MATERIAL AND METHODS

Between 2001 and 2005, we consecutively recruited 61 patients from 2 clinics at the Public
Dental Health Service, Skane County Council, Sweden, and from the Department of
Orthodontics, Faculty of Odontology, Malm University, Malm, Sweden. All patients met the
following inclusion criteria: mixed dentition (all incisors and rst molars erupted), unilateral
posterior crossbite, no sucking habits or sucking habit ceased at least 1 year before the trial,
and no previous orthodontic treatment. All patients except 1 participated in the study.
After written consent was obtained, the patients were randomized into 4 groups: quad-helix
(group A), expansion plate (group B), composite onlay (group C), and expectationie, the
untreated control (group D).
The subjects were randomized as follows: 4 opaque envelopes were prepared with 20 sealed
notes in each (5 notes for each group). Thus, for every new patient in the study, a note was
extracted from the rst envelope.
When the envelope was empty, the second envelope was opened, and the 20 new notes were
extracted as patients were recruited to the study. This procedure was then repeated 2 more
times. The envelope was in the care of 1 investigator (S.P.), who was contacted and randomly
extracted a note and informed the dentist which treatment strategy to use. The ethics committee
of Lund University, Lund, Sweden, which follows the guidelines of the Declaration of Helsinki,
approved the informed consent form and protocol.
Five experienced general practitioners gave the patients and parents both oral and written
information about the trial and then treated them according to a preset standard concept.
The main outcome measures to be assessed in the trial were (1) success rates of crossbite
correction (yes or no)ie, normal transverse relationships achieved for all teeth; (2) maxillary
and mandibular intercanine expansion at the shortest intercanine linear distance at the gingival
margins and the cusp tips of the teeth (Fig 1); (3) maxillary and mandibular intermolar
expansion at the shortest intermolar linear distance at the gingival margins and the mesiobuccal
cusp tips of the teeth (Fig 1); and (4) treatment timetime in months to correct the crossbite to
normal occlusion (if normal occlusion was not achieved, the treatment time was stated as 1
year, the total observation period).
Successful treatment was dened as normal transverse relationship within a year, and the
success rate was judged by examination of study casts taken before (T0) and after 1 year (T1).
The intercanine and intermolar measurements were made with a digital sliding caliper (Digital 6,
8M007906, Mauser - Messzeug GmbH, Oberndorf/Neckar, Germany). All measurements were
made to the nearest 0.1 mm by an orthodontist (L.B.). The determinations of crossbite
correction as well as intercanine and intermolar measurements were blinded; the examiner was
un aware of which treatment the patients had received or which models were taken at T0 and
T1. Changes in the different measuring points during treatment were calculated as the
difference between the T1 and T0 positions. Finally, the treatment time was registered from the
patient les.
Data on all patients were analyzed on an intentionto-treat (ITT) basisie, if the crossbite was
not corrected during the trial period of 1 year, the outcome was dened as unsuccessful, and
the eventual expansion effect was noted. This means that all patients, success-ful or not, were
included in the nal analysis. In addition, any dropouts during the trial were considered
unsuccessful and with no expansion.
The quad-helix consisted of a standard stainless steel arch (MIA system, 3M Unitek, Monrovia,
Calif) with stainless steel bands attached with glass ionomer cement on the maxillary rst
molars (Fig 2). The quad-helix was activated 10 mm before placement and then reactivated
every 6 weeks until a normal trans verse relationship was achieved; no overcorrection was
produced. The treatment result was retained for 6 months. To prevent or compensate for buccal
tipping, the appliance was adjusted for buccal root torque.
The expansion plate consisted of acrylic with an expansion screw and stainless steel clasps on
the deciduous and permanent rst molars (Fig 3). The plate was activated 0.2 mm once a week
by the patient until a normal transverse relationship was achieved; no overcorrection was
produced. The dentist thoroughly instructed the patient to use the plate day and night except for
meals and tooth brushing. Treatment progression was evaluated every 4 weeks, and the result
was retained for 6 months.
The composite onlay technique was based on the theory that bite raising will inhibit the forced
lateral movement and consequently allow the maxilla to grow and develop in the transverse
dimension without lock-ing the mandible in occlusion.13 The bite raising was achieved by
bonding composite (Point Four, 3M Unitek) on the occlusal surfaces on both mandibular rst
molars (Fig 4). The composite onlay was checked every 6 weeks and removed after a year. In
none of the patients did the composite onlay need improvement procedures.
The untreated control group received no orthodontic treatment during the 1-year observation
period.
Twenty randomly selected study casts were measured at 2 separate times. No signicant mean
differences between the records were found by using paired t tests. The method error according
to the Dahlberg22 formula did not exceed 0.2 mm for any measured variable.

Fig 1. Transversal linear measurements made on the study casts

F2 Occlusal view of the quad-helix appliance.
Fig 3. Occlusal view of the expansion plate
MATERIAL Y MTODOS
Entre 2001 y 2005, reclutamos consecutivamente a 61 pacientes de 2 clnicas del Servicio
Pblico de Salud Dental del Condado de Skane, Suecia, y del Departamento de Ortodoncia de
la Facultad de Odontologa de la Universidad de Malm, Malm, Suecia. Todos los pacientes
cumplieron los siguientes criterios de inclusin: denticin mixta (todos los incisivos y primeros
molares en erupcin), mordida cruzada posterior unilateral, ausencia de hbitos de succin o
hbito de succin al menos 1 ao antes del ensayo y sin tratamiento ortodncico previo. Todos
los pacientes excepto 1 participaron en el estudio.
Despus de obtener el consentimiento por escrito, los pacientes fueron asignados al azar en 4
grupos: cudruple hlice (grupo A), placa de expansin (grupo B), compuesto onlay (grupo C) y
expectativa, es decir, el control no tratado (grupo D).
Los sujetos fueron asignados al azar de la siguiente manera: 4 sobres opacos se prepararon
con 20 notas selladas en cada uno (5 notas para cada grupo). As, para cada nuevo paciente
en el estudio, se extrajo una nota del primer sobre.
Cuando el sobre estaba vaco, se abri el segundo sobre, y las 20 notas nuevas se extrajeron
como pacientes fueron reclutados para el estudio. Este procedimiento se repiti entonces dos
veces ms. El sobre estaba a cargo de un investigador (S.P.), que fue contactado y extrajo al
azar una nota e inform al dentista qu estrategia de tratamiento utilizar. El comit de tica de
la Universidad de Lund, Lund, Suecia, que sigue las directrices de la Declaracin de Helsinki,
aprob el formulario de consentimiento informado y el protocolo.
Cinco mdicos generales experimentados dieron a los pacientes y los padres informacin oral y
escrita sobre el ensayo y luego los trataron de acuerdo con un concepto estndar
preestablecido.
Las principales medidas de resultado a evaluar en el ensayo fueron (1) las tasas de xito de la
correccin de la mordida cruzada (s o no), es decir, las relaciones transversales normales
alcanzadas para todos los dientes; (2) expansin intercanina maxilar y mandibular a la distancia
lineal intercanina ms corta en los mrgenes gingivales y las puntas de la cspide de los
dientes (Fig. 1); (3) expansin intermolar maxilar y mandibular a la distancia lineal intermedia
ms corta en los mrgenes gingivales y las puntas de la cspide mesiobucal de los dientes
(Fig. 1); Y (4) tiempo de tratamiento en meses para corregir la oclusin cruzada a normal (si no
se alcanz la oclusin normal, el tiempo de tratamiento se estableci como 1 ao, el perodo
total de observacin).
El tratamiento exitoso se defini como una relacin transversal normal dentro de un ao, y la
tasa de xito se evalu mediante el examen de los modelos de estudio tomados antes (T0) y
despus de 1 ao (T1). Las mediciones intercaninas e intermedias se realizaron con un
calibrador digital deslizante (Digital 6, 8M007906, Mauser - Messzeug GmbH, Oberndorf /
Neckar, Alemania). Todas las mediciones se realizaron a 0,1 mm por un ortodoncista (L.B.). Las
determinaciones de la correccin de la mordida cruzada as como mediciones intercaninas e
intermedias fueron cegadas; El examinador no era consciente del tratamiento que los pacientes
haban recibido o de los modelos que tomaron en T0 y T1. Los cambios en los diferentes
puntos de medicin durante el tratamiento se calcularon como la diferencia entre las posiciones
T1 y T0. Finalmente, el tiempo de tratamiento se registr en los archivos del paciente.
Los datos de todos los pacientes se analizaron en base a intencin de tratar (ITT), es decir, si la
mordida cruzada no se corrigi durante el perodo de prueba de 1 ao, el resultado se defini
como fracasado y se observ el efecto de expansin eventual. Esto significa que todos los
pacientes, exitosos o no, fueron incluidos en el anlisis fi nal. Adems, los abandonos durante
el ensayo se consideraron infructuosos y sin expansin.
La hlice cudruple consisti en un arco de acero inoxidable estndar (sistema MIA, 3M Unitek,
Monrovia, CA) con bandas de acero inoxidable unidas con cemento de ionmero de vidrio en
los primeros molares superiores (Fig. 2). La hlice quad se activ 10 mm antes de la colocacin
y luego se reactiv cada 6 semanas hasta que se alcanz una relacin transver- sal normal; No
se produjo sobrecorreccin. El resultado del tratamiento se mantuvo durante 6 meses. Para
evitar o compensar la inclinacin bucal, el aparato fue ajustado para el par de torsin de la raz
bucal.
La placa de expansin constaba de acrlico con un tornillo de expansin y broches de acero
inoxidable en los primeros molares deciduos y permanentes (Fig. 3). La placa se activ 0,2 mm
una vez por semana por el paciente hasta que se alcanz una relacin transversal normal; No
se produjo sobrecorreccin. El dentista le orden al paciente que usara el plato da y noche
excepto para comidas y cepillado de dientes. La progresin del tratamiento se evalu cada 4
semanas, y el resultado se mantuvo durante 6 meses.

La tcnica de onlay compuesta se bas en la teora de que el aumento de mordida inhibir el

movimiento lateral forzado y, en consecuencia, permitir que el maxilar crezca y se desarrolle
en la dimensin transversal sin bloquear la mandbula en oclusin. Punto Cuatro, 3M Unitek)
sobre las superficies oclusales de los dos primeros molares mandibulares (Fig. 4). El onlay
compuesto se comprob cada 6 semanas y se elimin despus de un ao. En ninguno de los
pacientes se realiz el procedimiento de mejoramiento.
El grupo de control no tratado no recibi tratamiento ortodncico durante el perodo de
observacin de 1 ao.
Se midieron 20 muestreos de estudio seleccionados aleatoriamente en 2 tiempos separados.
No se encontraron diferencias significativas significativas entre los registros mediante el uso de
pruebas t pareadas. El error del mtodo de acuerdo con la frmula de Dahlberg22 no excedi
0,2 mm para cualquier variable medida.

Fig 1. Medidas lineales transversales realizadas en los modelos de estudio

F2 Vista oclusal del aparato de cuatro hlices.
Fig. 3. Vista oclusal de la placa de expansin