Beruflich Dokumente
Kultur Dokumente
doi:10.1093/ejo/cju005
Advance Access publication August 11, 2014
Correspondence to: Anna-Paulina Wiedel, Department of Oral and Maxillofacial Surgery, Jan Waldenströmsg. 18, Skane
University hospital, SE-205 02 Malmö, Sweden. E-mail: anna-paulina.wiedel@mah.se
Summary
Objective: To compare the effectiveness of fixed and removable orthodontic appliances in
correcting anterior crossbite with functional shift in the mixed dentition.
Subjects and methods: Consecutive recruitment of 64 patients who met the following inclusion
criteria: early to late mixed dentition, anterior crossbite with functional shift, moderate space
deficiency in the maxilla, i.e. up to 4 mm, a non-extraction treatment plan, the ANB angle > 0
degree, and no previous orthodontic treatment. Sixty-two patients agreed to participate. The study
was designed as a randomized controlled trial with two parallel arms. After written consent was
obtained, the patients were randomized, in blocks of 10, for treatment either with a removable
appliance with protruding springs or a fixed appliance with multi-brackets. The main outcome
measures assessed were success rate, duration of treatment, and changes in overjet, overbite, and
arch length. The results were also analysed on an intention-to-treat basis.
Results: The crossbite was successfully corrected in all patients in the fixed appliance group and all
except one in the removable appliance group. The average duration of treatment was significantly
less, 1.4 months, for the fixed appliance group (P < 0.05). There were significant increases in arch
length and overjet in both treatment groups, but significantly more in the fixed appliance group
(P < 0.05 and P < 0.01).
Conclusion: Anterior crossbite with functional shift in the mixed dentition can be successfully
corrected by either fixed or removable appliance therapy in a short-term perspective.
© The Author 2014. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
123
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124 European Journal of Orthodontics, 2015, Vol. 37, No. 2
In an evidence-based approach, randomized controlled trials Successful treatment was defined as positive overjet for all incisors
(RCTs) have become the standard design for evaluation. RCTs are within a year, and the success rate was assessed by comparing study
considered to generate the highest level of evidence and provide the models from before (T0) and after treatment (T1).
least biased assessment of differences in effects between two or more The overjet, overbite, and the arch length were measured with
treatment alternatives (11). To date, there is no RCT comparing the a digital sliding caliper (Digital 6, 8M007906, Mauser-Messzeug
effects of fixed and removable appliance therapy for correcting ante- GmbH, Oberndorf/Neckar, Germany). All measurements were made
rior crossbite with functional shift in the mixed dentition. to the nearest 0.1 mm by an orthodontist (A-PW). The measure-
Therefore, the aim of this study was to apply RCT methodol- ments were blinded, i.e. the examiner was unaware which treatment
ogy to assess and compare the effectiveness of fixed and removable the patient had received, or whether the data were for T0 or T1.
orthodontic appliances in correcting anterior crossbite with func- Changes in the different measures were calculated as the difference
tional shift in the mixed dentition. The null hypothesis was that between T1 and T0. Finally, the duration of treatment was registered
treatment with fixed and removable appliances is equally effective. from the patient files.
Data on all patients were analyzed on an intention-to-treat
(ITT) basis, i.e. if the anterior crossbite was not corrected during the
Outcome measures
The outcome measures to be assessed in the trial were the following: Figure 1. Sagittal and transversal measurements made on the maxillary study
casts. For definitions of the different variables, see Outcome measures section.
• Success rate of anterior crossbite correction (yes or no)
• Treatment duration in months: from insertion to date of appli-
ance removal
• Overjet and overbite in millimetres
• Arch length to incisal edge (ALI) in millimetres, (Figure 1)
• Arch length gingival (ALG) in millimetres (Figure 1)
• Tipping effect of maxillary incisor, i.e. incisal arch length minus
gingival arch length
• Maxillary dental arch length total (ALT) in millimetres (Figure 1)
• Transverse maxillary molar distance (MD) in millimetres
Figure 2. Occlusal view of the removable (A) and the fixed orthodontic
(Figure 1) appliance (B).
A.-P. Wiedel and L. Bondemark 125
An inactive expansion screw was inserted into the appliance. The accept the removable appliance and after the trial was treated with
screw was activated during the treatment period only if it was judged a fixed appliance. Thus, the success rate in both groups was very
to comply with the natural transverse growth of the jaw. The dentist high, and the intergroup difference was not significant. Apart from a
instructed the patient firmly to wear the appliance day and night, small number of minor complications, namely bond failures in few
except for meals and tooth brushing, i.e. the appliance should be patients, no untoward or harmful effects arose in any patient.
worn at least 22 hours a day. Progress was evaluated every 4 weeks, The average duration of treatment, including the 3-month reten-
and the result was retained for 3 months, with the same appliance tion period, was 6.9 months (SD = 2.8) in the removable appliance
serving as a passive retainer. group and 5.5 months (SD = 1.41) in the fixed appliance group.
Thus, treatment duration was significantly less in the fixed appliance
Fixed appliance group (P < 0.05).
The fixed appliance consisted of stainless steel brackets (Victory, slot The increase in overjet after treatment was significantly larger
.022, 3M Unitek, USA). Usually, eight brackets were bonded to the in the fixed appliance group (P < 0.05). Also, the increases in incisal
maxillary incisors, deciduous canines, and either to the first decidu- (ALI) and gingival arch length (ALG) after treatment were signif-
ous molars or to the first premolars if they were erupted (Figure 2B). icantly larger in the fixed than in the removable appliance group
Table 2. Changes of the different measures (in mm) within and be-
Eligible and invited
N = 64 tween groups and calculated as the difference between the after
(T1) and before treatment (T0).
Group Group B
Denied to enter the trial A (N = 31) (N = 31) P
N=2
Mean SD Mean SD A versus B
occlusion that is morphological stable and functional and aesthetically 4. Thilander, B. and Myrberg, N. (1973) The prevalence of malocclusion in
well adjusted. Since early correction of anterior crossbite is undertaken Swedish schoolchildren. Scandinavian Journal of Dental Research, 81,
in the growing child, it is important to also evaluate the posttreatment 12–20.
5. Lee, B.D. (1978) Correction of cross-bite. Dental Clinics of North Amer-
changes from a long-term perspective. Consequently, all subjects in
ica, 22, 647–668.
this study will be followed for at least a further 2-year period. These
6. Ngan, P., Hu, A.M. and Fields, H.W., Jr. (1997) Treatment of class III
follow-up results are to be presented in an upcoming study.
problems begins with differential diagnosis of anterior crossbites. Pediatric
This study evaluated a relatively limited number of outcome Dentistry, 19, 386–395.
measures. The primary aims were to compare success rates and treat- 7. Väkiparta, M.K., Kerosuo, H.M., Nyström, M.E. and Heikinheimo, K.A.
ment duration for correction of anterior crossbite by fixed or remov- (2005) Orthodontic treatment need from eight to 12 years of age in an
able appliances. Changes in overjet and maxillary arch length as well early treatment oriented public health care system: a prospective study.
as tipping effects on the maxillary incisors were included because The Angle Orthodontist, 75, 344–349.
these outcome measures are highly relevant to the clinician. Variables 8. Rabie, A.B. and Gu, Y. (1999) Management of pseudo class III malocclu-
such as cost-effectiveness and patients’ perceptions of the treatment sion in southern Chinese children. British Dental Journal, 186, 183–187.
9. Gu, Y., Rabie, A.B. and Hagg, U. (2000) Treatment effects of simple
are of course important and will be assessed in a forthcoming study.