Background
A posterior crossbite occurs when the top back teeth bite inside the bottom back teeth. When it affects one side of the mouth, the lower jaw may have to move to one side to allow the back teeth to meet together. Several treatments have been recommended to correct this problem. Some treatments widen the upper teeth while others are directed at treating the cause of the posterior crossbite (e.g. breathing problems or sucking habits). Most treatments have been used at each stage of dental development. This is an update of a Cochrane review first published in 2001.

Objectives
To assess the effects of orthodontic treatment for posterior crossbites.

Search methods
We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 21 January 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1), MEDLINE via OVID (1946 to 21 January 2014), and EMBASE via OVID (1980 to 21 January 2014). We searched the US National Institutes of Health Trials Register and the World Health Organization (WHO) Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching the electronic databases.

Selection criteria
Randomised controlled trials (RCTs) of orthodontic treatment for posterior crossbites in children and adults.

Data collection and analysis
Two review authors, independently and in duplicate, screened the results of the electronic searches, and extracted data and assessed the risk of bias of the included studies. We attempted to contact the first named authors of the included studies for missing data and for clarification. We used risk ratios (RR) and 95% confidence intervals (CIs) to summarise dichotomous (event) data, and mean differences (MD) with 95% CIs to summarise continuous data. We performed meta-analyses using fixed-effect models (we would have used random-effects models if we had included four or more studies in a meta-analysis) when comparisons and outcomes were sufficiently similar.

Main results
We included 15 studies, of which two were at low risk of bias, seven were at high risk of bias and six were unclear.

Fixed appliances with mid-palatal expansion

Nine studies tested fixed appliances with mid-palatal expansion against each other. No study reported a difference between any type of appliance.

Fixed versus removable appliances

Fixed quad-helix appliances may be 20% more likely to correct crossbites than removable expansion plates (RR 1.20; 95% CI 1.04 to 1.37; two studies; 96 participants; low-quality evidence).

Quad-helix appliances may achieve 1.15 mm more molar expansion than expansion plates (MD 1.15 mm; 95% CI 0.40 to 1.90; two studies; 96 participants; moderate-quality evidence).

There was insufficient evidence of a difference in canine expansion or the stability of crossbite correction.

Very limited evidence showed that both fixed quad-helix appliances and removable expansion plates were superior to composite onlays in terms of crossbite correction, molar and canine expansion.

Other comparisons

Very limited evidence showed that treatments were superior to no treatment, but there was insufficient evidence of a difference between any active treatments.

Authors' conclusions
There is a very small body of low- to moderate-quality evidence to suggest that the quad-helix appliance may be more successful than removable expansion plates at correcting posterior crossbites and expanding the inter-molar width for children in the early mixed dentition (aged eight to 10 years). The remaining evidence we found was of very low quality and was insufficient to allow the conclusion that any one intervention is better than another for any of the outcomes in this review.

Orthodontic treatment for posterior crossbites

https://dentistry.hsc.wvu.edu/media/1182/treatment-response-and-long-term-dentofacial-adaptations-to-maxillary-expansion-and-protraction.pdf

Treatment response and long-term dentofacial adaptations to maxillary expansion and protraction.

The objective was to evaluate long-term transverse, anteroposterior and vertical skel- etal changes after rapid maxillary expansion (RME). The data were clinical trials that assessed skeletal changes through cephalometric analysis. No surgical or other simultaneous treatment during the evaluation period was accepted. Electronic databases (PubMed, Medline, Medline In- Process & Other Non-Indexed Citations, Cochrane Database of Systematic Reviews, ASP Journal Club, DARE, CCTR, Embase, Web of Sciences and Lilacs) were searched with the help of a senior Health Sciences librarian. Abstracts that appeared to fulfill the initial selection criteria were selected by consensus. The original articles were then retrieved. A methodological checklist was used to evaluate the quality of the selected articles. Their references were also hand-searched for possible missing articles. Articles without an adequate control group to factor out growth chang- es were excluded. Only three articles (one measuring transverse and two anteroposterior and vertical changes) measured RME stability after active expansion, all of them had some method- ological flaws, which limit the attainable conclusions. An individual analysis of these articles was made. Long-term transverse skeletal maxillary increase is approximately 25% of the total dental expansion for prepubertal adolescents. Better long-term outcomes are expected in transverse changes because of RME in less skeletally mature patients. RME appears not to produce clinically significant anteroposterior or vertical changes in the position of the maxilla and mandible. The conclusions from this systematic review should be considered with caution because only a sec- ondary level of evidence was found. Long-term randomized clinical trials are needed. (Angle Orthod 2005;75:1046-1052.)

Long-term Skeletal Changes with Rapid Maxillary Expansion: A Systematic Review

The objective was to evaluate long-term transverse, anteroposterior and vertical skeletal changes after rapid maxillary expansion (RME). The data were clinical trials that assessed skeletal changes through cephalometric analysis. No surgical or other simultaneous treatment during the evaluation period was accepted. Electronic databases (PubMed, Medline, Medline In-Process & Other Non-Indexed Citations, Cochrane Database of Systematic Reviews, ASP Journal Club, DARE, CCTR, Embase, Web of Sciences and Lilacs) were searched with the help of a senior Health Sciences librarian. Abstracts that appeared to fulfill the initial selection criteria were selected by consensus. The original articles were then retrieved. A methodological checklist was used to evaluate the quality of the selected articles. Their references were also hand-searched for possible missing articles. Articles without an adequate control group to factor out growth changes were excluded. Only three articles (one measuring transverse and two anteroposterior and vertical changes) measured RME stability after active expansion, all of them had some methodological flaws, which limit the attainable conclusions. An individual analysis of these articles was made. Long-term transverse skeletal maxillary increase is approximately 25% of the total dental expansion for prepubertal adolescents. Better long-term outcomes are expected in transverse changes because of RME in less skeletally mature patients. RME appears not to produce clinically significant anteroposterior or vertical changes in the position of the maxilla and mandible. The conclusions from this systematic review should be considered with caution because only a secondary level of evidence was found. Long-term randomized clinical trials are needed.

Long-term skeletal changes with rapid maxillary expansion: a systematic review.

This systematic review evaluates long-term dental arch changes after rapid maxillary expansion treatment on orthodontic patients with constricted arches. Clinical trials that assessed dental arch changes through measurements on dental casts or cephalometric radiographs were selected. No patients with surgical or other simultaneous treatment during the active expansion period were accepted. Electronic databases were searched with the help of a senior Health Sciences librarian. Original articles were retrieved from the selected abstracts, and their references were also scanned for possible missing articles. Forty-one articles met the initial inclusion criteria, but 35 were later rejected because they lacked a control group or only evaluated dental changes or used a semirapid technique. Some of them also lacked a reported measurement error. From the remaining articles, two did not report a long-term evaluation. From the final four articles, two measured changes through dental casts and two assessed changes through radiographs (one through lateral cephalometric radiographs and one through posteroanterior radiographs). Similar maxillary molar and cuspid expansion could be found in adolescents and young adults. Significantly less indirect mandibular molar and cuspid expansion was attained in young adults compared with adolescents. A significant overall gain in the maxillary and mandibular arch perimeter was found in adolescents. More transverse dental arch changes were found after puberty as compared with before, but the difference may not be clinically significant. No anteroposterior dental changes were found on lateral cephalometric radiographs.

Long-Term Dental Arch Changes After Rapid Maxillary Expansion Treatment: A Systematic Review

The majority of rapid maxillary expansion studies have reported the use of appliances with metal bands attached to the posterior teeth. Tooth extrusion, dental tipping, and an increase in the vertical dimension are often encountered, which may not coincide with treatment objectives. Bonded appliances using interocclusal acrylic may control the vertical dimension and expand the maxillary halves in a more bodily and symmetrical fashion. The purpose of this clinical trial was to determine, by radiographic analysis, the differences between a conventional banded expander (Hyrax) and a bonded acrylic expander. Fourteen patients who exhibited a need for expansion were enrolled in the study. The results suggest that the increase in the vertical dimension often seen with the more conventional Hyrax appliance may be minimized or negated with the bonded appliance. However, there appeared to be no significant difference between the amount of dental tipping or symmetrical expansion between the two appliances, as previously theorized.

Comparison of Hyrax and bonded expansion appliances.

Cephalometric radiography has become a standard and invaluable means of obtaining diagnostic information for the management of malocclusion and skeletal disharmony. However, concerns over radiographic exposure, particularly in growing individuals, may limit its use, especially in longitudinal analyses. Less invasive means of obtaining vital information would be desirable. A recently introduced system (Digigraph™, Dolphin Imaging Systems; Valencia, Calif) provides sonically produced representations of cranial landmarks and has been introduced by its manufacturer as an alternative to standard cephalometric radiography. The purpose of the study was to compare the validity and reproducibility of cephalometric values generated sonically on a digital image analyzer (Digigraph™) with those obtained from standard cephalometric radiographs for 43 different measurements. Although 58.1% of the sonically produced measurements showed significant correlation with radiographically produced measurements, there w...

A comparison between radiographic and sonically produced cephalometric values

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Comparison of Hyrax and bonded expansion appliances.

A comparison between radiographic and sonically produced cephalometric values