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Table of Contents
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 124-128

Interdisciplinary management of traumatized maxillary incisors with an anterior crossbite in a young adult

Department of Orthodontics and Dentofacial Orthopaedics, Maulana Azad Institute of Dental Sciences, New Delhi, India

Date of Submission01-Jul-2020
Date of Decision25-Jul-2020
Date of Acceptance14-Sep-2020
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. Tulika Tripathi
Department of Orthodontics and Dentofacial Orthopaedics, Maulana Azad Institute of Dental Sciences, Bahadur Shah Zafar Marg, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_58_20

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Damage to the maxillary anteriors secondary to trauma is one of the primary concerns of a patient, attributable to his/her perceivability in the society. The clinical presentations of such a condition may vary vastly according to the extent of the injury. The present article describes the interdisciplinary management of an 18-year-old female with traumatized maxillary incisors and an anterior crossbite on a borderline skeletal Class III base. Orthodontic camouflage by means of fixed mechanotherapy was successfully attempted to produce a correction in the overjet and overbite. The esthetic rehabilitation was carried out using zirconium crowns and veneers placed on the central and lateral incisors, respectively, after crown lengthening. Thus, the interdisciplinary management ensured the restoration of optimal esthetics and function with a conservative approach.

Keywords: Esthetics, multidisciplinary research, tooth fractures, wound and injuries

How to cite this article:
Ganesh G, Tripathi T. Interdisciplinary management of traumatized maxillary incisors with an anterior crossbite in a young adult. J Interdiscip Dentistry 2021;11:124-8

How to cite this URL:
Ganesh G, Tripathi T. Interdisciplinary management of traumatized maxillary incisors with an anterior crossbite in a young adult. J Interdiscip Dentistry [serial online] 2021 [cited 2023 Jun 10];11:124-8. Available from: https://www.jidonline.com/text.asp?2021/11/3/124/333339

   Clinical Relevance to Interdisciplinary Dentistry Top

  • Traumatized maxillary incisors with an anterior crossbite commonly present with a myriad of symptoms affecting the esthetic, functional and psychological well of an individual.
  • An early multicentered approach toward the rectification of the same is of paramount importance to prevent any further deterioration of the condition.

   Introduction Top

Maxillofacial trauma producing complicated crown fractures[1] of the maxillary teeth in children aged between 11 and 12 years accounts for 5%–8% of the total traumatic injuries.[2],[3] The maxillary anterior teeth are most commonly affected due to their early eruption and position in the dental arch.[4] These traumatic injuries to the anterior teeth not only cause structural damage but are also associated with severe psychological impacts in the child and the parent due to negative social interactions.[5],[6] The timing of this loss is inevitably important, as trauma to the permanent teeth before the completion of root formation may produce dilacerations. Extreme cases may also lead to the palatal displacement of the entire maxillary anterior segment producing an anterior crossbite triggering peridodontal, functional, temporomandibular joint and esthetic abnormalities.

An anterior crossbite has been described by Moyers[7] as a malocclusion arising as a result of abnormal axial inclination of maxillary anterior teeth. The crossbite should be corrected as soon as it is seen in order to eliminate the development of any functional shift or wear of the erupted permanent teeth.[8],[9] The treatment approach to correction of an anterior crossbite varies according to the underlying etiology, i.e., skeletal, dental or functional.[10] In either case, this treatment approach can be decided and executed only after a scrupulous diagnosis by the orthodontist.

A complicated crown fracture can be managed in various ways depending upon the level of fracture. A fracture below the level of gingival attachment has very poor prognosis and usually indicates extraction. However, a strategically important tooth can be saved by surgical crown lengthening, followed by orthodontic extrusion and rehabilitation.[11] The prognosis of fractures presenting with minimal violation of the biological width is better as the detached dental fragment can be reattached. However, the strength and longevity of the reattachment remains debatable.[12] A popular and widely used approach is endodontic treatment of the tooth followed by the use of posts with laminates or veneers to provide longer durability and preserve esthetics.

This article describes the interdisciplinary management of a patient who reported with an anterior crossbite accompanied by a complicated incisor crown fracture, to optimally restore function and esthetics.

   Case Report Top

An 18-year-old female patient reported to the outpatient department with a chief complaint of discolored and backwardly placed upper front teeth causing hesitancy in smiling along with the inability to bite using the upper front teeth. She elucidated a history of trauma 10 years ago which led to fracture and discoloration of her upper front teeth. These traumatized central incisors were endodontically treated.

On examination, maxillary central and lateral incisors were discolored with a complicated crown fracture in the central and an uncomplicated crown fracture in the lateral incisor.[1] The extraoral examination displayed a straight profile, an obtuse nasolabial angle with no anterior deviation of the mandible during the closure. Intraorally, she presented with Angle's Class I Type 3 malocclusion with the index of orthodontic treatment need Grade 4, an anterior deepbite and a reverse overjet of 3 mm. The radiographic examination confirmed the presence of endodontically treated upper central incisors. Cephalometrically, the patient was in the cervical vertebral maturity index (CVMI) maturation stage with borderline Skeletal Class III pattern due to a retrognathic maxilla and orthognathic mandible (N perpendicular to Pt A:–4 mm, SNA: 77°, SNB: 79°, ANB: −2°, Wits: −5 mm, Beta Angle –38°, Yen Angle – 127°, and NA parallel HP: −8 mm) with an average growth pattern (FMA –23°, GoGn Sn –32°). Retroclined upper and proclined lower incisors were observed (1-SN: 92, IMPA: 94). The lower incisors displayed signs of attrition due to constant trauma resulting from the crossbite [Figure 1]. The patient was requested to fill the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ),[13] which revealed the severe psychosocial impact of the malocclusion (Total score –43).
Figure 1: Pretreatment extra- and intra-oral photographs and radiographs

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A written consent for patient information and images to be published was obtained from the patient before the commencement of the treatment. All procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Fixed mechanotherapy using 022 slot MBT mechanics was initiated after cementing a lower disocclusion plate. The alignment was done using sequential nickel-titanium (NiTi) wires [Figure 2]. Open coil springs and vertical loops on SS wires were incorporated to flare the upper incisors to generate a positive overjet [1-SN: 107, 1-NA: 34] [Figure 3]. The disocclusion plate was removed and a good occlusion was achieved by coordinated of both arches. The total treatment time was 24 months.
Figure 2: Alignment using sequential nickel-titanium wires and disocclusion plate

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Figure 3: Upper incisor flaring using vertical loops on stainless steel wires

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After attaining a positive overjet of 2 mm with an anterior clearance, the patient underwent crown lengthening in the upper incisors to facilitate prosthetic rehabilitation. Post crown lengthening, the rehabilitation was achieved using zirconia crowns and veneers on the upper and lateral incisors, respectively, producing an esthetically pleasing smile and improving her self-esteem [Figure 4]. Cephalometric superimpositions are visualized in [Figure 5].
Figure 4: Posttreatment extra- and intra-oral photographs and radiographs

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Figure 5: Complete pre- and post-cephalometric superimpositions

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   Discussion Top

Interdisciplinary dentistry plays an indispensable role in the proper management and correction of traumatic injuries involving the teeth and the surrounding structures. Early initiation of treatment not only allows the harmonization of occlusion but also prevents the development of detrimental skeletal, functional, and esthetic problems, thus improving the overall quality of life.[14]

The present case describes the interdisciplinary management of an 18-year-old female who reported with discolored maxillary anteriors subsequent to trauma sustained during childhood. A borderline Skeletal Class III malocclusion due to a retrognathic maxilla with an anterior crossbite was observed. A previous study by McNamara JJ has described that 32%–63% of Skeletal Class III malocclusions arise owing to the retrognathic maxilla.[14] The present case presented with retrognathic maxilla with a fairly good soft-tissue profile with an obtuse nasolabial angle possibly due to retroclined maxillary incisors. Since, the patient was in CVMI maturation stage with 5%–10% of the growth potential left. Any attempt to perform growth modification for correction of maxillary retrognathism was not indicated. Moreover, the presence of a good soft-tissue profile with a bilateral well-settled Class I molar relation did not suggest orthognathic surgery. Correction of the retroclined incisors by proclination would aid in camouflaging the skeletal sagittal discrepancy due to maxillary hypoplasia in addition to resolving the chief complaint of the patient. Thus, the final treatment plan elucidated to the patient was orthodontic camouflage, followed by prosthetic rehabilitation by an interdisciplinary approach.

Treatment modalities by removable appliances described by Graber and Croll for anterior crossbite correction were not suitable for the present case,[15],[16],[17] hence fixed mechanotherapy was initiated in the maxillary arch after an endodontist's opinion was sought for the prognosis of the maxillary anteriors using intraoral periapical radiographs [Figure 1]. Similar to a previous study describing the effects of an anterior crossbite,[9] the present case displayed signs of occlusal trauma in the lower anteriors. An acrylic disocclusion plate was provided in the mandibular arch to disocclude and aid in jumping the bite for uninterrupted flaring of the upper anteriors. Initially, the plate was removable, but due to poor patient compliance, the plate had to be cemented. For proper torque correction, brackets were inverted and placed on the upper incisors. The alignment was done was using sequential NiTi wires. Open coil springs and vertical loops on SS wires were incorporated to flare the upper incisors to generate a positive overjet, followed by coordination of the two arches to attain a good occlusion.

At the end of treatment, the proclination of maxillary incisors (1-SN: 107, 1-NA: 34) and retroclination of mandibular incisors (IMPA: 92) with minimal skeletal effects were observed [Table 1]. A significant change was seen in the nasolabial angle and the lip position as well. However, the short clinical crown length and discoloration of the incisors persisted. The management of the discolored incisors by conventional composite resin restoration was disregarded as it would have not matched the ideal contours, incisal translucency, or color.[18] Yeo et al. in 2003 have reported that the composites take up stains from food and beverages producing compromised esthetics and poor longevity.[19] Thus, zirconia crowns on the central incisors with veneers on the lateral incisors were selected after performing clinical crown lengthening to aid in the easy placement. The zirconia crowns in the anterior region have better optical qualities, superior gingival response, and lesser biocompatibility issues compared to porcelain fused to metal crowns. The PIDAQ showed significant improvement from 43 to 21 over a period of 24 months. An Essix retainer in the upper and a lingual bonded retainer was given in the lower arch for posttreatment retention.
Table 1: The mean pre- and posttreatment cephalometric values

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Thus, the interdisciplinary management of traumatized maxillary incisors accompanied by an anterior crossbite aided in restoring optimal function, esthetics, and self-confidence to the patient.

   Conclusion Top

The esthetic, functional and biological restoration of complicated crown fracture is an intimidating challenge to a clinician, which needs to be managed by an interdisciplinary approach. However, a thorough diagnosis with combined treatment planning, followed by the proper execution of the treatment protocol is the key to achieve predictable and successful results with minimal side effects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Andreasen J, Andreasen FM, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. Copenhagen: Munksgaard; 1994.  Back to cited text no. 1
Chosack A, Eidelman E. Rehabilitation of a fractured incisor using the patient's natural crown: Case report. J Dent Child 1964;31:139-57.  Back to cited text no. 2
Ravishankar TL, Kumar MA, Nagarajappa R, Chaitra TR. Prevalence of traumatic dental injuries to permanent incisors among 12-year-old school children in Davangere, South India. Chin J Dent Res 2010;13:57-60.  Back to cited text no. 3
Macedo GV, Diaz PI, De O Fernandes CA, Ritter AV. Reattachment of anterior teeth fragments: A conservative approach. J Esthet Restor Dent 2008;20:5-20.  Back to cited text no. 4
Taiwo OO, Jalo HP. Dental injuries in 12-year old Nigerian students. Dent Traumatol 2011;27:230-4.  Back to cited text no. 5
Jain V, Gupta R, Duggal R, Parkash H. Restoration of traumatized anterior teeth by interdisciplinary approach: Report of three cases. J Indian Soc Pedod Prev Dent 2005;23:193-7.  Back to cited text no. 6
[PUBMED]  [Full text]  
Moyers RE. Handbook of Orthodontics. 4th ed. Chicago: Year Book Medical Publishers Inc.; 1988. p. 418.  Back to cited text no. 7
Langberg BJ, Arai K, Miner RM. Transverse skeletal and dental asymmetry in adults with unilateral lingual posterior crossbite. Am J Orthod Dentofacial Orthop 2005;127:6-16.  Back to cited text no. 8
Tariq M, Asif S. Correction of anterior crossbite in a female adult patient - A case report. Univ J Dent Sci 2018;4:70-3.  Back to cited text no. 9
Profit WR. Contemporary Orthodontics. 4th ed. Mosby, St. Louis Mosby; 2007.  Back to cited text no. 10
Delivanis P, Delivanis H, Kuftinec MM. Endodontic-orthodontic management of fractured anterior teeth. J Am Dent Assoc 1978;97:483-5.  Back to cited text no. 11
Oz IA, Haytaç MC, Toroglu MS. Multidisciplinary approach to the rehabilitation of a crown-root fracture with original fragment for immediate esthetics: A case report with 4-year follow-up. Dent Traumatol 2006;22:48-52.  Back to cited text no. 12
Klages U, Claus N, Wehrbein H, Zentner A. Development of a questionnaire for assessment of the psychosocial impact of dental aesthetics in young adults. Eur J Orthod 2006;28:103-11.  Back to cited text no. 13
McNamara JA Jr. An orthopedic approach to the treatment of Class III malocclusion in young patients. J Clin Orthod 1987;21:598-608.  Back to cited text no. 14
Graber TM. Orthodontics Principles and Practice. 3rd ed. Philadephia: W.B Saunders Company; 1972. p. 673-5.  Back to cited text no. 15
Croll TP. Correction of anterior tooth crossbite with bonded resin-composite slopes. Quintessence Int 1996;27:7-10.  Back to cited text no. 16
Liepa A, Abeltins A. Anterior crossbite correction in primary and mixed dentition with removable inclined plane (Bruckl appliance). Balt Dent Maxillofac J 2008;10:140-4.  Back to cited text no. 17
Piassi E, Antunes LS, Andrade MR, Antunes LA. Quality of life following early orthodontic therapy for anterior crossbite: Report of cases in twin boys. Case Rep Dent 2016;2016:3685693.  Back to cited text no. 18
Yeo IS, Yang JH, Lee JB. In vitro marginal fit of three all-ceramic crown systems. J Prosthet Dent 2003;90:459-64.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1]


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