Timely intervention, lasting results: Managing dental anterior crossbite with a removable appliance

 Corresponding author: Prawati Nuraini Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. Timely intervention, lasting results: Managing dental anterior crossbite with a removable appliance Alocitta Anindyanari, Betadion Rizki Sinaredi and Prawati Nuraini * Department of Pediatric Dentistry, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia. World Journal of Advanced Research and Reviews, 2025, 26(02), 1964-1968 Publication history: Received on 01 April 2025; revised on 09 May 2025; accepted on 11 May 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.26.2.1799 Abstract Introduction: Anterior crossbite, a common malocclusion in early mixed dentition, is characterized by one or more lower incisors positioned anterior to the upper incisors. Early identification and management are essential to prevent progression to more severe malocclusion and associated complications. Description of Case: A 7-year-old female patient presented with a dental anterior crossbite involving the upper right permanent incisor. Clinical examination revealed a 1 mm reversed overjet and sufficient space for correction. A removable orthodontic appliance of Hawley's retainer with Z spring was utilized to treat crossbite after obtaining parental consent. The appliance was activated weekly, and the patient was instructed on proper use and oral hygiene. Positive overjet was achieved within four weeks, with complete alignment observed after an additional six weeks, despite a brief period of non-compliance. Discussion: Early interceptive treatment of anterior dental crossbite is crucial to restore normal occlusion and prevent more complex problems. Removable orthodontic appliances, such as the Hawley’s retainer with Z spring, are effective in cases with adequate space and active tooth eruption. These appliances offer advantages including ease of fabrication, maintenance of oral hygiene, and cost-effectiveness. However, patient compliance remains a key factor influencing treatment duration and success. Conclusion: Timely intervention using removable appliances with Z spring is an effective and practical approach for correcting dental anterior crossbite in young patients. Appliance selection should be tailored to individual patient factors, emphasizing the importance of early diagnosis and patient cooperation for optimal outcomes Keywords: Anterior crossbite; Removable orthodontic appliance; Interceptive orthodontic; Human and health 1. Introduction The developing dentition and occlusion play a crucial role in the well-being of infants, children, and adolescents. The American Academy of Pediatric Dentistry emphasizes the importance of managing the developing dentition and occlusion, which involves identifying, diagnosing, and appropriately treating dentofacial abnormalities [1,2]. Malocclusion refers to the misalignment between the dental arches or within the arches in any plane and any anomalies in the tooth's position. Malocclusion is a common oral condition, especially among children [2,3]. Anterior crossbite is a malocclusion defined by one or more lower incisors positioned more anteriorly than upper incisor. Anterior crossbite can be divided into skeletal and dental. When anterior crossbite arises due to a skeletal discrepancy (maxillary retrognathia and mandibular prognathism), it is classified as a skeletal crossbite. On the other World Journal of Advanced Research and Reviews, 2025, 26(02), 1964-1968 1965 hand, if the crossbite results from the upper incisor being displaced palatally and is often associated with the labioversion of the lower incisor, it is considered a dental crossbite [4,5]. Anterior dental crossbite accounts for 4%-5% of the population, and other reports stated that anterior dental crossbite prevalence ranging from 1.6% to 8%, mainly in the early mixed dentition phase [5–7]. Possible causes of dental anterior crossbite involve trauma to the preceding primary tooth leading to the permanent teeth being pushed inward, ectopic position of the permanent tooth germ, supernumerary teeth, a habit of biting the upper lip, over-retained of deciduous teeth or their roots, odontoma, anomalies in tooth shape and size, and arch length inadequacy [8–10]. Early management of anterior crossbite is recommended to prevent more complicated or more severe malocclusion and treatment at a later stage [6]. Various treatment options, ranging from simple to complex methods, are available to treat anterior crossbite; removable appliances and other fixed appliances can be used for treating anterior crossbite. The most suitable treatment option for anterior crossbite depends on the etiology of the crossbite, the patient’s age and compliance, eruption status of the tooth, space availability, and treatment costs [10]. Several appliances, including Hawley's Z spring, tongue blade, and Inclined bite plane (Catlan’s) appliance, are often used for treating dental anterior crossbite [6,8,11]. In the present case, a removable orthodontic appliance with a Z spring was used to correct the crossbite. 2. Description of Case A 7-year-old healthy female patient, accompanied by her mother, was referred to the Department of Pediatric Dentistry at Airlangga Dental Hospital with the chief complaint of her upper right permanent incisor positioned behind the lower incisors, which sometimes caused discomfort when biting food. The patient had no family history of class III malocclusion. There was a history of a persistent upper right central primary incisor, which had been extracted before. Extraoral examination revealed a straight facial profile and no TMJ problems. Intraoral examination showed a dental anterior crossbite of tooth #11 and a class I molar relationship (Figure 1). It was measured that the patient had a 1 mm reversed overjet and 2 mm overbite on tooth #11, and the freeway space was 3 mm. Furthermore, the maxillary and mandibular lateral incisors had not erupted yet. From clinical examination and history-taking, no parafunctional habit was observed in the patient. Sufficient mesiodistal space width was available for tooth #11 to move labially. Figure 1 Intraoral examination showed dental anterior crossbite of tooth #11 The treatment objective for the patient was to correct the anterior crossbite, to ameliorate the overjet to normal, and to align the patient's anterior teeth, which may enhance the patient's facial and dental aesthetics and prevent more severe malocclusion. 0 A removable orthodontic appliance consisting of Z Spring, Adam’s clasp, and Hawley retainer was constructed to correct the crossbite after the parents consented (figure 2). The Z spring was activated by slowly pulling the active part labially, and it should be ensured that the Z spring arm was already in contact and parallel to the palatal surface of the desired tooth upon insertion. The patient and the parents were trained to insert and remove the appliance independently under parental guidance. Furthermore, instructions on maintaining proper oral hygiene and the cleanliness of the appliance were also given to both the patient and the parents. The patient and the parents were also instructed to wear the appliance continuously, except when eating and practicing oral hygiene. The patient was recalled every 7 days to activate the Z spring. World Journal of Advanced Research and Reviews, 2025, 26(02), 1964-1968 1966 Figure 2 Inserted removable orthodontic appliance After four weeks of using the appliance, a positive overjet had been achieved on tooth #11. However, patient compliance declined afterward; the patient did not show up for the next four weeks, and when the patient came back, activation of Z spring was performed, and alignment of the incisor was seen corrected after the next two weeks (Figure 3). The patient was still instructed on the appliance's utilization for the retention phase, although the desired position of the tooth was already achieved. It was intended to maintain the stable overjet and overbite of the incisor. Figure 3 Intraoral condition Post-treatment 3. Discussion Anterior crossbite is a common condition in children during the early mixed dentition period, most of which comes from dental origin. Interceptive treatment to correct an anterior crossbite may help eliminate the severity of the existing problem and prevent further malocclusion [10–12]. It is recommended to treat anterior dental crossbite when they are identified to promote normal dental and skeletal development. Delayed treatment can lead to serious complications, such as loss of arch dimensions, asymmetric midlines, traumatic occlusion with stripping of gingival tissue on the labial aspect of a lower tooth, and even untoward growth patterns if functional shift is involved [12,13]. Treatment methods of correcting dental anterior crossbite should be considered based on these several factors, such as the incisor positioning and available space to direct the movement of the tooth forward, stage of eruption of the displaced tooth; if the tooth is in active eruption, the treatment may use simple leveraging techniques, and the degree of overbite [13,14]. Anterior crossbite correction can be achieved using several removable or fixed appliances such as inclined bite plane, tongue blade, Hawley retainer with Z spring and screws, and reverse crown [15,16]. Each of these appliances comes with its advantages and disadvantages. In the present case, a removable orthodontic appliance (Hawley retainer with Z spring) was utilized to treat the anterior crossbite. The reasons for choosing this appliance were based on the patient-specific factors, including age, occlusal analysis, and skeletal development. The patient's age was in early mixed dentition, and the tooth was in active eruption. Based on those factors, a removable appliance was a suitable treatment option for crossbite in the early mixed dentition phase [14]. Z-springs or palatal springs were chosen as they provided the best choice for this case since the right lateral incisor of both the upper and lower jaw had not erupted yet. Z spring arm was placed on the palatal of teeth #11, making World Journal of Advanced Research and Reviews, 2025, 26(02), 1964-1968 1967 the pressure from the palatal direct the tooth to move forward labially. Enough freeway space was available in this patient, so the need for bite opening by incorporating occlusal bite planes can be eliminated [13]. The removable appliance was fabricated in a laboratory, so chairside time was significantly reduced. Moreover, the design of this appliance allowed the patient to clean it easily, hence good oral hygiene could be achieved. More importantly, the removable appliance is cost-effective and easy to manage [14,17]. However, patients' and parents' lack of compliance can be a hurdle practitioners might face. As in this case, the patient was not compliant regarding the recall visit. Lack of patient’s compliance may lead to longer treatment duration [18]. In this case, the treatment period for correcting the reverse overjet was four weeks, and another six weeks were needed to align the tooth. Once the desired adjustment was achieved, the use of Hawley appliance was continued to establish adequate overjet and overbite [16]. Successful anterior crossbite correction is achieved by establishing normal overjet and overbite, and ensuring the incisors are aligned in their normal relationship [19]. 4. Conclusion Early treatment of an anterior crossbite highlights the importance of timely intervention to prevent more complex malocclusions. The practitioner can effectively treat dental anterior crossbite with the right appliance based on the patient's specific factors, such as age, skeletal, and occlusion analysis. A removable appliance with a Z spring is one of the appropriate treatment options for treating dental anterior crossbite. Compliance with ethical standards Acknowledgments The authors thank the reviewers for their insightful suggestions Disclosure of conflict of interest The authors declare that there is no conflict of interest regarding the publication of this document. Statement of informed consent Informed consent was obtained from patient included in the study. References [1] American Academy of Pediatric Dentistry. Management of the Developing Dentition and Occlusion in Pediatric Dentistry. In: The Reference Manual of Pediatric dentistry. Chicago: American Academy of Pediatric Dentistry; 2024. p. 475–93. [2] Saket P, Arumugam S, Archana SP, Chonat A, Vasanthakumari A, Dhivya S. 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