Odontology (2005) 93:56–60
DOI 10.1007/s10266-005-0053-x
ORIGINAL ARTICLE
Junko Shimomura · Yoshihiro Tanabe · Yo Taguchi
Shohachi Shimooka · Tadashi Noda
Anterior crossbite in the primary dentition: proposal for a new analytical
method in children
Received: December 8, 2004 / Accepted: April 26, 2005
Abstract The aim of this study was to clarify the features
of profiles of patients with anterior crossbite in early child-
hood, using a new method of analysis. Lateral cephalograms
of 139 (68 males; 71 females) untreated child patients with
anterior crossbite in the primary dentition were assessed.
The patients were aged from 3 to 5 years. To evaluate
disharmony between the maxilla and the mandible, a pro-
prietary calculating system, the Theoretical Individualized
Profile drawing System (TIPS), was applied. Using this
system, individualized standard cephalometric values were
obtained for normal occlusion. This standard profile, which
was harmonized with the cranial base structure of each
patient, was compared with the child’s original profile. The
sizes of the mandibles in the children with anterior cross-
bite, subclassified into three age groups (3, 4, and 5 years)
were greater, both horizontally and vertically, than those in
the mean profiles derived from TIPS. The vertical size of the
maxilla was smaller than that derived from TIPS in the
patients aged 3 years. In contrast, in the patients aged 5
years, the vertical size of the maxilla was larger than that
derived from TIPS. These results suggest that, in children
with anterior crossbite, the vertical growth of the maxilla is
closely related to the variation of morphological conditions
with development.
Key words Analysis · Diagnosis · Anterior crossbite ·
Primary dentition · Growth
J. Shimomura · Y. Tanabe · Y. Taguchi · T. Noda
Division of Pediatric Dentistry, Department of Oral Health Science,
Niigata University Graduate School of Medical and Dental Sciences,
Niigata, Japan
J. Shimomura (*)
Pediatric Dentistry, The Nippon Dental University Hospital at
Niigata, 1-8 Hamaura-cho, Niigata 951-8580, Japan
Tel. +81-25-267-1500 (ext. 336); Fax +81-25-265-5819
e-mail: jshimo@ngt.ndu.ac.jp
S. Shimooka
Department of Pediatric Dentistry, The Nippon Dental University
School of Dentistry at Niigata, Niigata, Japan
© The Society of The Nippon Dental University 2005
Introduction
Background
There are highly complex relationships between the cranial
base structure and the maxillofacial components. These
relationships have been reported by Hasund and Böe,1
Järvinen,2 and Senger.3 On the basis of these relationships,
a table of floating norms was designed for evaluating the
individual skeletal patterns of young adult patients. As a
guide for early diagnosis and treatment planning in child
patients, Tollaro et al.4 attempted to determine floating
norms for the assessment of individual craniofacial patterns
in the primary dentition period, computing floating norms
from subjects aged 5.67 ± 0.82 years.
At the growth stage of the craniofacial structures, there
are a number of difficulties associated with the clarification
of the relationship between the cranial base structure and
the maxillofacial components. Tanabe et al.5 used the mag-
nitude of the cranial base angle to categorize individual pro-
files with normal occlusion. Using multivariate analysis, they
clarified the relationships between the cranial base angle
and the morphological variations of maxillofacial compo-
nents undergoing growth. With the results, they attempted
to construct theoretical models of individualized skeletal
profiles of children with normal occlusion, naming the
process the Theoretical Individualized Profile drawing
System (TIPS).
A TIPS was prepared from the database of the Japanese
Society of Pediatric Dentistry,6 which consisted of data on
122 children with normal occlusion in the primary dentition
(63 males and 59 females). TIPS was designed to calculate
the standard shape and size of a cephalometric profile with
normal occlusion from the cranial base angle and anterior
cranial base length of each child patient. In the present
study, this system was used to obtain a computed maxillo-
facial component that was harmonized with the patient’s
cranial base structure.
Susami et al.7 reported a high incidence of anterior cross-
bite in the primary dentition in Japanese children. Opinions
 57

of clinicians vary, however, on the effect of early treatment

of anterior crossbite in the primary dentition. Yano8
remarked that primary anterior crossbite would relapse into
crossbite in the permanent dentition, even if treated in the
primary dentition. Nagahara et al.9 stated that some cases
of primary anterior crossbite were found to correct them-
selves spontaneously. There is a contrasting view that cross-
bite may be aggravated by growth without treatment.
Baccetti and Tollaro10 assumed that the optimum timing for
improving the skeletal relationship in class III malocclu-
sions would be during the primary dentition.

Aim of this study

The purpose of the present study was, using TIPS, to clarify

the morphological differences in the maxillofacial structure
between children with anterior crossbite and children with
normal occlusion, taking account of their growth.

Subjects and methods

Subjects

Lateral roentgenographic cephalograms of 139 untreated

child patients with anterior crossbite in the primary denti-
tion (68 males, 71 females) were selected randomly from
dental charts of the Pediatric Dental Clinic, Niigata Uni-
versity Medical and Dental Hospital. All cephalograms had
been taken for diagnosis. Patients and their parents or
guardians provided informed consent for the use of the
cephalograms. Patients who had severe caries in the decid-
uous molar teeth, or cleft lip and/or palate were excluded
from the present investigation. The anterior crossbite
involved all eight primary incisors in all the patients; they
were not selected by their severity of crossbite, because one
of the aims of the present investigation was to clarify the
relationship between the age of the patients and the mor-
phological conditions of crossbite. The ages of the patients
ranged from 3 to 5 years (mean age: 4.64 years). They were
classified into three age groups: the 3Y group, the 4Y group,
and the 5Y group, consisting of the patients aged 3 years, 4
years, and 5 years, respectively (Table 1).
Methods
The coordinates (X, Y) of 16 cephalometric landmarks for
each child (Fig. 1) were fed into a computer. The S-N line
Table 1. Number of child patients
Age (years) Male Female Total
3 10 20 30
4 31 24 55
5 27 27 54
Total 68 71 139
Fig. 1. Cephalometric landmarks and lines. In this study, all profiles
were oriented horizontally on the sella-nasion (S-N) line to clarify the
relationship between the cranial base and the maxillofacial compo-
nents. The S-N line was defined as the X-axis, with the Y-axis perpen-
dicular to this. The intersection of axes was the sella turcica (S). The
following cephalometric landmarks and lines were used in the study.
N, nasion; Or, orbitale; Po, porion; ANS, anterior nasal spine; A, point
A; U1, upper central incisor tip; U1root, upper central incisor apex; L1,
lower central incisor tip; L1root, lower central incisor apex; B, point B;
Pog, pogonion; Me, menton; Go, gonion; Ar, articulare; Mo, upper first
molar; NSL, sella-nasion line; ML, mandibular line
was defined as the X-axis, with the Y-axis perpendicular to
this. The intersection of the axes was the sella turcica (S).
An individualized standard profile for each patient was
computed using TIPS, and this was compared with the orig-
inal profile of the same child. At point A and point B, to
clarify the differences between the patients; profiles and
those derived from TIPS, four variables were defined. A_X
was the difference of point A on the X-axis, A_Y was the
difference of point A on the Y-axis, B_X was the difference
of point B on the X-axis, and B_Y was the difference of
point B on the Y-axis.
As standard cephalometric values, the data of the Japan-
ese Society of Pediatric Dentistry6 were used. All subjects
in the database had normal occlusion in the primary denti-
tion and were aged between 3 and 6 years (mean age, 5.15
years). In general, 11 common angular measurements
(Table 2) were compared with those of the child patients to
display the differences in skeletal features.
Factor analysis was performed to elucidate the
relationships among cephalometric variables, the four
defined variables, and the age of the patients. The cephalo-
metric variables used were SNA, SNB, ANB, the Y-axis and
58

Table 2. Mean cephalometric values in the patients and Japanese children with normal occlusion
Patients SD Japanese standardsa SD

Facial plane angle 84.08 2.38* 83.40 2.32

Convexity 174.76 4.45** 167.69 4.24
A-B plane angle -0.14 2.87** -5.71 2.98
Interincisal angle 150.92 10.21** 146.21 10.25
U1-NSL 87.60 7.37* 89.34 6.01
L1 to mandibular line 84.98 6.02** 87.18 7.64
SNA 79.96 3.27* 80.99 3.12
SNB 78.85 3.39** 76.59 2.75
ANB 1.14 1.93** 4.41 1.71
NSL-ML 36.48 4.58* 37.08 4.75
Gonial angle 128.67 5.41 128.24 6.34
* P < 0.05; ** P < 0.01 (degrees)
a
Japanese Society of Pediatric Dentistry (1995)6

the cranial base angle (NS-Ar) as angular measurements,

and N-M as liner measurement.

Results

Comparison of cephalometric variables

The mean values of all the cephalometric variables of

the patients and the Japanese children with normal occlu-
sion (Japanese standards) are shown in Table 2. Compared
to the standard values, the mean values of the A-B
plane angle, the U1-NSL, the L1 to mandibular line (ML),
SNA, ANB, and NSL-ML in the patients were smaller,
and the facial plane angle, convexity, interincisal angle,
and SNB of the patients were significantly larger. Only
the gonial angle showed no difference between the two Fig. 2. Points A and B in the mean profiles of the patients and the
Theoretical Individualized Profile drawing System (TIPS) profiles of
groups. normal children in each age group. The mean profiles of each age group
are shown as dotted lines. The TIPS profiles were computed to fit each
mean profile and were superimposed as solid lines on the figure. A_Y,
Comparison of points A and B in the mean profiles of difference of point A on the Y-axis; B_Y, difference of point B on the
Y-axis
the patients and in TIPS

Points A and B in the mean profiles of the patients and in
TIPS in the three age groups are shown in Fig. 2, where the
mean profile of each age group is drawn as a dotted line.
The TIPS profile of each age group was computed to fit both
the anterior cranial length (S-N) and NS-Ar into the mean
profile, and was superimposed as a solid line on the figure.
Horizontal growth (X coordinate)
In all age groups, the X coordinate of point A was smaller,
while the X coordinate of point B was larger than those of
the respective TIPS profiles.
nate of point A was almost equal to that of the TIPS pro-
files, while the Y coordinate of point B was larger than those
of the respective TIPS profiles. In the 5Y group, the Y coor-
dinates of points A and B were larger than those of the TIPS
profiles.
From Fig. 2, it can be seen that the Y coordinates of both
point A and point B, as indices of the vertical growth of the
maxilla and mandible, gradually increased with age. In Table
3, these findings are displayed by the mean values of A_X,
A_Y, B_X, and B_Y.
Factor analysis

Table 4 shows the results of the factor analysis performed

Vertical growth (Y coordinate)
In the 3Y group, the Y coordinate of point A was smaller,
while the Y coordinate of point B was larger than those of
the respective TIPS profiles. In the 4Y group, the Y coordi-
to demonstrate the relationship among the defined vari-
ables and the cephalometric variables. The proportion of
variance for the first factor was 27.62%; for the second
factor, 22.60%; for the third factor, 16.29%; and for the
fourth factor, 13.97%. The cumulative proportion of vari-
 59

ance was 80.48% from the first to the fourth factor. For the
first factor, the factor loadings of SNA, SNB, A_X, and B_X
were more than 0.40 – this factor indicated the horizontal
relationship of points A and B. For the second factor, the
factor loadings of age, Y-axis, N-M, A_Y, and B_Y were
more than 0.40, this factor indicating the vertical growth of
the maxillofacial components. For the third factor, the
absolute values for Y-axis, ANB, and B_X were more than
0.40, and indicated the feature of mandibular protraction.
For the fourth factor, the absolute values of SNA, SNB, and
NS-Ar were more than 0.40 – this factor indicated the rela-
tionship between the cranial base angle and facial flexure.
Discussion
In the present investigation, 139 untreated patients aged 3–5
years were randomly selected to clarify the morphological
features of the maxillofacial structure in children with ante-
rior crossbite in the primary dentition. The mean values of
the SNA, SNB, and ANB angles in the patients and in the
Japanese standards (Japanese Society of Pediatric Den-
tistry, 1995)6 showed significant differences (Table 2). These
mean values indicated that children with anterior crossbite
have, in general, a smaller SNA and larger SNB than
children with normal occlusion. In the 139 patients, the mag-
nitudes of the SNA and SNB angles showed great variation;
however, these magnitudes do not show the severity of
anterior crossbite directly. Moreover, the relationship
between these angular measurements and skeletal growth
in 3- to 5-year-old patients is not clear. Therefore, four
defined variables (A_X, A_Y, B_X, B_Y) were used in the
investigation.
Table 3. Variations in the mean values of the differences of points A
and B (mm) with age
Age (years) A_X A_Y B_X
3 -0.72 -1.34 2.13
4 -1.86 -0.49 1.37
5 -1.40 0.87 1.93
According to the mean values for the horizontal and
vertical differences of points A and B in Table 3, the child
patients in all age groups displayed a tendency to have a
smaller maxilla horizontally than the TIPS profile. For the
vertical measurement, on the other hand, compared to the
TIPS profiles, the A_Y value of the 3Y group was smaller,
that of the 4Y group was almost the same, and that of the
5Y group was somewhat larger. These findings showed that
the variation of the A_Y value displayed a specific dishar-
mony with the vertical size of the maxilla in each age group.
The B_X and B_Y values in all age groups were larger than
those of the TIPS profiles. The mean profile of the 5Y group
showed a stronger tendency toward vertical overgrowth in
the mandible than that of the 3Y group.
In regard to the factor analysis (Table 4), the high score
of the cumulative proportion of variance in this analysis
shows the suitability of the model. The first and second
factors suggested a new explanation regarding craniofacial
components in early childhood. In addition, the third factor
showed the severity of disharmony between the maxilla and
mandible, and the fourth factor supported the findings of
Järvinen,2 regarding the association between the NS-Ar and
SNA angles.
For the first factor, a horizontal relationship between
points A and B was shown by the values for SNA, SNB,
A_X, and B_X. This factor also suggested that patients with
a larger SNA and SNB had a larger A_X and B_X. This
means that the horizontal differences between a patient’s
original values and the TIPS values are influenced by the
magnitudes of the patient’s SNA and/or SNB. However, the
magnitude of factor loading of age was almost equal to 0.
Therefore, this horizontal relationship shown in the first
factor is independent of the age of the patients.
For the second factor, a relationship between vertical
variation and age was suggested. This factor suggested that
the facial heights of older patients were greater than those
of younger patients, and the vertical differences between
B_Y the patients’ values and the TIPS values were also greater
in older patients.
2.05 The findings of the present investigation suggested that
2.53 there were some morphological differences in maxillofacial
4.66
components between the 3Y group and the 5Y group. From

Table 4. The results of factor analysis

Item Factor 1 Factor 2 Factor 3 Factor 4

Age 0.00 0.54 -0.13 0.04

SNA 0.84 0.04 0.20 -0.50
SNB 0.77 0.06 -0.36 -0.51
Y-axis -0.17 0.49 0.50 0.09
ANB 0.07 -0.01 0.96 0.06
NS-Ar -0.08 0.05 0.09 0.99
N-M -0.16 0.75 0.00 -0.01
A_X 0.94 -0.07 0.29 0.14
A_Y 0.03 0.82 0.09 -0.09
B_X 0.87 -0.07 -0.48 0.04
B_Y 0.18 0.85 0.31 0.08
Eigenvalue 3.04 2.49 1.79 1.54
Proportion of variance (%) 27.62 22.60 16.29 13.97
Cumulative proportion of variance (%) 27.62 50.22 66.51 80.48
60
the mean values in the present cross-sectional study, the
proportion of children in the 3Y group with anterior cross-
bite from vertical undergrowth of the maxilla was higher
than that in the 5Y group. Conversely, in the 5Y group, most
of the children had a harmonized maxilla size with a verti-
cally larger mandible. These findings were supported by the
first and the second factors in the factor analysis. The results
suggested that some patients with a vertically smaller
maxilla and a harmonized mandible size at 3 years of age
could potentially achieve relief of their symptoms by 5 years
of age.
Susami et al.7 reported that the incidence of anterior
crossbite reached its peak between 3 and 5 years of age and
decreased with age thereafter. Their epidemiological find-
ings probably support our speculation from the viewpoint
of maxillary vertical growth. Because the present study was
indeed a cross-sectional study, early diagnosis of crossbite,
using TIPS at 2 or 3 years of age, as well as a longitudinal
investigation, would be required to demonstrate the rela-
tionship between maxillary vertical growth and anterior
occlusion in the primary dentition.
Conclusions
In children with anterior crossbite aged 3 years, the vertical
length of the maxilla was shorter than that in the profile
with normal occlusion, which was harmonized with the
patient’s cranial base structure. In the patients aged 5 years,
the maxillary vertical size was harmonized with the anterior
cranial base length. The relationship between age and ver-
tical length of the maxilla was significant.
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