Anterior crossbite correction in early mixed dentition is highly recommended as this kind of malocclusion do not diminish with age. Uncorrected anterior crossbite may lead to abnormal wear of the lower incisors, dental compensation of mandibular incisors leading to thinning of labial alveolar plate and/or gingival recession. There are several methods for solving this problem. In this article we would like to describe removable inclined plane. This is a removable simple functional appliance on the lower arch (jaw), which works as inclined plane. One of the advantage of the Bruckl appliance is that it can also be used as retention appliance after active treatment as well as it is possible to add acrylic teeth if necessary. Therefore it can be used as a removable partial denture in lower jaw in case where there is a premature loss of the primary teeth. The use of this appliance is illustrated with three cases.publishersversionPeer reviewe

Abeltins, Andris

Jirgensone, Irena

Liepa, Andra

English

Anterior crossbite correction in early mixed dentition is highly recommended as this kind of malocclusion do not diminish with age. Uncorrected anterior crossbite may lead to abnormal wear of the lower incisors, dental compensation of mandibular incisors leading to thinning of labial alveolar plate and/or gingival recession. There are several methods for solving this problem. In this article we would like to describe removable inclined plane. This is a removable simple functional appliance on the lower arch (jaw), which works as inclined plane. One of the advantage of the Bruckl appliance is that it can also be used as retention appliance after active treatment as well as it is possible to add acrylic teeth if necessary. Therefore it can be used as a removable partial denture in lower jaw in case where there is a premature loss of the primary teeth. The use of this appliance is illustrated with three cases

Jirgensone, I.

Abeltins, A.

Online Research @ Cardiff

Anterior crossbite correction in primary and mixed dentition with removable inclined plane (Bruckl appliance)

Anterior crossbite correction in early mixed dentition is highly recommended as this kind of malocclusion do not diminish with age. Uncorrected anterior crossbite may lead to abnormal wear of the lower incisors, dental compensation of mandibular incisors leading to thinning of labial alveolar plate and/or gingival recession. There are several methods for solving this problem. In this article we would like to describe removable inclined plane. This is a removable simple functional appliance on the lower arch (jaw), which works as inclined plane. One of the advantage of the Bruckl appliance is that it can also be used as retention appliance after active treatment as well as it is possible to add acrylic teeth if necessary. Therefore it can be used as a removable partial denture in lower jaw in case where there is a premature loss of the primary teeth. The use of this appliance is illustrated with three cases.Peer reviewe

Riga Stradins university

140 Stomatologija, Baltic Dental and Maxillofacial Journal, 2008, Vol. 10, No. 4Anterior crossbite correction in primary and mixed denti-tion with removable inclined plane (Bruckl appliance)Irena Jirgensone, Andra Liepa, Andris AbeltinsCLINICAL CASE REPORTS  Stomatologija, Baltic Dental and Maxillofacial Journal, 10:140-144, 2008SUMMARYAnterior crossbite correction in early mixed dentition is highly recommended as this kind ofmalocclusion do not diminish with age. Uncorrected anterior crossbite may lead to abnormal wearof the lower incisors, dental compensation of mandibular incisors leading to thinning of labialalveolar plate and/or gingival recession. There are several methods for solving this problem. Inthis article we would like to describe removable inclined plane. This is a removable simple func-tional appliance on the lower arch (jaw), which works as inclined plane. One of the advantage ofthe Bruckl appliance is that it can also be used as retention appliance after active treatment aswell as it is possible to add acrylic teeth if necessary. Therefore it can be used as a removablepartial denture in lower jaw in case where there is a premature loss of the primary teeth. The useof this appliance is illustrated with three cases.Key words: anterior crossbite, early treatment.*Department of Orthodontics, Riga Stradins University, Riga, LatviaIrena Jirgensone* – D.D.S., Dr. Med., professor assistantAndra Liepa* – D.D.S., Dr. Med., professor assistantAndris Abeltins* – Doctorant student in orthodonticAddress correspondence to Dr. Irena Jirgensone, Department ofOrthodontics, 20 Dzirciema street, Riga, Latvia, LV 1007.E-mail address: i.krauze@latnet.lvINTRODUCTIONAnterior crossbite can be defined as upper fron-tal primary or individual permanent teeth lingual posi-tion in relationship to lower incisor teeth. There isrelatively little literature data about the treatment meth-ods of anterior crossbite in primary and early mixeddentition (Fig 1, 2).Nevertheless the malocclusion origin – skeletalor dentoalveolar, the treatment of anterior crossbiteis recommended in primary and early mixed denti-tion. However early treatment does not always elimi-nates orthodontic treatment need in permanent oc-clusion. The aim of early treatment of this type ofmalocclusion is to correct anterior crossbite, as oth-erwise often can lead to very serious Class IIImallocclusion which would be possible to treat onlywith combined orthodontic and orthognatic method[1, 10].As the treatment is carried out with removableappliance good cooperation between the specialist andpatient is one of the most important conditions forsuccessful treatment result.In this paper we would like to show quit simpleand inexpensive method of treatment of anteriorcrossbite in decidious and mixed dentition. We wouldlike to describe removable inclined plane (Bruckl ap-pliance) [2, 3, 4, 5, 8, 9].This is a removable simple functional applianceon the lower arch (jaw), which works as inclinedplane. One of the advantage of the Bruckl applianceis that it can also be used as retention appliance afteractive treatment as well as it is possible to add acrylicteeth if necessary. Therefore it can be used as a re-movable partial denture in lower jaw in case wherethere is a premature loss of the primary teeth.Anterior crossbite in the primary dentition canbe eliminated by grinding of deciduous teeth, with re-movable appliances or combination of both.What can you get from grinding of primary teeth?With grinding it is possible to remove disturbingcontact points. It is important to take in mind the di-rection of the surfaces which are grinded [11].For definition of the grinding direction articula-tion paper is used. It is also important to evaluate theabrassion of primary canine incisal surfaces (Fig. 3).If there is not possible to get the result with grind-ing of teeth then a simple functional appliance can beused to treat the malloclussion. For instance, it canbe an inclined plane which prevents the mandibularprotrusion. This plane is described as it forms thebasic active part of the Bruckl appliance (Fig. 4, 5).Stomatologija, Baltic Dental and Maxillofacial  Journal, 2008, Vol. 10, No.4 141CLINICAL CASE REPORTS I. Jirgensone et al.Fig. 4. Acrylic lower inclined plane. The lower inclined planecaps the lower incisors and deciduous canines.Fig. 3. The grinding of primary teeth developing inclined planes [11]Fig. 2. Anterior crossbite in early mixed dentition, there is noabrasion of dd 73 and 83Fig. 1. Anterior crossbite in primary dentitionFig. 5. Diagrammatic representation of the lower inclined plane:A – working scheme of the inclined plane; B – inclined planefixed on the lower teeth (frontal view)[5]; C – the scheme showsthe distance between the inclined plane and palate which needto be considered when wearing the appliance.Fig. 8. Cross sec-tion view ofBruckl's applianceFig. 9. Force vectors of the inclinedplane with different angulations. Thesteeper the plane the greater the forwardpressure on the maxillary incisor [3].Fig. 6. A – in centric occlusion; B – edge to edge bite.Fig. 7. A – anterior crossbite in early mixed dentition;B – Bruckl appliance; C – normal overbite after treatment.ACBABABC142 Stomatologija, Baltic Dental and Maxillofacial Journal, 2008, Vol. 10, No. 4I. Jirgensone et al. CLINICAL CASE REPORTSFig. 10. Steps in fabrication of Bruckl appliance: A-C – acrylic plate with inclined plane in wax; D, E – appliance is ready forusing.A B C D EThe inclined plane is used if there isenough space indental arch to procline up-per incisors. Clinically it can be used incases when upper incisors are in crossbitewith more than one half of vertical over-bite. The movement of teeth occurs fromthe resulting force of closing muscle andinclined plane interaction. The acrylic baseof the inclined plain should be wide enough.For better stability it is advised to use teethwith different axial inclination. For example,incisors, canines and sometimes evenpremolars.The lower inclined plane caps the lowerincisors and is inclined at about 45° to theocclusal plane. On closing, the upper inci-sors, which formely occlude behind thelower incisors, bite on the inclined planeand the pressure of the bite (P) divaids intwo force vectors P1 and P2. The pres-sure (P1) proclines the upper incisors. Thepressure (P2) intrudes the incisors. Thesteeper the plane the greater the forwardpressure on the maxillary incisors. Theadvisable angle is 45 degrees [2].If there are two or more teeth incrossbites then the lower jaw should beaccessed not only in centric occlusion butalso in edge to edge relationship [1, 11].If it is possible to bite edge to edge thatmeans the anomaly is of dentoalveolar ori-gin and removable appliance can be used.The primary canine guidance forward andsideways also should be accessed. Thecanines can be grinded, if necessary (Fig.6).TREATMENTMandibular removable applianceBruckl appliance is a simple functionalappliance. It is used when there is anteriorcrossbite involving several teeth (2-4). Ver-tical overbite approximately 1/2-2/3 ormore. It is not recommended in cases withcrowded maxillary incisors (Fig. 7).Fig. 15. Patient A. L. before treatmentFig. 16. Patient A. L. after treatmentFig. 14. Patient M. S. after treatmentFig. 11. Patient P. E. before treatmentFig. 12. Patient P. E. after treatmentFig. 13. Patient M. S. before treatmentStomatologija, Baltic Dental and Maxillofacial  Journal, 2008, Vol. 10, No.4 143CLINICAL CASE REPORTS I. Jirgensone et al.Parts of Bruckl appliance: mandibular Hawley-type retainer, inclined plane added to Hawley – typeretainer, labial bow for retraction of lower incisors.The inclined plane stimulates the forward movementof maxillary incisors which are in crossbite. Muscleforce provides sufficient force for maxillary incisormovement.When activated labial bow acrylic is cut awayon the lingual surface of mandibular incisors. The la-bial bow exerts a retrusive force to upright lower in-cisors, close spaces and correct anterior crossbite[2, 3] (Fig. 8, 9).Steps in fabrication of Bruckl appliance (Aremovable acrylic plane) (Fig. 10).Bruckl appliance is made on stone model. At firstacrylic base plate is made with Adams clasps on 36and 46, and labial bow. The inclined plane is built upin wax. Wax inclined plane caps the incisors and ca-nine teeth.The wax inclined plane is adjusted for height andangulation in mouth. Then the plane is fabricated inacrylic, and finally polished [2, 3, 8, 9].In the next appointment: the acrylic Bruckl ap-pliance is inserted, it is necessary to use the articula-tion paper for detection of the right angulation andgrinding the acrylic inclined plane. Periodical obser-vation may show that more inclined plane grinding isnecessary.The appliance should be worn full time and thepatient is instructed to adopt soft diet until the incisorrelationship is corrected and the appliance can be re-moved.The treatment should only take a matter of 7-8weeks. If the improvement does not apper, a checkshould be made on the wearing of appliance and thediagnosis of the case.CASE REPORTS• Patient P.E. aged 8 years before treatment,girl with anterior crossbite, involved 52; 11; 21. Thereare premature loss 73; 83; 84; 85 and dentoalveolardeformation (Fig. 11). Treatment was started withBruckl appliance. Treatment time – 2.5 month. Aftertreatment overbite: +2 mm. The girl needs remov-able acrylic partial denture in lower jaw (Fig. 12).• Patient M.S. aged 11 years before treatment,girl with anterior crossbite, involved 12; 11; 21. Over-bite: -6 mm (Fig. 13). Treatment was strated withBruckl appliance. Treatment time – 1.5 month. Aftertreatment overbite: +1.5 mm (Fig. 14). Bruckl appli-ance with cutted off inclined plane was used for re-tention.• Patient A. L. aged 10 years, before treat-ment, girl with anterior crossbite, involved 11; 21.Overbite: ~2 mm (Fig. 15). Spaces and median di-astema in lower jaw. Treatment was started withBruckl appliance.  Treatment time – 2 month. Aftertreatment overbite: +1.5 mm. Frontal teeth of thelower jaw were retroinclined; spaces were closed(Fig. 16). Bruckl appliance with cutted off  inclinedplane was used for retention.DISCUSSIONThe problems of anterior crossbite in permanentdentition shows progression in severity, so that earlyintervention aim at stimulating well balance growthand occlusal development is indicated [12].The important role plays not only the age of thechild but also the motivation for treatment, how he orshe percieves the problem. There are differences ingender as well – girls are more keen for treatmentthan boys [13].One for the shortcomings of early treatment isthe possibility of two phase orthodontic therapy asoften it is difficult to estimate the further growth ofthe mandible [14].Early treatment of the patients with Class III mal-occlusion depends whether the problem is mandibu-lar prognathism or deficiency in maxillary growth [7].The aim of our case report was to show easyand cheap method how to deal with this problem. Theshortcoming of this method is that it is removable soneeds good cooperation with patients and parents.The other methods such as 2x4 appliance is fixed,not so compliant [15].Other simple treatment methods in mixed denti-tion are: a palatal plate with anterior springs; a QuadHelix to which springs can be soldered. Each of thesemethods can be used to correct the anterior crossbite,but to choose the right one the thorough diagnosis isneeded [6].CONCLUSIONSThe main advantage of early treatment of ante-rior crossbite is the opportunity to influence the pro-cess of growth in the upper jaw with quite simple andnot expensive appliance as well as to avoid in manycases orthognatic surgery in future.• Before treatment it is necessary to consider ifthe possible treatment result will justify all the usedmethods and input – material as well as psychological.• Choosing the appliance for correction of an-terior crossbite you have to consider the amount ofvertical overbite. If it is 1/2 to 2/3 and more from the144 Stomatologija, Baltic Dental and Maxillofacial Journal, 2008, Vol. 10, No. 4REFERENCES1. Arvystas MG. The rationale for early orthodontic treatment.Am J Orthod Dentofacial Orthop 1998:133:15-8.2. Adams P. The design, construction and use of removableorthodontic appliances. 5th  ed.  Bristol; 1984. p.111-2.3. Graber TM,  Neuman B. Removable orthodontic appliances.2nd ed.  Saunders; 1984. p.  57-9.4. Horosilkina FJ, Maligin JM. Osnovi konstruirovanija itehnologija izgotovlenija ortodontoticeskih aparatur. Moskva:Medicina; 1977. p. 168-9. Rus5. Kalvelis DA. Aparatūras, kas darbojas pēc slīpās plāksnesprincipa. Ortodontija 1964:135-6;6. Patti A, Perier G. Preface. In: Clinical success in early orth-odontic treatment. Quintessence; 2005. p.  8.7. Proffit WR. The timing of eraly treatment: An overview. AmJ Orthod Dentofacial Orthop 2006;4:S48;8. Sztele R. Herstellung Kieferorthopädisher apparate. Berlin;1960. S. 53.9. Taatz H. Kieferorthopädische Prophylaxe und Frühbehandlung.I. Jirgensone et al. CLINICAL CASE REPORTSReceived: 05 08 2007Accepted for publishing: 19 12 2008length of a cusp and there are 3 or all 4 frontal teethin crossbite, then it is advisable to use Bruckl appli-ance. If the vertical overbite is less than 1/2 from thelength of the crown, then is better to use a removableupper plate with protraction spring or a screw forcorrection of the malocclusion.• It is possible to correct several dentoalveolaranomalies if you start to treat early. Therefore it isMünchen,Wien: Hanser; 1976. p. 238-9.10. Vadiakas G, Viazis AD. Anterior crossbite correction in theearly deciduous dention.  Am J Orthod Dentofacial Orthop1992;102:160-2.11. Zachrisson B, Thilander B. Treatment of Dento-alveolaranomalies. In: Introduction to orthodontics. Stockholm; 1994.p. 146-182.12. Tausche E, Luck O, Harzer W. Prevalence of malocclusionsin the early mixed dentition and orthodontic treatment need.Eur J Orthod 2004;26:237-44.13. Kiyak AH. Patients’ and parents’ expectations from early treat-ment. Am J Orthod Dentofacial Orthop 2006;129:S50-54.14. Ngan P. Biomechanics of maxillary expansion and protrac-tion in Class III patients. Am J Orthod Dentofacial Orthop2002;121:58283.15. Dugoni S, Aubert M, Baumrind S. Differential diagnosis andtreatment planning for early mixed dentition malocclusions.Am J Orthod Dentofacial Orthop 2006; 129:S80-1.possible to prevent development of severe anomaliesand shorten the orthodontic treatment time in perma-nent dentition [6].The main emphasis need to be placed on thediagnosis and evaluation of the malocclusion. Thisis a competence of a dentist who than refer the pa-tient to the orthodontic specialist for future treat-ment.View pub l i ca t i on  s ta t s

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Anterior crossbite correction in primary and mixed dentition with removable inclined plane (Bruckl appliance)

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