions in the mandible were performed on all
the available posterior teeth that were not significantly repositioned
during the T0-T1 period, as assessed through visual inspection. The
clinical crowns of these teeth were used for superimposition; the tech-
nique, including software settings and the origin and orientation of the
reference axes where tooth movements were recorded, was similar to
that used for the maxillary arch. In eight cases, the first permanent and
the first and second primary molars were used, whereas in the remain-
ing three, only the first permanent molars were used. These mandibu-
lar superimposition results were visually inspected by two researchers
(G.V. & N.G.) and were judged to be satisfactory.
Statistical analysis
Statistical analysis was carried out by using the SPSS (v.20.0, SPSS
Inc., USA) software. Raw data were tested for normality of distribu-
tion with the Shapiro-Wilk test; due to evidence of non-normality
in some variables, parametric and non-parametric statistics were
applied, as required.
To evaluate measurement error in overbite, overjet, and crowd-
ing evaluation, 30 measurements were repeated by the same exam-
iner after a 2 week washout period. Intraexaminer agreement was
tested with the paired Student’s t-test and the intraclass correlation
coefficient [intraclass correlation coefficient (ICC); absolute agree-
ment, two-way fixed model]. Mean differences between repeated
measurements were also calculated.
Results
The paired Student’s t-test showed no statistically significant dif-
ference between the repeated measurements (P > 0.05). The ICC
showed perfect agreement for overjet (mean: 0.95; 95 per cent con-
fidence interval: 0.86–0.98), overbite (mean: 0.96; 95 per cent con-
fidence interval: 0.88–0.99), and crowding (mean: 0.99; 95 per cent
confidence interval: 0.98–0.99) measurements. The mean difference
between repeated measurements was 0.03 mm (95 per cent confi-
dence interval: −0.27–0.33) for overjet, 0.11 mm (95 per cent confi-
dence interval: −0.05–0.26) for overbite, and −0.05 mm (95 per cent
confidence interval: −0.18–0.08) for crowding.
In total, 16 patients with anterior crossbite, who fulfilled the
inclusion criteria, were included in the study and there were no
G. Vasilakos et al.
Figure 3. Superimposed pre-treatment (light green) and follow-up (purple)
maxillary models. The axes where movement was recorded were parallel to
the midline palatal suture (Y: green, antero-posterior movement; positive:
anterior), perpendicular to the midline (X: red, lateral movement; positive:
right), and perpendicular to the occlusal plane (Z: blue, vertical movement;
positive: up). Rotation of each tooth around the X (red; inclination, positive:
buccal crown for the maxilla and lingual crown for the mandible), Y (green;
tip, positive: left for the maxilla and right for the mandible), and Z (blue;
rotation, positive: right buccal) axis was also recorded.
drop-outs. In seven patients, occlusal resin was placed at the man-
dibular second primary molars, whereas in nine patients at the man-
dibular first permanent molars. In two patients, occlusal resin was
lost twice and had to be replaced and in other four patients this hap-
pened once. Compliance of all 16 patients with recall appointments
was good. In 14 of them, the anterior crossbite was corrected (87.5
per cent). Results remained stable during the follow-up period with-
out using any retention regime. Patients were followed for a median
of 9.6 (range: 6.0–19.9) months after the end of active treatment,
which lasted 2.5 (range: 0.6–8.9) months concerning the 14 success-
fully treated cases. The detailed patient sample characteristics and
treatment results are provided in Table 1.
In two cases, treatment did not succeed, and the crossbite was
planned to be corrected at a later stage during full fixed appliance
treatment, since no significant functional shift was present. Both had
two anterior teeth in crossbite, whereas one case had a mild (1/4
cusp) Class III relationship both at T0 and T1. In contrast, most of
the successfully treated cases had one tooth in crossbite, and no suc-
cessful case had a Class III dental relationship (Table 1).
3D superimpositions of serial dental casts showed that crossbite
correction of central incisors was achieved by a 2.05 mm (range:
0.97–5.45) forward movement and 9.25° (range: 2.32–14.52°) buc-
cal inclination of the crowns. These values were significantly differ-
ent from those of the contralateral control teeth that were not in
crossbite (Table 2) (Figure 3). In one case, two corrected lateral inci-
sors showed a similar correction (2.01 mm mean forward movement
and 12.50° buccal crown inclination). A similar pattern of change in
tooth position was observed in the central incisors of the two cases
where treatment failed. 1.72 mm (range: 1.24–2.20) of forward
movement and 6.31° (range: 5.52–7.09°) of buccal crown inclination
were observed. However, this was not enough to achieve correction.
The mandibular central incisors that were the antagonists of the
teeth in crossbite, moved −0.93 mm posteriorly (range: −2.39–−0.16)
367
and showed 4.15° (range: −3.04–8.76°) lingual crown inclination.
These values were significantly different from those of the contralat-
eral control teeth that were the antagonists of teeth, which were not
in crossbite (Table 3) (Figure 4).
Apart from 7 patients that reported moderate to severe discom-
fort during mastication (5–8 of 10) at the first week of treatment,
no other important adverse events were reported by the patients
(Table 4).
Discussion
The present study is the first to perform a prospective evaluation of
the performance of a quite simple, non-compliance approach for treat-
ing anterior crossbite of dental origin in the mixed dentition. This
concerned simply opening of the bite using cemented bite planes on
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the posterior teeth. Thus, this approach is expected to have much
lower costs than the conventional approaches of removable or fixed
appliances (25). Results were quite promising since the crossbite was
corrected in 14 out of the 16 patients in a relatively short period of
time, which was comparable to that required with the conventional
approaches (26). No important adverse effects were reported by the
patients apart from some discomfort during mastication on the first
week of treatment, which was also documented previously for fixed
appliance treatment of anterior crossbite (27). Results remained stable
after treatment, which is also in line with the situation with conven-
tional approaches (28). Furthermore, the technique for 3D superim-
position and analysis of 3D dental models used here, which allows
for precise evaluation of single tooth movement in all three planes of
space, is suggested as a powerful tool for studying both clinical and
research questions.
Raising the bite for anterior crossbite correction has been pre-
viously reported in a primary dentition case (29). Following case
reports (14, 15) have shown favourable results of this technique also
in the mixed dentition. However, no study has evaluated a cohort of
such cases so far. Here, we prospectively followed a group of patients
to assess the performance of this approach.
Based on the present results, this approach can be suggested
for anterior crossbite correction during the early and intermediate
mixed dentition phases in patients with Class I or Class II malocclu-
sion and corresponding skeletal pattern. A prerequisite, met in all
cases where this approach was implemented, was the availability of
adequate space for the labial movement of the incisor, even in cases
where lack of space was present in other places of the arch. All cases
with a single tooth in crossbite were successfully treated (n = 11),
whereas 2 out of the 5 cases with more than one teeth in crossbite
failed. Thus, this approach is highly effective in cases with a single
tooth in crossbite. Unfortunately, the cases which failed are too few
to draw valid conclusions for the reasons of failure. However, from
the available data we can suggest that through the present method,
in most cases, crossbite correction is achieved within 3 months and
in case of non-correction, one should not insist for a period longer
than 9 months.
3D superimposition of the dental casts revealed the pattern of
movement from the crossbite to the non-crossbite position and the
consequent adaptive movements of the antagonists in the mandible.
More technical details of this technique have been presented previ-
ously (16). In the present study, contralateral teeth within each jaw
that were not in crossbite were used as controls. Results showed that
correction was achieved by forward movement and buccal crown
inclination of the maxillary teeth in crossbite, whereas the opposing
mandibular teeth showed adaptive posterior repositioning and lin-
gual crown inclination.
 368

Table 1. Detailed patient sample characteristics. Regarding continuous variables, median values are presented, accompanied by range values shown in parentheses.

Treatment
duration Follow- Teeth in Tooth type Maxillary Maxillary Mandibular Mandibular
Age at T0 (T0-Tf) up (Tf-T1) crossbite in crossbite Angle class Overjet Overjet Overbite Overbite crowding crowding crowding crowding
(years) (months) (months) at T0 at T0 at T0a at T0b (mm) at T1b (mm) at T0b (mm) at T1b (mm) at T0 (mm) at T1 (mm) at T0 (mm) at T1 (mm)

Treatment 7.9 2.5 9.6 1 (1, 4) #21: n = 6, Class I: n = 11, ¼ Crossbite: Crossbite: Crossbite: Crossbite: Anterior: Anterior: Anterior: Anterior:
succeeded (6.2, 9.3) (0.6, 8.9) (6.0, 17.7) #11: n = 5, Class II: n = 2, ½ −1.5 (−1.1, −2.4) 1.7 (0.1, 3.4) 1.4 (−0.4, 3.3) 2.2 (0.0, 5.1) 0.3 (−4.5, 4.8) 0.3 (−5.0, 4.7) 0.5 (−3.1, 2.2) −0.3
N = 14 (#11, #21): Class II: n = 1 Control: Control: Control: Control: Total: Total: Total: (−3.2, 1.6)
(9 m, 5 f) n = 2, 1.9 (0.4, 4.0) 2.0 (0.5, 3.8) 1.4 (−1.5, 3.8) 3.2 (0.0, 4.9) 0.3 (−4.5, 6.2) 0.3 (−5.8, 6.5) 0.1 (−3.1, 2.6) Total: −0.3
(#12-#22): (−3.2, 2.6)
n=1
Treatment 8.5 10.3 14.5 2 (2, 2) (#11, #21): Class I: n = 1, ¼ Crossbite: Crossbite: Crossbite: Crossbite: Anterior: Anterior: Anterior: Anterior:
failed (8.1, 8.8) (8.0, 12.5) (9.1, 19.9) n = 1, (#11, Class III: n = 1 −2.4 (−1.7, −3.5) −1.6 (0.7, −2.0) 2.5 (1.0, 3.8) 0.9 (0.1, 2.0) −3.0 (−4.8, −1.2) −5.2 (−5.6, −4.8) −1.4 (−2.2, −0.5) −1.4
N = 2 (2 m) #12): n = 1 Control: Control: Control: Control: Total: Total: Total: (−2.2, −0.5)
- - - - −3.0 (−4.2, −1.8) −0.7 (−1.9, 0.5) −1.3 (−3.1, 0.5) Total: −1.3
(−3.1, 0.5)
Total N = 16 8.0 2.6 9.6 1 (1, 4) - - Crossbite: Crossbite: Crossbite: Crossbite: Anterior: Anterior: Anterior: Anterior:
(11 m, 5 f) (6.2, 9.3) (0.6, 12.5) (6.0, 19.9) −1.7 (−1.1, −3.5) 1.6 (−2.0, 3.4) 1.5 (−0.4, 3.8) 2.2 (0.0, 5.1) −0.4 (−4.8, 4.8) −0.3 (−5.6, 4.7) 0.1 (−3.1, 2.2) −0.4
Control: Control: Control: Control: Total: Total: Total: (−3.2, 1.6)
1.9 (0.4, 4.0) 2.0 (0.5, 3.8) 1.4 (−1.5, 3.8) 3.2 (0.0, 4.9) −0.4 (−4.5, 6.2) 0.3 (−5.8, 6.5) 0.1 (−3.1, 2.6) Total: −0.3
(−3.2, 2.6)

The contralateral teeth were used as controls. M, males; f, females; Tf, Treatment finished.
a
No change at T1.
b
Measured at the central incisors in crossbite at T0.
European Journal of Orthodontics, 2018, Vol. 40, No. 4

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G. Vasilakos et al. 369

Table 2. Movement of the corrected-maxillary teeth in crossbite compared with the contralateral control teeth of the 14 successfully
treated cases.

X (mm) Y (mm) Z (mm) X-rotation (°) Y-rotation (°) Z-rotation (°)

Successful Central incisor −0.09 2.05 −0.38 9.25 1.84 −0.12

cases corrected (n = 14)a (−1.10, 0.79) (0.97, 5.45) (−2.10, 2.41) (2.32, 14.52) (−8.00, 10.88) (−5.01, 4.22)
(n = 14) Central incisor −0.18 0.29 −0.31 −1.31 1.79 −0.13
control (n = 10) (−0.84, 1.04) (−0.63, 1.51) (−1.78, 1.97) (−7.44, 7.27) (−8.11, 12.62) (−9.19, 9.61)
P-valueb 0.639 0.000* 0.815 0.000* 0.815 0.682

Median values are presented, accompanied by range values in parentheses.

X, lateral movement (positive: right); Y, antero-posterior movement (positive: anterior); Z, vertical movement (positive: up/apical); X-rotation, inclination
(positive: buccal crown); Y-rotation, tip (positive: left); Z-rotation, rotation (positive: right buccal).
a
In three cases, measurements of two such teeth were averaged.
b
Mann–Whitney U-test.
*P < 0.05.

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Table 3. Movement of the antagonists of the maxillary teeth in crossbite.

X (mm) Y (mm) Z (mm) X-rotation (°) Y-rotation (°) Z-rotation (°)

Central incisor 0.09 (−0.42, 0.93) −0.93 (−2.39, −0.16) 0.50 (−0.76, 1.95) 4.15 (−3.04, 8.76) −1.77 (−3.66, 3.26) 0.18 (−5.43, 7.94)
corrected (n = 11)a
Central incisor −0.19 (−0.97, 0.37) −0.26 (−1.25, 0.49) 0.39 (−0.29, 1.21) −0.77 (−3.03, 3.07) −1.85 (−3.67, 1.27) −1.40 (−5.94, 4.99)
control (n = 9)b
P-valuec 0.342 0.025* 0.732 0.002* 0.849 0.239

The antagonists of contralateral teeth that were not in crossbite, or of teeth where crossbite was not corrected, were used as controls. All these teeth were man-
dibular central incisors. Median values are presented, accompanied by range values in parentheses.
X, lateral movement (positive: right); Y, antero-posterior movement (positive: anterior); Z, vertical movement (positive: up/occlusal); X-rotation, inclination
(positive: lingual crown); Y-rotation, tip (positive: right); Z-rotation, rotation (positive: right buccal)
a
In three cases, measurements of two such teeth were averaged.
b
In one case, measurements of two such teeth were averaged. This was the only case of the group were antagonists of teeth in uncorrected crossbite was used.
c
Mann–Whitney U-test.
*P < 0.05.

maxillary teeth (30). Another possibility could be that forces exerted

Figure 4. Superimposed pre-treatment (light green) and follow-up (purple)
mandibular models on the first permanent and the first and second primary
molars, showing the spontaneous lingual reposition of teeth 41 and 42,
following the correction of the antagonist teeth in crossbite. Note that only
minor tooth movement occurred at the contralateral teeth.
We assume that maxillary tooth movement was induced by
tongue forces, exerted to the crossbite teeth during function, such
as speech and swallowing, as well as during rest. Mandibular tooth
movement could occur also as an adaptation to the new equilibrium
established by the opening of the bite and the new position of the
during healing of the possible occlusal trauma of these lower inci-
sors caused this reaction, as it has been shown previously for patho-
logically migrated teeth after periodontal treatment (31). Apart from
the direct benefits deriving from anterior crossbite correction that
were explained earlier, repositioning of the mandibular teeth within
the arch could also be beneficial in terms of reducing the risk of
recession (32). Indeed, a previous study (33) reported that 1 year
following anterior crossbite correction, there was approximately
a 1 mm reduction of vestibular recessions of these teeth, reduced
mobility and thickening of the periodontal tissues, compared with
pre-treatment condition and to the contralateral teeth that were not
in crossbite. It was speculated that the normalization of the mas-
ticatory forces stabilized the tooth in the periodontium and led to
the improvement of the periodontal status. However, in the present
study, we showed spontaneous lingual repositioning of the lower
incisors within the arch following the crossbite correction. Thus,
we suggest that the improvement of the periodontal status can be
attributed, among others, to the repositioning of the tooth in a more
favourable position within the alveolar envelope (32). During cor-
rection and especially after removing the occlusal pads, temporary
occlusal trauma may occur until the anterior teeth achieve a more
stable occlusal relation. However, this occurs also inevitably during
treatment with fixed appliances and is fully reversible (32).
Overeruption of teeth that do not bite with antagonists dur-
ing treatment was not expected due to limited length of treatment.
Indeed, minimal vertical changes in incisor position were evident
370
Table 4. Responses of patients to the questionnaire assessing adverse effects of treatment with 0 corresponding to ‘not at all’ and 10
­corresponding to ‘extreme’.
Mastication pain Mastication discomfort
First week 0 (0, 3) 3 (0, 8)
Next weeks 0 (0, 0) 0 (0, 5)
Median values are presented, accompanied by range values in parentheses.
during the observation period. For the same reason, any significant
effect on vertical dimension of the face is also not expected. Previous
studies have shown that even with more extensive approaches, it
is difficult to change the vertical dimension of the face using con-
servative orthodontic approaches (34). On the other hand, overbite
was increased during the observation period, as expected for this
age group in untreated subjects (35, 36). This increase in overbite
could also have contributed to the stable results achieved without
any retention measure.
The main advantage of this approach is that minimum compli-
ance is required. The patient should simply attend regular appoint-
ments and inform the practice if a bite plate is debonded, so that
it can be timely replaced. Recent studies have shown that patients
are not compliant with prescribed wear times even when they know
that their compliance is objectively recorded (12). Patient compli-
ance with removable appliances, which would be a valid alternative
of the current approach, has been shown to be sufficient, in general,
for retention purposes, but not adequate for active tooth movement
(12). Regarding the second alternative for anterior crossbite cor-
rection, which is fixed appliance treatment, it would be beneficial
in terms of adverse effects, patient compliance, and satisfaction, if
orthodontists could avoid or reduce treatment time with fixed appli-
ances (37, 38). In any case, most patients will inevitably receive fixed
appliances following the establishment of permanent dentition for
the correction of other orthodontic problems. Care providers also
benefit from more efficient treatments (39).
Limitations
This was a prospective study following consecutively treated
patients. However, although significant differences between test
and control teeth were detected, the sample size could still be con-
sidered limited, especially regarding the cases where treatment
failed. This did not allow for drawing safe conclusions regarding
the reasons which could lead to failure. Furthermore, the question-
naire part used for assessing adverse effects was referring to the
past, and thus results should be interpreted accordingly. Finally,
comparisons of changes in tooth positions induced by treatment
were performed with contralateral teeth of the same patient. No
alternative treatment approach was tested. Comparative studies
are needed to better understand the performance of this approach,
in contrast also to other approaches.
Conclusions
Bite opening is a promising, simple approach for dental anterior
crossbite correction in the mixed dentition, which has high success
rates and requires minimum level of compliance. Correction was
achieved by forward movement and buccal crown inclination of
the maxillary teeth in crossbite, whereas the opposing mandibular
teeth showed adaptive posterior repositioning and lingual crown
inclination. Future comparative studies should test this approach in
terms of effectiveness, efficiency, adverse effects, costs, and long-term
European Journal of Orthodontics, 2018, Vol. 40, No. 4
Speech pain Speech discomfort TMJ Pain Other remarks
0 (0, 1) 0 (0, 3) 0 (0, 0) –
0 (0, 1) 0 (0, 0) 0 (0, 0) –
stability, in comparison with common alternatives, such as remov-
able Hawley type appliances with springs or expansion screws.
Conflict of Interest
None to declare.
Downloaded from https://academic.oup.com/ejo/article/40/4/364/4558651 by guest on 24 July 2022
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