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Case Report

Judicial Use Of Expansion Screws In Removable Appliances For Anterior Crossbite Correction - Case Reports.
G.J. Anbuselvan1, M. Karthi2

Professor& Head of the Department, Department of Orthodontics. 2 Senior Lecturer, Department of Orthodontics.

K.S.R. Institute of Dental Science and Research, K.S.R. Kalvi Nagar, Thokkavadi Post, Tiruchengode, Nammakkal District, Tamilnadu PIN: - 637 215 Address for correspondence Dr. G.J. Anbuselvan, M.D.S, 174, Brough Road, Opp. Telephone Bhavan, Erode- 638 001 Mobile No: - 9788292602 E-mail:- gobijanbu@gmail.com

ABSTRACT Anterior cross bite is best managed once it is diagnosed early. Anterior cross bite might be of dental, skeletal or functional origin. Dental cross bite in mixed dentition is managed by Inclined plane, 24 appliance, Expansion screw with posterior bite plane. Functional cross bite is managed by functional guidance and occlusal grinding. Skeletal cross bite is managed by Reversepull headgears. Here we have shown four case reports showing management of dental anterior cross bite using Removable Expansion Screw with posterior bite plane. KEY WORDS Inclined Plane, 24 appliance, Expansion Screw with Posterior Bite Plane, Functional Guidance, Occlusal Grinding, Reversepull Headgears.

Introduction The correct alignment of teeth is the key of the development of a healthy occlusion - Angle 1 Overjet is a horizontal measurement referring to the distance between the lingual aspect of the maxillary incisors and the labial surface of the Mandibular incisors when the teeth are in habitual or centric occlusion. Normal overjet is around 2 mm. Negative overjet is characteristic feature of anterior cross bite. Anterior cross bite might be 2 dental, functional or skeletal . Anterior cross bite can be defined as upper frontal primary or individual permanent teeth lingual position in relationship to lower incisor teeth. There is relatively little literature data about the treatment methods of anterior cross bite in primary and early 3 mixed dentition . Case Reports We have shown four case reports in the age group of 8, 7, 7 , and 11 years respectively of correction of anterior cross bite by use of Removable Appliance incorporated with Expansion Screw and Posterior Bite Plane. Screws are advantageous over springs because it is Easier to manage, Activated by patients with a key, Lesser tendency to dislodge, More stability, Forces can be well controlled.

CASE 1
PRE-TREATMENT MID-TREATMENT

POST-TREATMENT

An eight year old boy reported with an anterior cross bite of 1 1 and spacing. It was decided to treat him by an Anterior Expansion appliance for the forward movement of 1 1 with a Posterior Bite Plane. After active treatment the cross bite was corrected in three months.
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Judicial Use Of Expansion Screws In Removable Appliances

Anbuselvan & Karthi

CASE 2
PRE-TREATMENT MID-TREATMENT

CASE 4
PRE-TREATMENT POST-TREATMENT

POST-TREATMENT (AFTER 21 DAYS)

A seven year old boy reported with an anterior cross bite of 1 . It was decided to treat him by an Expansion screw incorporated removable appliance with a Posterior Bite Plane. Correction was achieved in 21 days time.
CASE 3
PRE-TREATMENT POST-TREATMENT

An eleven year old female patient with anterior cross bite in left upper central incisor reported to us. It was decided to treat with removable appliance incorporated with Expansion Screw and Posterior Bite Plane. Correction was achieved in two and half months. DISCUSSION TYPES OF ANTERIOR CROSSBITE There are three types of anterior cross bites found in children: (a) The simple dental cross-bite (b) The functional or pseudo cross-bite (c)The skeletal cross-bite

(a) Simple Dental Cross-bite Simple anterior cross-bites are generally the result of an abnormal eruption of the permanent incisors. Various etiologic factors can be involved including: trauma to the primary incisors with displacement of the permanent tooth bud; delayed exfoliation of a primary incisor with palatal deflection of the erupting permanent incisor; supernumerary anterior teeth; odontomas; congenitally abnormal 4 eruption patterns, and a arch perimeter deficiency . Patients who have a simple anterior dental cross-bite exhibit the following characteristics: The cross-bite usually involves only one or two teeth.

A seven and half year old male patient with an anterior cross bite reported. It was decided to treat him by a removable appliance incorporated with an Expansion Screw and Posterior Bite Plane. Before starting treatment retained right lower deciduous central and lateral incisors were extracted. Correction was achieved within two and a half months

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Judicial Use Of Expansion Screws In Removable Appliances

Anbuselvan & Karthi

(b) The Functional Anterior Cross-bite (Pseudo Class III) Patients who have a functional anterior crossbite exhibit the following characteristics: In centric relation or in a relaxed postural position, the patient presents with a normal facial 5 profile convexity . In centric relation the opposing incisors generally contact edge to edge with the molars separated but in an Angle Class I relation. During closing an early occlusal interference causes an anterior shift of the mandible. As the mandible shifts forward into centric occlusion, the incisors are placed into cross-bite and the molars into a Class III relationship. (c) The Skeletal Anterior Cross-bite Patients who have a true skeletal Class III or mesiocclusion have a problem of skeletal dysplasia involving mandibular hypertrophy, a marked shortening of the cranial base or maxilla, or a 6 combination of both . Some of the characteristics they will exhibit are: In centric relation, their facial profile will be straight or concave. In centric relation, there will be a Class III molar relationship and an anterior cross-bite. In centric occlusion, there will he a Class III molar relationship and an anterior cross-bite. The arc of mandibular closure remains smooth without any occlusal interference. In an attempt to compensate for the skeletal discrepancy during growth, the maxillary incisors usually become proclined and the mandibular incisors become retroclined. ETIOLOGY The possible causes of anterior cross bite include: Inadequate upper arch length (crowding) Lingual eruption path of maxillary incisors. Delayed shedding of deciduous teeth. Trauma to deciduous teeth resulting in displacement of permanent tooth germs. Supernumerary teeth, odontomes or other pathological conditions leading to displacement of the teeth in anterior region. Early occlusal interference (dental). This results in a forward mandible displacement to achieve maximum intercuspation (functional anterior cross bite)

Skeletal causes. There is discrepancy in the size or position of the maxilla and mandible. Rationale For Early Treatment Little possibility for self-correction. A cross bite in the primary dentition is believed to transfer to the permanent dentition. Postponing treatment results in prolonged treatment of greater complexity. If left untreated, it can cause growth modifications and dental compensations. May eventually lead to a permanent deviation and craniofacial asymmetry as well as potentially deleterious masticatory patterns. Associated with an increase in condylar deviation and temporomandibular joint sounds. Interference with growth of the middle third of the face. Abnormal speech patterns. Loss of arch integrity. Periodontal disease. Undesirable esthetics. Root resorption of central incisors. Treatment Treatment Modalities Various options are available based on the severity and types of the crossbites. The competency of the operator has to be taken in to consideration. These options are: Removable appliance with expansion screw. Fixed appliance. Combination of Removable & Fixed appliances. Functional appliances. Face Mask. Chin- Cup/Cap. Orthognathic Surgery is not an option for the mixed dentition stage and is only considered when growth has ceased. Treatment With Removable Anterior Expansion Screw Appliance Screws are used to procline two or more teeth. A screw applies a large intermittent force to the teeth. It is placed parallel to the intended tooth movement. Screw plates have an added advantage whereby the teeth to be moved can also be clasped simultaneously. This is particularly useful in cases where there is inadequate number of teeth to be clasped for
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Judicial Use Of Expansion Screws In Removable Appliances

Anbuselvan & Karthi

example in partially erupted or badly carious teeth . However, screws are bulky and expensive. 8 Screws are advantageous over springs : Easier to manage Activated by patients with a key Lesser tendency to dislodge More stability Forces can be well controlled Indications 9 When space necessary for the correction of malocclusion is less than 3 mms. Fo r t h e c o r r e c t i o n o f d e n t a l c r o s s b i t e : -Anterior -Posterior To correct single tooth malposition Basic Design of an Expansion Screw

ACTIVATION Screws are activated by the patient in the direction of the arrow shown in the baseplate. The principle of the orthodontic screw is that its ends are threaded in opposite directions and when it is turned the metal end plates move apart. The basic orthodontic screw is rigid, therefore it can only be adjusted by only a small amount at any one time, and otherwise the appliance cannot be inserted. The activation is done one-quarter turn once weekly which separates the acrylic by about 0.25 mm producing forces ranging from 3 to 10 pounds. This compresses the teeth in the socket by 0.12mm per side, which is within the width of Periodontal Ligament (0.25mm). Such a mild reduction of periodontal ligament space wouldn't interrupt the blood circulation and creates ideal condition for the teeth movement & bone transformation 11. More frequent adjustments, of up to onequarter turn twice a week is sometimes possible but care must be taken not to overdo it as this can cause the appliance to be ill-fitting. FREQUENCY OF OPENING THE SCREW Depends on, Pitch of the screw. Types and range of correction required. Age of patient. (Children-twice a week Adultsonce) Ideally frequency of opening the screw is done every 3 7 days in slow expansion & about 54 84 days in the mixed dentition. ANCHORAGE Anchorage is the source of resistance to the reaction from the active components. The active components in removable appliance are springs and Expansion Screws. Anchorage in the removable appliance is provided by the (a) baseplate and (b) the retentive component. Baseplate The acrylic baseplate hold together the other components of the appliance. A posterior bite plane should be incorporated to free the occlusion and allow the tooth in cross bite to move effectively. Baseplate design is very important for patient comfort. A bulky baseplate is uncomfortable and often interfere with speech. This will reduce patient cooperation and tolerance to the appliance.
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GUIDE PIN CENTRAL CYLINDER SCREW THREAD KEY HOLE

PITCH OF SCREW When the expansion screw given one complete turn, the two halves of the orthodontic appliance advance a distance equal to the space between the neighboring lines often called as thread's height. This distance moved is called pitch of the screw 10.

Judicial Use Of Expansion Screws In Removable Appliances

Anbuselvan & Karthi

Conclusion Appliances with expansion screws used at right place & right time, JUDICIALLY would produce more stable results. Acknowledgements We would like to thank Staff of the Department of Orthodontics & P Vishnudev Intern, KSR Institute .V. of Dental Science and Research for his support in the preparation of the manuscript. References
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Major, Glover. Treatment of anterior cross-bites in the early mixed dentition, Journal. 1992; 58 : 574-579. 5) Croll, Fixed inclined plane correction of anterior crossbite of the primary dentition, The Journal of Pedodontics.1984; 9: 84-94. 6) Moyers: Handbook of Orthodontics, Third Ed, Y e a r book Publishers Inc.Chicago.1973; 15: 564-577. 7) Vadiakas G, Viazis AD. Anterior crossbite correction in the early deciduous dention. Am J Orthod Dentofacial Orthop.1992; 102: 160-2. 8) Graber TM, Neuman B. Removable orthodontic appliances.2nd ed. Saunders; 1984:57-9. 9) Ngan P Biomechanics of maxillary expansion . and protraction in Class III patients. Am J Orthod Dentofacial Orthop 2002;121:582 583. 10) Adams P The design, construction and use of . removable orthodontic appliances. 5th ed. Bristol; 1984: 111-112. 11) Estreia F, Almerich J, Gascon F. Interceptive correction of anterior crossbite. J Clin Pediatr Dent 1991; 15: 157-159.

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