On cross bite and approaches to its treatment in children and adults

The authors | Last update: 2019

Cross bite is considered to be characterized by the intersection (crossing) of the dentition when the jaws are closed. This pathology is often quite difficult to treat, and the duration of the necessary procedures and their success are largely determined by the severity of the clinical case and the reasons that, in fact, led to the appearance of a cross bite.

Be that as it may, it’s important to understand that this malocclusion requires adequate and timely treatment, since without appropriate orthodontic intervention, very unpleasant, and sometimes dangerous, consequences are possible (we will also talk about them a little lower).

The photo below shows examples of cross-bite in a child and an adult:

Types of Cross Bite by Orthodontists

There are several types of cross bite, and depending on the type of this pathology, the plan for appropriate treatment may also be different.

So, let's see what types of cross-bite doctors emit today.

Cross bite in the anterior region - it is diagnosed when one or more teeth are in an abnormal position, most often tilted to the side of the tongue, thereby creating a back overlap. For example, one or two incisors can cross together.

The photograph below shows an example of the anterior cross bite:

As a rule, a cross bite in the anterior part is combined with an abnormal mesial bite in the lateral part of the dentition, or with the usual shift of the lower jaw forward and the formation of a false cross bite. In the second case, it is important to understand the reason why it is more convenient for the patient to push the lower jaw forward.

A cross bite in the lateral section is also distinguished - the pathology is characterized by improper closure of premolar and molars (i.e. 4, 5, 6 and 7 teeth, as well as wisdom teeth). As in the anterior region, with a cross bite of the posterior teeth, the anomaly can affect only one tooth, several or even the entire lateral segment.

When diagnosing a cross bite in the lateral region, it is important to clarify in which direction the lower jaw is displaced, and whether there is a displacement on only one side of the dentition, or both. Depending on this, orthodontists distinguish a unilateral and bilateral lateral cross bite.

In turn, a unilateral cross lateral bite can manifest itself in different ways, namely:

One-sided cross bite with displacement towards the tongue (lingual bite). This type of cross bite often occurs due to crowding, as a result of a lack of space in the dental arch. Or in children with a delay in the change of milk teeth in the milk bite;
One-sided cross bite with displacement towards the cheek (buccal bite). This type of anomaly is quite rare, it can be, for example, due to improper laying of the tooth buds, which causes the teeth to erupt outside the dentition towards the cheek. However, the more teeth are in such an abnormal closure, the more likely it is that the cause of this type of cross bite is the asymmetry of the development of the jaws;
And finally, a one-sided cross bite with a shift towards the palate (palatinal bite). It is diagnosed when one or more teeth in the lateral segment are inclined towards the sky. The causes of this type of occlusion may be macrodentia (excessively large teeth) and the absence of individual teeth.As a rule, pathology is more common with congenital malformations, or injuries and diseases of the temporomandibular joint (TMJ).

An example of a one-sided cross bite in an adult:

As for bilateral cross-bite, the most common cause of this pathology is a mismatch in the size of the dental arches. Often this is combined with a pathological bite of class II according to Engle and the front position of the upper jaw, which sometimes requires treatment with an oral and maxillofacial surgeon to completely correct the pathology.

On a note

Cross bite is true and false. In the case of a true cross bite, the doctor makes this diagnosis, taking into account the information obtained during the main and additional examination methods. A false cross bite occurs when the patient, for whatever reason, pushes the lower jaw into its usual position, thereby creating cross blocking contacts.

Therefore, when examining a patient, it is very important to determine the position of the so-called central occlusion, that is, the position of the teeth, convenient for the person at rest. To do this, the doctor asks the patient to open his mouth and, having relaxed the lower jaw, calmly close his mouth, without intentionally adjusting the position of the jaws (interestingly, not everyone can do this the first time).

The second way to determine the central ratio is that the doctor puts his thumbs on the skin landmarks of the corners of the lower jaw, the patient opens his mouth with his head slightly tilted back, the doctor asks the patient to relax his jaw, and, shaking it slightly and feeling muscle relaxation, quickly directs the jaw up without effort. This procedure is usually also repeated several times to make sure that the central ratio is achieved.

Causes of pathology

As a rule, a cross bite is formed in childhood. There may be several reasons for this - let's look at the main ones in more detail.

Bad habits in early childhood. In a child, the structures in the body are more pliable than in an adult, and the maxillofacial region is no exception. Even the slightest regular pressure sometimes contributes to the development of deviations. For example, the habit of sleeping on one side with the arm under your head, the habit of biting your lip, sucking fingers and other foreign objects, the habit of propping your cheek with your hand - all these daily repeated actions often contribute to the displacement of the lower jaw, individual teeth, and in some cases even disrupt normal growth jaws;
Ankylosis and arthritis of the TMJ. Ankylosis is a pathological fusion of the elements of the joint between themselves, which in our case limits the mobility of the lower jaw. This process can be the result of prolonged arthritis, that is, an inflammatory process, or the result of an injury - for example, resulting from the application of forceps during obstetric care. Treatment of ankylosis is usually very laborious and requires long-term orthodontic treatment in a team with a maxillofacial surgeon. Sometimes treatment takes 10 years or more, respectively, and the cross bite will be corrected gradually, as the patient grows older. An example of a patient with ankylosis is shown in the photo below:
Violations of the timing and sequence of teething. Each tooth should normally erupt in the dentition in determining the time and in the place specified for this tooth. If, for example, a tooth does not erupt for a long time for some reason, then existing teeth often move to fill a void (compensate for a dentition defect) - as a result, pathological contacts are created, which is the reason for the development of a cross bite.And if the teeth erupt much later, when the dentition is already formed, then “belated comrades” have to literally find a place for themselves. For example, a tooth can cut through the transitional folds of the gums, toward the lips, cheeks or palate;
Diseases of the ENT organs (frequent colds, nasal congestion, tonsillitis, adenoids). The fact is that a pathological enlargement of the tonsils often leads to difficulty in nasal breathing, forced oral breathing, which is directly related to the formation of a pathological bite. Inflammatory processes of the ear can affect the structures of the temporomandibular joint, since it is in close proximity to the ears, and the septa that separate one formation from another are quite thin. Accordingly, inflammation in the middle ear can provoke arthritis, or, in more severe cases, ankylosis of the joint. That is why, with otitis media, sometimes patients note difficult painful opening of the mouth and swelling just below the earlobe;
Early loss of primary teeth. Removal of temporary teeth due to caries and its complications quite often leads to the formation of a cross and other types of abnormal bite. As they say, nature does not tolerate emptiness, and if there is a free space, the remaining milk teeth will fill it with themselves, bending over and moving towards the defect, forcing further permanent teeth to erupt outside the dentition, or with an inclination or rotation along the axis;
Congenital malformations (various syndromes). An example is the syndrome of the first and second branchial arches - this disease is hereditary, it is based on violations of the formation of these formations in the human embryo in the first weeks of its development in the womb. And as you know, it is from the gill arches that the structures of the maxillofacial region, the upper and lower jaw are formed. The appearance of a patient with hemifacial microsomy (the scientific name of the disease) is presented in the photo below:
Cleft lip and alveolar ridge of the palate can also become the reasons for the formation of a cross bite. These congenital malformations of the child are characterized by the presence of an anastomosis between the oral cavity and the nasal cavity, which greatly complicates the normal development of the child, its feeding, speech and the formation of occlusion. Treatment of children with cleft lip and alveolar ridge of the palate is a complex and long process, planned from the moment the pathology of the fetus is detected. After birth, at certain stages of growth, the child undergoes surgical treatment to correct the defect and close the anastomosis.

It is also useful to read: What are malocclusions and how are they treated today?

How is cross-bite diagnosed?

Diagnosis of a cross bite in a child begins with a routine external examination. In addition to the initial examination, the orthodontist must carefully collect an anamnesis of the child’s life, find out how the mother went through pregnancy and childbirth.

It is also important to clarify whether there were any serious injuries, bumps, falls, that is, factors that could affect the development of the maxillofacial region.

The second important point of diagnosis is to determine the position of the central occlusion according to the methods described above, or using other methods, for example, using wax bite patterns (orthopedists use this method for prosthetics in patients with complete or partial loss of teeth in order to correctly make the prosthesis).

It is interesting

In rare cases, after dental prosthetics (that is, after orthopedic treatment), patients notice that their bite has become incorrect - for example, there may be signs of a cross bite.In other words, when using the prosthesis, contacts that block the normal closure of the jaw appear, which cause discomfort when talking and chewing food. This may be a sign of the so-called artificially formed cross bite, and is a consequence of the fact that the doctor incorrectly determined the central ratio of the patient's jaws.

Other mandatory diagnostic methods for bite pathologies, including cross bite, include functional tests. For example, a test can be performed according to Ilyina-Markosyan - this test allows you to assess the degree of pathological displacement of the lower jaw:

First, the doctor evaluates the patient’s face at rest and during a conversation (to identify imbalance in the work of muscles and their excessive tension);
The patient is then asked to close his mouth and grit his teeth without opening his lips. This technique allows you to evaluate the usual displacement of the lower jaw in one direction or another;
Next, the patient is asked to open his mouth wide and pay attention to how much the lower jaw is mixed with respect to the midline of the face;
After determining the central ratio, the doctor evaluates how much the patient’s face in this position aesthetically improves compared to his usual occlusion.

Of the additional diagnostic methods, radiological examinations are mandatory:

Orthopantomogram (in children older than 5 years). Allows you to evaluate the asymmetry of the bone structures of the jaws;
The roentgenogram. Allows you to evaluate the patient’s skull as a whole and see which fragments of the jawbones are shorter than others;
X-ray of the child’s hand - performed in adolescence in order to understand at what stage of bone growth the child is now (this is important for choosing the best treatment plan)
An TMJ x-ray in the patient’s open and closed mouth is carried out by the doctor to ensure that the temporomandibular joint is not the cause of the cross bite.

What problems can arise when there is a cross bite?

Teeth that cut through the outside of the dentition and create cross-contact can seriously injure the mucous membranes of the oral cavity during conversation and eating. Patients often complain of biting their cheeks, lip injury - in such cases, you should seek help from an orthodontist as soon as possible, since permanent soft tissue injury is dangerous and can lead to ulceration of the wounds and their suppuration. Moreover, if this process is long (chronic), then such injuries can degenerate into malignant formations of the oral cavity.

It is also useful to read: Characteristics of orthognathic bite

Further. Due to the excessive pathological load on the teeth located in the cross bite, there is a danger of increased abrasion of the teeth, for example, the cutting edges of the incisors. Sometimes this problem is very acute when some kind of “stumps” remain from the teeth.

In severe cases, patients may be disturbed by severe facial asymmetry, pain in the TMJ and difficulty opening the mouth, and regular headaches.

If you study the reviews of adult patients, then among other described problems, people sometimes note the impossibility of taking solid food and problems with the gastrointestinal tract (as a result of an unbalanced diet).

Parents of children with a pronounced cross bite often note their excessive shyness, isolation, communication problems, low self-esteem, because in childhood any aesthetic defects often entail ridicule from peers. In some such cases, to achieve the best treatment effect, the orthodontist may additionally recommend classes with a qualified psychologist who will improve the emotional status of the child.

Approaches to the treatment of pathology in children

Depending on the severity of the cross bite and the age of the child, the treatment of the pathology can vary markedly.

In an early removable bite (but usually not earlier than a child aged 5–6 years), the treatment of choice on removable plate devices with an expanding screw and a sectoral cut will be the method of choice. That is, the screw will expand exactly the segment of the dentition that needs such correction.

In addition, the doctor may include additional elements in the design of the apparatus for correcting cross bite - buccal and labial pelots to normalize the functioning of the muscles of this area, as well as to move soft tissues away from the teeth - to prevent unwanted pressure that tissues can exert on the teeth.

Generally speaking, an experienced orthodontist can include a variety of additional elements in the design of a removable device to increase the effectiveness of the treatment.

Such functionally functioning devices as the regulator of the Frenkel function work well when correcting the cross bite: this device normalizes the natural myodynamic balance of the maxillofacial region.

In addition, the cross bite is often combined with improper closure of the first molars, so the orthodontist may suggest the use of devices such as the Andresen-Goiplya activator and Persina activator for the treatment of class II and III anomalies.

On a note

Starting from the age of 10-12 years, if the desired effect could not be achieved on removable equipment, frame devices made individually according to the model of the child's jaws can be used. The frame apparatus is soldered to the orthodontic rings selected in advance by the orthodontist. The doctor adjusts the device so as to enhance its effect on the desired side of the dentition.

With a significant narrowing of the upper jaw, the doctor can use expanding structures such as the Biderman apparatus for rapid palatal expansion to treat a cross bite (also with a screw, the doctor sets the activation mode). Activation is performed either by the parents or by the patient himself, on average once every 7-10 days.

An example of such an apparatus is shown in the photo:

Sometimes the correction of the cross bite is carried out in two stages, that is, treatment with the help of devices is a preparatory stage for treatment on the bracket system, which works directly with the angle of inclination of the teeth, corrects excessive rotations and puts each tooth in its place in the jaw arch.

Cross-bite treatment in adults

In adult patients, treatment of the cross bite usually begins on the bracket system. It is also possible to use the frame extension devices described above, in conjunction with the bracket system, or before preparing for fixing braces.

To correct the actual cross overlap at the stage of wearing rigid rectangular arches, the doctor additionally connects elastic cross traction in the lateral and front sections of the dentition, which the patient wears 12 hours a day and at night, taking off with meals.

Sometimes you can limit yourself to partial fixation of braces only on those segments of the dentition that need treatment.

On a note

With a pronounced severity of the pathology, the orthodontist stipulates with the patient the possibility of using orthognathic surgery. If the patient agrees to surgery, then the treatment plan is adjusted according to what exactly needs to be achieved for the surgeon to work properly.

Often, patients immediately abandon this method of treatment because of fear of surgery on the maxillofacial region. Then the orthodontist, as far as possible, corrects the pathology only with the help of occlusion correction, however, while the jaw bones remain in the wrong position.

Preventive actions

To prevent the development of a cross bite in a child, it is important from infancy to deal with the bad habits of the baby, regularly visit a pediatrician and a dentist (caries on baby teeth must be treated promptly and promptly).

At the age of 5-6 years, it is advisable to go to a doctor’s consultation with an orthodontist to insure himself and start treatment on time, if necessary. It is very important to monitor the formation of the correct posture of the child: a lot of scientific research has been carried out proving the relationship between persistent impaired posture and a pathological bite.

Go in for sports, attend therapeutic massage courses. This will help to avoid many health problems, and not just bite, because our body is a single whole, and everything in it is closely interconnected.

Be healthy!

(If you have personal experience of correcting a cross bite in yourself or in a child, be sure to leave your review at the bottom of this page in the comments box. Such information will be of great interest to those who are in a similar situation, but are just starting their the path to a beautiful smile ...)