Agostino Et Al-2014-Cochrane Database of Systematic Reviews PDF

Cochrane Database of Systematic Reviews
Orthodontic treatment for posterior crossbites (Review)
Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P
Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P.

Orthodontic treatment for posterior crossbites.
Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD000979.
DOI: 10.1002/14651858.CD000979.pub2.
www.cochranelibrary.com

Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 17
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Analysis 1.1. Comparison 1 Fixed rapid (Haas) versus fixed rapid (Hyrax), Outcome 1 Molar expansion (3 months after
completion of expansion phase). . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Analysis 2.1. Comparison 2 Fixed slow (quad-helix) versus removable slow (expansion plate), Outcome 1 Crossbite
correction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis 2.2. Comparison 2 Fixed slow (quad-helix) versus removable slow (expansion plate), Outcome 2 Molar
expansion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis 2.3. Comparison 2 Fixed slow (quad-helix) versus removable slow (expansion plate), Outcome 3 Canine
expansion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 59
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Orthodontic treatment for posterior crossbites (Review) i

[Intervention Review]
Orthodontic treatment for posterior crossbites
Paola Agostino1 , Alessandro Ugolini2 , Alessio Signori3 , Armando Silvestrini-Biavati2 , Jayne E Harrison4 , Philip Riley5
1 Private practice, Chiavari, Italy. 2 Orthodontics Department, University of Genoa, Genoa, Italy. 3 Unit of Biostatistics, Health Sciences
Department, University of Genoa, Genoa, Italy. 4 Orthodontic Department, Liverpool University Dental Hospital, Liverpool, UK.
5 Cochrane Oral Health Group, School of Dentistry, The University of Manchester, Manchester, UK
Contact address: Alessandro Ugolini, Orthodontics Department, University of Genoa, Largo Rosanna Benzi 10, Genoa, 16132, Italy.
alexugolini@yahoo.it.
Editorial group: Cochrane Oral Health Group.

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 8, 2014.
Citation: Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P. Orthodontic treatment for posterior crossbites.
Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD000979. DOI: 10.1002/14651858.CD000979.pub2.
ABSTRACT
Background
A posterior crossbite occurs when the top back teeth bite inside the bottom back teeth. When it affects one side of the mouth, the lower
jaw may have to move to one side to allow the back teeth to meet together. Several treatments have been recommended to correct this
problem. Some treatments widen the upper teeth while others are directed at treating the cause of the posterior crossbite (e.g. breathing
problems or sucking habits). Most treatments have been used at each stage of dental development. This is an update of a Cochrane
review first published in 2001.
Objectives
To assess the effects of orthodontic treatment for posterior crossbites.
Search methods
We searched the following electronic databases: the Cochrane Oral Health Group’s Trials Register (to 21 January 2014), the Cochrane
Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1), MEDLINE via OVID (1946 to 21 January
2014), and EMBASE via OVID (1980 to 21 January 2014). We searched the US National Institutes of Health Trials Register and the
World Health Organization (WHO) Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or
date of publication when searching the electronic databases.
Selection criteria
Randomised controlled trials (RCTs) of orthodontic treatment for posterior crossbites in children and adults.
Data collection and analysis
Two review authors, independently and in duplicate, screened the results of the electronic searches, and extracted data and assessed
the risk of bias of the included studies. We attempted to contact the first named authors of the included studies for missing data
and for clarification. We used risk ratios (RR) and 95% confidence intervals (CIs) to summarise dichotomous (event) data, and mean
differences (MD) with 95% CIs to summarise continuous data. We performed meta-analyses using fixed-effect models (we would
have used random-effects models if we had included four or more studies in a meta-analysis) when comparisons and outcomes were
sufficiently similar.
Orthodontic treatment for posterior crossbites (Review) 1
Main results
We included 15 studies, of which two were at low risk of bias, seven were at high risk of bias and six were unclear.
Fixed appliances with mid-palatal expansion
Nine studies tested fixed appliances with mid-palatal expansion against each other. No study reported a difference between any type of
appliance.
Fixed versus removable appliances
Fixed quad-helix appliances may be 20% more likely to correct crossbites than removable expansion plates (RR 1.20; 95% CI 1.04 to
1.37; two studies; 96 participants; low-quality evidence).
Quad-helix appliances may achieve 1.15 mm more molar expansion than expansion plates (MD 1.15 mm; 95% CI 0.40 to 1.90; two
studies; 96 participants; moderate-quality evidence).
There was insufficient evidence of a difference in canine expansion or the stability of crossbite correction.
Very limited evidence showed that both fixed quad-helix appliances and removable expansion plates were superior to composite onlays
in terms of crossbite correction, molar and canine expansion.
Other comparisons
Very limited evidence showed that treatments were superior to no treatment, but there was insufficient evidence of a difference between
any active treatments.
Authors’ conclusions
There is a very small body of low- to moderate-quality evidence to suggest that the quad-helix appliance may be more successful than
removable expansion plates at correcting posterior crossbites and expanding the inter-molar width for children in the early mixed
dentition (aged eight to 10 years). The remaining evidence we found was of very low quality and was insufficient to allow the conclusion
that any one intervention is better than another for any of the outcomes in this review.
PLAIN LANGUAGE SUMMARY

Orthodontic treatment for posterior crossbites
Review question
We conducted this review to assess the effects of different orthodontic treatments for correcting posterior crossbites.
Background
Posterior crossbite is when the top back teeth bite down inside the bottom back teeth. It occurs when the top teeth or jaw are narrower
than the bottom teeth and can happen on one or both sides of the mouth. The condition affects between 1% and 16% of children
who only have their baby teeth. Most posterior crossbites (50% to 90%) remain even when the permanent teeth erupt. In a minority
of children, the problem self corrects.
In order to obtain a more comfortable bite, the lower jaw shifts to one side into a position that allows more teeth to come into contact.
However, this shifting of the lower jaw may lead to tooth grinding, and this may lead to other dental problems including the tooth
surface being worn away, abnormal growth and development of the teeth and jaws, and jaw joint problems.
Therefore, we need to find safe and effective treatments to correct posterior crossbites or expand the top back teeth, or both. One way
of doing this is using orthodontic treatments. This can be more effective in children because the two halves of the roof of the mouth
have not fully joined yet, so the top back teeth can be expanded more easily. Orthodontic treatments can also be used to treat posterior
crossbites in adults, but they are more likely to need surgical treatments, which are not the focus of this review.
Study characteristics
Authors from the Cochrane Oral Health Group carried out this review update of existing studies and the evidence is current up to
21 January 2014. It includes 15 studies published from 1984 to 2013. Nine of these studies compared fixed (always in the mouth)
appliances either against different fixed appliances, or against the same fixed appliance but comparing different rates of expansion. Two
studies compared a fixed appliance with a removable appliance. The remaining four studies evaluated other comparisons that were
more difficult to classify.
Key results
There is some evidence to suggest that the quad-helix (fixed) appliance may be more successful than removable expansion plates at
correcting posterior crossbites and expanding the top back teeth for children with a mixture of baby and adult teeth (aged eight to 10
years). The remaining evidence we found did not allow the conclusion that any one treatment is better than another.
Quality of the evidence
The evidence presented is mostly of low to very low quality due to the small amount of available studies and issues with the way in
which they were conducted.

Orthodontic treatment for posterior crossbites (Review) S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
Fixed appliances compared with other fixed appliances for treating posterior crossbites
Patient or population: Children with posterior crossbites (adults would be included in the review but no studies with adults were f ound)
Settings: Typically university orthodontic/ dental clinics
Intervention: Fixed appliance
Comparison: The sam e f ixed appliance attached dif f erently or expanded at dif f erent speeds or a dif f erent f ixed appliance
Outcomes Illustrative comparative risks (95% CI) Relative effect No of participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
Group A Group B
M olar expansion N/ A N/ A N/ A 53 ⊕ 2 studies (1 high risk of

(m m ) (2) very low bias; 1 unclear), which
(rapid ex- were not possible to
pansion) banded Hyrax pool in a m eta-analy-
(tooth borne) versus sis due to no reporting
bonded Hyrax (tooth/ of variance in 1 study.
tissue borne) Im precision due to low
sam ple sizes. Dif f erent
tim ings of f ollow-up af -
ter com pletion of ex-
pansion. Both studies
reported no dif f erence
in m olar expansion
M olar expansion The m ean expansion The m ean expansion in N/ A 27 ⊕ 2 studies at unclear risk
(m m ) ranged across the Haas the Hyrax groups was (2) very low of bias with serious in-
(3 m onths af ter com - groups f rom 0.7 mm lower consistency (I 2 = 94%)
pletion of expansion 6.5 to 8.49 m m (1.66 lower to 0.25 and im precision due to
phase) higher) low sam ple size
(rapid ex-
pansion) tooth- tissue
borne (Haas) versus
4
tooth borne (Hyrax)
N/ A N/ A N/ A N/ A N/ A N/ A The rem aining com -

parisons were all sin-
gle studies (Additional
Table 1). The quality of
the evidence (GRADE)
f or all com parisons and
outcom es in Additional
Table 1 is ⊕ very
low (all at unclear or
high risk of bias with
im precision due to low
sam ple sizes). None of
these studies showed a
statistically signif icant
dif f erence f or any out-
com e
CI: conf idence interval; N/ A: not applicable.
GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
5
BACKGROUND habit (e.g. thumb sucking) or some pathology (Bresolin 1983;
Cheng 1988; Modeer 1982; Ogaard 1994; Subtelny 1980).
Description of the condition Description of the intervention

Posterior crossbite is the term used to describe the situation when As described above, a posterior crossbite may self correct but, as self
the top back teeth bite inside the bottom back teeth. A posterior correction occurs in only a very small minority of cases, treatment
crossbite occurs when the top teeth or jaw are narrower than the of this malocclusion can be recommended. Treatment of a poste-
bottom teeth and can happen on one (unilateral) or both (bilat- rior crossbite usually involves expansion of the maxillary (upper
eral) sides of the mouth. The prevalence of posterior crossbites is jaw) arch, removal of any occlusal interferences and elimination
between 1% and 16% of children who only have their baby teeth, of the functional displacement of the mandible.
and is likely to be higher in white populations compared with chil- Maxillary expansion treatment initiated during the early mixed
dren of African or Asian ethnicity (Malandris 2004). Most pos- dentition stage (children younger than eight years of age) may re-
terior crossbites (50% to 90%) persist when the permanent teeth quire the use of lower forces to achieve expansion of the upper
erupt, though, in a minority of children, the malocclusion self arch because the mid-line bony suture has not yet fused. However,
corrects. obtaining co-operation with treatment may be more difficult in
A functional posterior crossbite occurs when there is an interfer- younger children and treatment may be complicated by the loss
ence between two or more teeth when an individual closes their of deciduous teeth. In older children (aged 12 years and above)
jaws together. In order to obtain a more comfortable bite, the who are in the early permanent dentition, greater forces may be
mandible (lower jaw) shifts to one side into a position that al- required to achieve maxillary expansion. Maxillary expansion can
lows more teeth to come into contact. However, this displacement be achieved using either fixed or removable appliances and ex-
may increase the likelihood of the individual developing bruxism pansion can be either rapid or slow. Expansion of the top jaw is
(tooth grinding), which may lead to other dental problems includ- termed ’rapid’ when expansion takes place at a rate of 0.5 mm per
ing the tooth surface being worn away (Malandris 2004), abnor- day, and ’slow’ when expansion takes place at a rate of 0.5 mm
mal growth and development of the teeth and jaws, and jaw joint per week. Braces that can bring about this expansion are fixed to
problems. the back teeth by either metal bands around the individual teeth
While it is unlikely that young children with a posterior crossbite (banded rapid/slow maxillary expansion) or acrylic splints over
will experience any pain or have problems with chewing, there several teeth (bonded rapid/slow maxillary expansion) joined by
has been concern that the abnormal movement of the lower jaw a wire framework attached to a screw in the mid-line that can be
associated with a crossbite could potentially have long-term effects opened to expand the top jaw.
on the growth and development of the teeth and jaws. The strain Removal of occlusal interferences involves grinding of teeth (usu-
on the jaw muscles and joints due to the abnormal movement and ally deciduous teeth) to enable the jaws to bite together in a more
position of the lower jaw may lead to skeletal facial asymmetries normal position. The reported success rate of this approach varied
that can be corrected during adulthood only by means of a com- widely between 27% and 64% (Kennedy 2005; Lindner 1989).
bination of orthodontics and maxillofacial surgery. Alternatively, composite onlays can be placed to prevent the jaw
Some studies have reported a correlation between posterior cross- from shifting when interferences exist.
bite with a shift on closure and temporomandibular joint prob- Where functional displacement of the mandible is associated with
lems in later life, for example pain, clicking or locking of the jaw reversible causes such as non-nutritive sucking habits (sucking on
joints. Such problems have many causes but studies of teenagers a dummy, thumb, finger(s), etc.), eliminating the causal behaviour
and adults have shown that some people with a crossbite may is a desirable adjunct to orthodontic treatment.
have an increased risk of developing jaw joint problems and show
more signs and symptoms of these problems (Egermark 1990;
McNamara 1997; Ninou 1994; O’Bryn 1995; Pullinger 1993).
However, some more recent studies have been less conclusive re-
How the intervention might work
garding an association between posterior crossbites and jaw prob- Expansion of the maxillary arch can be achieved through use of
lems (Gesch 2004; Iodice 2013; Thilander 2002; Thilander 2012). either fixed or removable appliances (see Appendix 1 for a descrip-
A posterior crossbite may develop or improve at any time from tion of appliances). These have expansion screws that are adjusted
when the deciduous (baby) teeth come into the mouth to when during treatment to increase the width of the maxillary arch. Ex-
the permanent (adult) teeth come through (Heikinheimo 1987; pansion may be either rapid (one-quarter turn of the expansion
Kurol 1992; Leighton 1966; Thilander 1984). It is unclear what screw one or two times per day, giving 0.5 mm expansion per day)
causes posterior crossbites but they may be due to skeletal, soft over two to six weeks or slow (one-quarter turn twice per week,
tissue, dental or respiratory factors, or develop as the result of a giving 0.5 mm expansion per week) over six to 12 weeks. Over-

expansion may be appropriate to allow for some relapse after the Types of interventions
appliance is removed. The use of maxillary expansion at the stage We included studies of any orthodontic or dentofacial orthopaedic
of the early mixed dentition may also have the benefit of reducing (not surgical) treatment used to correct posterior crossbites or ex-
crowding of the permanent dentition. pand the top back teeth, or both, when compared against another
Orthodontic appliances may also be used to correct the sideways such treatment or no treatment.
displacement of the mandible, which may reduce the pressure on
the temporomandibular joint.
Types of outcome measures
Why it is important to do this review Primary

A crossbite is a common transverse feature seen in malocclusions • Correction of the posterior crossbite.
in the posterior region of the dental arch. There is still debate
about the optimum timing of orthodontic treatment, the use of
either fixed or removable appliances, and the type of appliance Secondary
that leads to the best outcomes for the person. This updated sys- • Expansion of the upper jaw/teeth measured as changes in
tematic review will summarise the evidence available from ran- the width between the molars or canines, or both.
domised controlled trials to inform treatment decision making. • Stability of crossbite correction.
The Cochrane Oral Health Group recently carried out a prioriti- • Signs and symptoms of temporomandibular joint
sation exercise for their portfolio of orthodontic reviews, and this dysfunction (e.g. pain, clicking, locking of the jaw joints,
review was ranked in the top 10 most important orthodontic re- problems eating).
views by an international panel of oral health professionals, the • Signs and symptoms of respiratory disease (e.g. mouth
majority of whom were extremely experienced and internationally breathing, nasal airway resistance).
renowned orthodontists. • Quality of life (using any validated measurement tool).
This is an update of a Cochrane review first published in 2001.
Search methods for identification of studies

For the identification of studies included or considered for this
OBJECTIVES review, we developed detailed search strategies for each database
searched. These were based on the search strategy developed for
To assess the effects of orthodontic treatment for posterior cross-
MEDLINE (OVID) but revised appropriately for each database.
bites.
The search strategy used a combination of controlled vocabulary
and free-text terms and was linked with the Cochrane Highly Sen-
sitive Search Strategy (CHSSS) for identifying RCTs in MED-
METHODS LINE: sensitivity maximising version (2008 revision) as referenced
in Chapter 6.4.11.1 and detailed in box 6.4.c of the Cochrane
Handbook for Systematic Reviews of Interventions Version 5.1.0 (up-
dated March 2011) (Higgins 2011). Details of the MEDLINE
Criteria for considering studies for this review
search are provided in Appendix 2. The search of EMBASE was
linked to the Cochrane Oral Health Group filter for identifying
RCTs.
Types of studies
We included randomised controlled trials (RCTs) of parallel de-
sign that assessed orthodontic treatments to correct a posterior Electronic searches
crossbite or expand the top back teeth, or both. We included stud- We searched the following electronic databases:
ies irrespective of language or publication status. • the Cochrane Oral Health Group’s Trials Register (to 21
January 2014) (Appendix 3);
• the Cochrane Central Register of Controlled Trials
Types of participants (CENTRAL) (The Cochrane Library, 2014, Issue 1) (Appendix
We included RCTs of children and adults with a posterior cross- 4);
bite, without a Class III skeletal relationship, cleft lip or palate (or • MEDLINE via OVID (1946 to 21 January 2014)
both) or other syndrome associated with craniofacial anomalies. (Appendix 2)

• EMBASE via OVID (1980 to 21 January 2014) (Appendix Data extraction and management
5). Two review authors extracted data from the included studies, inde-
pendently and in duplicate, using a piloted data extraction form.
We manually checked all the references lists of the included studies We resolved any disagreements through discussion. We contacted
to identify any additional studies. study authors for clarification or missing information where nec-
We placed no restrictions on the language or date of publication essary and possible.
when searching the electronic databases. We entered the following extracted data into the Characteristics
of included studies table.
• Study design, location, number of centres, recruitment
Searching other resources period, funding, experience level of clinician.
We searched the following databases for ongoing trials (see • Inclusion and exclusion criteria, age, gender, number of
Appendix 6 for the search strategy): participants randomised to each group, number of participants
• US National Institutes of Health Trials Register ( evaluated.
clinicaltrials.gov) (to 21 January 2014); • Details of the type of intervention/comparator, timing,
• The WHO Clinical Trials Registry Platform (apps.who.int/ duration.
trialsearch/default.aspx) (to 21 January 2014). • Details of the outcomes reported, including method of
assessment, and time(s) assessed.
We handsearched the following journals from 1970 to 2012: • Sample size calculations, any other notable details.
• European Journal of Orthodontics;
• American Journal of Orthodontics and Dentofacial
Assessment of risk of bias in included studies
Orthopedics;
• Orthodontics and Craniofacial Research; Two review authors assessed the risk of bias of each included study,
• The Angle Orthodontist. independently and in duplicate, following the domain-based two-
part tool described in the Cochrane Handbook for Systematic Reviews
In the previous version of this review we also handsearched: of Interventions (Higgins 2011). We contacted study authors for
• British Journal of Orthodontics; clarification or missing information where necessary and possible.
• Journal of Orthodontics. We compared our assessments and discussed and resolved any
inconsistencies between the review authors.
We also searched personal references. We contacted the investiga- We assessed the following six domains of risk of bias for each
tors of the included studies by email to ask for additional details included study.
of their trials and for any information they may have about any • Random sequence generation (selection bias).
further published and unpublished trials. • Allocation concealment (selection bias).
• Blinding of outcome assessment (detection bias).
• Incomplete outcome data (attrition bias).
• Selective reporting (reporting bias).
Data collection and analysis • Other bias.
We did not consider the blinding of participants and personnel
(performance bias) as the interventions being compared in all stud-
Selection of studies ies were different and it would not have been possible to blind
Two review authors screened the titles and abstracts of the results them as to which group they were allocated. Therefore, a risk of
of the searches, independently and in duplicate. We obtained full- performance bias is possible in all of the included studies. How-
text copies of all studies that appeared to meet the inclusion cri- ever, it should be possible for outcome assessors to be blinded if
teria, and of all those that were unclear due to insufficient infor- measuring casts/models or radiographs or both, if the appliances
mation in the title or abstract, or both. Two review authors as- had been removed. Therefore, we focused on assessing the risk of
sessed the full-text papers independently and in duplicate in or- detection bias.
der to ensure that they met the inclusion criteria. We contacted We completed a ’Risk of bias’ table for each included study. For
study authors for clarification or missing information where nec- each of the above domains, we described what was reported to
essary and possible. We resolved any disagreements by discussion. have happened in the study and this formed the rationale for our
A member of The Cochrane Collaboration translated any non- corresponding judgement of ’low risk’ of bias, ’high risk’ of bias
English language studies. We recorded any studies that did not or ’unclear risk’ of bias for each domain.
meet the inclusion criteria at this stage, along with the reasons, in We categorised overall risk of bias in any included study according
the Characteristics of excluded studies table. to the following.

• Low risk of bias (plausible bias unlikely to seriously alter the 1997; Higgins 2011), provided there were more than 10 studies
results) if all key domains were assessed as at low risk of bias. in a meta-analysis.
• Unclear risk of bias (plausible bias that raises some doubt
about the results) if one or more key domains were assessed as at
Data synthesis
unclear risk of bias.
• High risk of bias (plausible bias that seriously weakens We only carried out a meta-analysis when studies of similar com-
confidence in the results) if one or more key domains were parisons reported the same outcomes. We combined MDs for con-
assessed as at high risk of bias. tinuous outcomes, and RRs for dichotomous outcomes, using a
fixed-effect model when there were fewer than four studies, or a
We have presented the results of our risk of bias assessments graph- random-effects model when there were four or more studies. We
ically. summarised single-study comparisons in additional tables.
Measures of treatment effect Subgroup analysis and investigation of heterogeneity

For dichotomous outcomes (e.g. posterior crossbite corrected or In future updates, if sufficient data are available for each compar-
not), we expressed the estimate of treatment effect as risk ratios ison and outcome, we will conduct subgroup analyses according
(RR) with 95% confidence intervals (CI). For continuous out- to age, gender and the degree of severity of maxillary transversal
comes (e.g. width between the molars), we used the means and deficiency.
standard deviations (SD) reported in the studies to calculate mean
differences (MD) with 95% CIs.
Sensitivity analysis
In future updates, if sufficient data are available for each compar-
Dealing with missing data ison and outcome, we will assess the robustness of the results by
Where possible, we attempted to contact the author(s) of studies to excluding studies at high and unclear risk of bias from the meta-
obtain missing data or for clarification. We performed the analyses analyses.
using only the available data (ignoring missing data); however, we
intended to use methods for estimating missing SDs as described
Presentation of main results
in Section 7.7.3 of the Cochrane Handbook for Systematic Reviews
of Interventions (Higgins 2011), if appropriate. We did not use any We produced ’Summary of findings’ tables following GRADE
further statistical methods or carry out any further imputation to methods (GRADE 2004), and using GRADEPro software. We
account for missing data. assessed the quality of the body of evidence by considering the
overall risk of bias of the included studies, the directness of the
evidence, the inconsistency of the results, the precision of the esti-
Assessment of heterogeneity mates and the risk of publication bias. We categorised the quality
Where meta-analyses were performed, we assessed heterogeneity of the body of evidence of each of the main outcomes for each
by visual inspection of the forest plots. If there was a lack of overlap comparison as high, moderate, low or very low.
of the CIs, we considered heterogeneity to be present. We assessed
heterogeneity statistically by means of a Chi2 test, where a P value <
0.1 indicated statistically significant heterogeneity. We quantified
heterogeneity using the I2 statistic. An approximate guide to the RESULTS
interpretation of the I2 statistic given in the Cochrane Handbook
for Systematic Reviews of Interventions is: 0% to 40% might not be
important; 30% to 60% may represent moderate heterogeneity;
50% to 90% may represent substantial heterogeneity and 75% to Description of studies
100% may represent considerable heterogeneity (Higgins 2011).
Results of the search
Assessment of reporting biases The electronic searches retrieved 779 references to studies. After
We have already described the assessment of within-study report- removing duplicates, this was reduced to 515. We obtained two
ing bias in the section Assessment of risk of bias in included studies. additional reports through other sources. After examination of
In order to assess reporting biases that can occur when the publish- the titles and abstracts of these references, we discarded all but
ing (or not publishing) of research findings is related to the results 33 with no further assessment. We obtained full-text copies of
(e.g. a study with a non-significant result may not be published), these potentially relevant studies and we excluded 16 of them at
we would have created a funnel plot to check for asymmetry (Egger this stage (17 references). However, we did not record 14 (15

references) of these in the table of excluded studies, as they were
clearly not eligible upon examining the full text. We linked two of
the remaining 16 articles together under a single study reference.
Therefore, 15 studies met the inclusion criteria for this review.
This process is presented as a flow chart in Figure 1.

Figure 1. Study flow diagram.

Martina 2012; Oliveira 2004; Ramoglu 2010), one study en-
Included studies
rolled children in either the late deciduous or early mixed denti-
tion (Lippold 2013), and seven studies did not state the stage of
dental development of the children at study entry (Asanza 1997;
Characteristics of the trial design and setting
Kilic 2008; Lagravere 2010; McNally 2005; Mossaz-Joelson 1989;
Fifteen studies met the inclusion criteria and were included in this
Oshagh 2012; Thilander 1984).
review (see Characteristics of included studies tables).
The age range of participants was from five to 16 years old with
All studies, by necessity, were of parallel design. Nine studies
variations between studies, but almost homogeneous within indi-
(Asanza 1997, USA; Garib 2005, Brazil; Kilic 2008, Turkey;
vidual studies.
Lagravere 2010, Canada; Lippold 2013, Germany; Martina 2012,
Italy; Mossaz-Joelson 1989, Switzerland; Oshagh 2012, Iran;
Ramoglu 2010, Turkey) were carried out in university orthodon-
tics departments. One of these studies stated that the clinicians Characteristics of the interventions and comparisons
were two specialist orthodontists (Lippold 2013), but in the re- Six of the included studies evaluated two different types of fixed
maining eight studies it was unclear who the clinicians undertak- appliances for rapid palatal expansion (Asanza 1997; Garib 2005;
ing the treatment were and what experience or qualifications they Kilic 2008; Lagravere 2010; Lamparski 2003; Oliveira 2004), one
had. There were three multicentre studies: one was carried out in study compared two different fixed appliances for slow palatal
a general hospital and a university dental hospital in the UK by expansion (Mossaz-Joelson 1989), and two studies compared the
experienced orthodontists (McNally 2005); one was carried out effects of fixed appliances used for differing rates of expansion
in two public dental health service clinics and one university or- (Martina 2012; Ramoglu 2010).
thodontic department in Sweden by experienced general practi- Two studies compared a fixed appliance with a removable appli-
tioners under the supervision of specialist orthodontists (Petrén ance for slow expansion (Godoy 2011; Petrén 2008), and the re-
2008); and one study was carried out in three university orthodon- maining studies evaluated other comparisons that were more diffi-
tic clinics and one private practice in Brazil, but it was unclear cult to classify (see below) (Lippold 2013; McNally 2005; Oshagh
who the clinicians undertaking the treatment were and what expe- 2012; Thilander 1984).
rience or qualifications they had (Oliveira 2004). One study took See Appendix 1 for a description of appliances.
place in a basic dental unit in Brazil, conducted by the local uni-
versity, with treatment carried out by one specialist orthodontist
with over 10 years of experience (Godoy 2011). Participants in
another study were treated in a private orthodontic practice in the 1. Fixed appliance with mid-palatal expansion
USA by a board-certified orthodontist with 27 years of experience
(Lamparski 2003). The remaining study was carried out in Swe-
den by the public dental health service, but the experience of the
orthodontist was not reported (Thilander 1984).
Rapid expansion
• Banded Hyrax (tooth borne) versus bonded Hyrax (tooth/
Characteristics of the participants tissue borne) (Asanza 1997; Kilic 2008).
Seven studies enrolled participants with either a unilateral or bilat- • Tooth-tissue borne Haas versus tooth borne Hyrax (Garib
eral crossbite malocclusion (Garib 2005; Martina 2012; McNally 2005; Oliveira 2004).
2005; Mossaz-Joelson 1989; Oliveira 2004; Petrén 2008; Ramoglu • Hyrax tooth-borne expander versus bone-anchored
2010), two studies included only participants with a unilateral expander (Lagravere 2010).
crossbite (Godoy 2011; Lippold 2013), two studies included only • Four-point banded (Hyrax) versus two-point banded
participants with a bilateral crossbite (Kilic 2008; Oshagh 2012), (Hyrax) (Lamparski 2003).
while the remaining four studies did not specify the type of cross-
bite that participants presented with at study entry (Asanza 1997;
Lagravere 2010; Lamparski 2003; Thilander 1984).
One study enrolled only children in the permanent dentition
Slow expansion
(Garib 2005), two studies enrolled only children in the mixed
dentition (Godoy 2011; Petrén 2008), four studies enrolled chil- • Bonded Minne versus banded Minne appliances
dren in either the mixed or permanent dentition (Lamparski 2003; (Mossaz-Joelson 1989).

Different rates of expansion Characteristics of the outcomes
• Slow versus rapid expansion (two-band palatal expanders) The primary outcome of this review, correction of the posterior
(Martina 2012). crossbite, was reported by three studies (Godoy 2011; Petrén 2008;
• Semi-rapid versus rapid expansion (splint type tooth- and Thilander 1984). In 11 studies, the correction of crossbite is taken
tissue-borne modified bonded appliances) (Ramoglu 2010). for granted because it was the end point of the treatment and the
point at which activation of the appliances ceased (Asanza 1997;
Garib 2005; Kilic 2008; Lagravere 2010; Lamparski 2003; Lippold
2013; Martina 2012; McNally 2005; Oliveira 2004; Oshagh 2012;
2. Fixed versus removable Ramoglu 2010). In the remaining study, no data were provided
on whether the expansion obtained by these appliances did correct
the participants’ crossbite (Mossaz-Joelson 1989).
All included studies, with the exception of Thilander 1984, re-
ported expansion of the upper jaw/teeth measured as changes
Slow expansion in the width between the molars or canines (or both). Two
• Quad-helix versus expansion plate (Godoy 2011; Petrén studies assessed stability of crossbite correction (Godoy 2011;
2008). Mossaz-Joelson 1989).
None of the included studies reported any of the other outcomes
of this review.
3. Other comparisons
Excluded studies
• Early treatment with fixed bonded Hyrax appliance
We excluded two studies from this review. One of these studies
followed by U-bow activator therapy versus no treatment
was excluded because it included a subset of participants from one
(Lippold 2013).
of the included studies (Petrén 2008), plus other participants and
• Grinding - occlusal grinding in the primary dentition (aged
matched controls (Petrén 2011). The other study was excluded
five years old) with/without an upper removable expansion
after attempting to contact the authors because the participants
appliance in the mixed dentition versus no treatment (Thilander
were only described as having maxillary deficiency, rather than
1984).
crossbite (Weissheimer 2011).
Risk of bias in included studies
Slow expansion We have based our assessment of risk of bias on the reports of
the included studies because we could not access copies of the
• Quad-helix plus multi-bracket versus expansion arch plus study protocols. Where the reports were unclear on aspects of the
multi-bracket (McNally 2005). methodology, we attempted to contact the study authors to obtain
• Conventional mid-line expansion screw versus spring- clarification or missing information. We present the results of our
loaded expansion screw (Oshagh 2012). risk of bias assessment graphically in Figure 2.

Figure 2. Risk of bias summary: review authors’ judgements about each risk of bias item for each included
study.

Allocation
Three studies clearly stated that the measurement of outcomes was
blinded, so we judged these studies to be at low risk of detection
bias (Godoy 2011; Martina 2012; Petrén 2008).
Sequence generation
The remaining 12 studies did not mention blinding, even though
Seven studies described adequate methods of sequence generation it was feasible that it could have occurred, and, therefore, we judged
and we judged them to be at low risk of bias for this domain: three these studies to be at unclear risk of bias for this domain.
used a table of random numbers (Lagravere 2010; Oliveira 2004;
Oshagh 2012); two used block randomisation (Lippold 2013;
Martina 2012); one used a method of drawing lots (Godoy 2011); Incomplete outcome data
and the remaining study used a similar method involving opaque
We judged eight studies to be at low risk of attrition bias as they
sealed envelopes (Petrén 2008).
either clearly described drop-outs (which were for similar reasons
One study used random number tables to allocate the first half of
and in similar numbers per group), or the numbers of participants
the participants and then allocated the remaining half to receive
stated in the analyses were the same as those randomised, or an
the alternative treatment to those in the initial allocation (McNally
intention-to-treat analysis included all randomised participants
2005). Therefore, only half the participants were truly randomly
(Asanza 1997; Godoy 2011; Kilic 2008; Lippold 2013; McNally
allocated and we judged this study to be at high risk of bias for
2005; Oliveira 2004; Petrén 2008; Ramoglu 2010).
this domain.
One study clearly described the numbers and reasons for drop-
The remaining seven studies stated only that participants were
out but the high attrition rate (48% per group) meant that, if the
randomly allocated and we were unable to obtain further details
missing participants had higher mean scores in one group than
from the authors, so we judged these studies to be at unclear risk
the other, as the attrition rate increased, so would over/understate-
of bias for this domain (Asanza 1997; Garib 2005; Kilic 2008;
ment of the mean difference (Martina 2012). In another study, the
Lamparski 2003; Mossaz-Joelson 1989; Ramoglu 2010; Thilander
attrition rate was very different between the treated group (3%)
1984).
and the untreated group (18%) (Thilander 1984). Therefore, we
judged these two studies to be at high risk of attrition bias.
Allocation concealment The remaining five studies did not report whether or not there
were any drop-outs and it was unclear how many participants were
Four studies described adequate methods of allocation conceal-
included in the outcome assessment. Therefore, we judged these
ment and we judged them to be at low risk of bias for this domain
studies to be at unclear risk of attrition bias (Garib 2005; Lagravere
(Godoy 2011; Martina 2012; Oliveira 2004; Petrén 2008).
2010; Lamparski 2003; Mossaz-Joelson 1989; Oshagh 2012).
The method of sequence generation carried out in one study, as
described above, would allow for the prediction of the allocation
of half of the participants, and therefore we judged this study to
Selective reporting
be at high risk of bias for this domain (McNally 2005).
The remaining 10 studies did not mention any method of alloca- Eleven studies reported all outcome measures described in the cor-
tion concealment, so we judged these studies to be at unclear risk responding methods sections in full and we assessed them as being
of bias for this domain (Asanza 1997; Garib 2005; Kilic 2008; at low risk of reporting bias (Garib 2005; Godoy 2011; Kilic 2008;
Lagravere 2010; Lamparski 2003; Lippold 2013; Mossaz-Joelson Lagravere 2010; Martina 2012; McNally 2005; Mossaz-Joelson
1989; Oshagh 2012; Ramoglu 2010; Thilander 1984). 1989; Oliveira 2004; Petrén 2008; Ramoglu 2010; Thilander
1984).
We judged the remaining four studies to be at high risk of reporting
Blinding of outcome assessment (detection bias) bias for the following reasons: no measure of variance reported
We did not consider the blinding of participants and personnel (Asanza 1997; Lippold 2013); one outcome was not reported by
(performance bias) as the interventions being compared in all stud- group and the other was reported without a measure of variance
ies were different and it would not have been possible to blind (Lamparski 2003); and the results were so inadequately reported
them as to which group they were allocated. Therefore, a risk of that we were unable to use any data (Oshagh 2012).
performance bias is possible in all of the included studies.
However, it would have been possible for an independent blinded
person to perform the clinical, model and radiographic assess- Other potential sources of bias
ments. Therefore, we have focused on whether the included stud- In one study, there were imbalances between the treatment groups
ies minimised the possible effects of detection bias. in terms of numbers of participants and gender, possibly indicating

a problem with the randomisation (Oshagh 2012). We assessed completion of the expansion phase, but the difference was not
this study as being at high risk of bias for this domain. We did not statistically significant (Analysis 1.1). As the sample size was so
identify any other potential sources of bias in any of the remaining small, and there was considerable heterogeneity (I2 = 94%), this
14 studies and, therefore, we judged them to be at low risk of bias result should be interpreted with caution.
for this domain. No other outcomes of the review were assessed in this comparison.
Overall risk of bias

Hyrax tooth-borne expander versus bone-anchored expander
• Two studies were at low risk of bias (Godoy 2011; Petrén
2008). One study at unclear risk of bias, analysing no more than 41
• Seven studies were at high risk of bias (Asanza 1997; participants (unclear attrition), assessed molar expansion at six and
Lamparski 2003; Lippold 2013; Martina 2012; McNally 2005; 12 months after completion of the expansion phase (Lagravere
Oshagh 2012; Thilander 1984). 2010). There were no statistically significant differences at either
• Six studies were at unclear risk of bias (Garib 2005; Kilic time point (Additional Table 1).
2008; Lagravere 2010; Mossaz-Joelson 1989; Oliveira 2004; No other outcomes of the review were assessed in this comparison.
Ramoglu 2010).
Effects of interventions Four-point banded (Hyrax) versus two-point banded (Hyrax)

See: Summary of findings for the main comparison Fixed One study at high risk of bias, analysing no more than 30 partic-
appliances compared with other fixed appliances for treating ipants (unclear attrition), assessed molar and canine expansion at
posterior crossbites; Summary of findings 2 Fixed appliances three months after completion of the expansion phase (Lamparski
compared with removable appliances for treating posterior 2003). There were no statistically significant differences for either
crossbites; Summary of findings 3 Other comparisons for treating outcome (Additional Table 1).
posterior crossbites No other outcomes of the review were assessed in this comparison.
See Appendix 1 for a description of appliances.
1. Fixed appliance with mid-palatal expansion Slow expansion
Rapid expansion
Bonded Minne versus banded Minne appliances
One study at unclear risk of bias, analysing no more than 10 par-
Banded Hyrax (tooth borne) versus bonded Hyrax ticipants (unclear attrition), assessed molar and canine expansion
(tooth/tissue borne) seven to 15 weeks after the start of treatment, and stability (relapse
We included two studies, one at unclear and one at high risk of bias, of molar and canine expansion) 24 weeks after completion of the
analysing 53 participants, in this comparison (Asanza 1997; Kilic expansion phase (Mossaz-Joelson 1989). There were no statisti-
2008). Due to problems with reporting of the data in one study cally significant differences for any outcome (Additional Table 1).
(Asanza 1997), we were unable to combine the results in a meta- No other outcomes of the review were assessed in this comparison.
analysis. Both studies assessed molar expansion and reported no
statistically significant difference (Table 1). One study measured
the outcomes three months after completion of the expansion
Different rates of expansion
phase (Asanza 1997), while the other study measured it one week
after completion of the expansion phase (Kilic 2008).
No other outcomes of the review were assessed in this comparison.
Slow versus rapid expansion (two-band palatal expanders)
Tooth-tissue borne Haas versus tooth borne Hyrax One study at high risk of bias, analysing 26 participants, assessed
Two studies, both at unclear risk of bias, analysing 27 participants, molar expansion seven months after the start of treatment (Martina
assessed molar expansion (Garib 2005; Oliveira 2004). The pooled 2012). There was no statistically significant difference (Additional
mean difference (MD) was 0.7 mm (95% confidence interval (CI) Table 1).
-0.25 to 1.66) in favour of Haas appliances at three months after No other outcomes of the review were assessed in this comparison.

Semi-rapid versus rapid expansion (splint type tooth- and No other outcomes of the review were assessed in this comparison.
tissue-borne modified bonded appliances) One study also compared both appliances in this comparison
One study at unclear risk of bias, analysing 35 participants, as- against composite onlays (Petrén 2008). There were statistically
sessed molar and canine expansion (Ramoglu 2010). There were significant differences for the outcomes crossbite correction, mo-
no statistically significant differences for either outcome (Addi- lar expansion and canine expansion in favour of the fixed and re-
tional Table 1). movable appliances (Additional Table 2).
No other outcomes of the review were assessed in this comparison.
3. Other comparisons
2. Fixed versus removable
Early treatment with fixed bonded Hyrax appliance followed
by U-bow activator therapy versus no treatment
Slow expansion
One study at high risk of bias, analysing 66 participants, assessed
molar and canine expansion 12 months after the start of treatment
(Lippold 2013). Statistically significant differences were reported
Quad-helix versus expansion plate for both outcomes in favour of treatment (Additional Table 3).
We included two studies, both at low risk of bias, analysing 96 No other outcomes of the review were assessed in this comparison.
participants, in this comparison (Godoy 2011; Petrén 2008). The
two studies included children in the early mixed dentition (aged
eight to 10 years). For the outcome crossbite correction, the pooled Grinding - occlusal grinding in the primary dentition (at age
risk ratio (RR) suggests that fixed quad-helix appliances may be five years) with/without subsequent upper removable
20% more likely to correct crossbites than removable expansion expansion appliance in the mixed dentition versus no
plates (RR 1.20; 95% CI 1.04 to 1.37) (Analysis 2.1). The 95% treatment
CI indicates that the true effect estimate lies somewhere between One study at high risk of bias, analysing 61 participants, assessed
a 4% and 37% better correction rate for quad-helix appliances. crossbite correction after one, two, five and eight years (Thilander
However, the sample size was small and there was substantial het- 1984). A statistically significant difference was reported in favour
erogeneity (I2 = 68%), so this result should be interpreted with of treatment (Additional Table 3).
caution, and the results may not be the same in the permanent
dentition.
For the outcome molar expansion, the pooled MD suggests that Slow expansion
quad-helix appliances can achieve 1.15 mm more expansion than
expansion plates (MD 1.15 mm; 95% CI 0.40 to 1.90) (Analysis
2.2). The 95% CI indicates that the true effect estimate lies some- Quad-helix plus multi-bracket versus expansion arch plus
where between 0.4 mm and 1.9 mm in favour of quad-helix ap- multi-bracket
pliances. While there was no heterogeneity (I2 = 0%), the result One study at high risk of bias assessed molar (analysing 55 par-
should be interpreted with caution as the sample size was small ticipants) and canine (analysing 52 participants - lower number
and the follow-up times differed between the studies. due to unerupted canines) expansion 12 weeks after the start of
For the outcome canine expansion, the pooled MD was 0.19 mm treatment (McNally 2005). There were no statistically significant
(95% CI -0.47 to 0.85) in favour of quad-helix appliances, but differences for either outcome (Additional Table 3).
the difference was not statistically significant (Analysis 2.3). Due
to considerable heterogeneity (I2 = 91%), small sample size and
Conventional mid-line expansion screw versus spring-loaded
different follow-up times, the result should be interpreted with
expansion screw
caution.
One study also assessed the stability of crossbite correction (re- One study at high risk of bias assessed molar and canine expansion
lapse 12 months after correction) (Godoy 2011). There was no but we were unable to extract any data from the study report
statistically significant difference (Additional Table 2). (Oshagh 2012).

Orthodontic treatment for posterior crossbites (Review) A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]
Fixed appliances compared with removable appliances for treating posterior crossbites
Settings: Public Dental Health Service and university orthodontic/ dental clinics
Intervention: Fixed appliance
Comparison: Rem ovable appliance
Outcomes Illustrative comparative risks* (95% CI) Relative effect No of participants Quality of the evidence Comments
Removable - slow Fixed - slow expansion

expansion (expansion (quad- helix)
plate)
Crossbite correction 833 per 1000 1000 per 1000 RR 1.2 (1.04 to 1.37) 96 ⊕⊕ 2 studies at low risk of
(Follow-up af ter reten- (867 to 1000) (2) low bias, but with serious in-
tion period, theref ore, it consistency (I 2 = 68%)
was variable) and im precision due to
low sam ple size
M olar expansion The m ean expansion The m ean expansion N/ A 96 ⊕⊕⊕ 2 studies at low risk of
(m m ) ranged across the in the f ixed appliance (2) moderate bias, but with im preci-
(Follow-up af ter reten- rem ovable appliance group was sion due to low sam ple
tion period, theref ore, it groups f rom 3.09 to 3. 1.15 mm higher size
was variable) 5 mm (0.4 to 1.9 higher)
Canine expansion The m ean expansion The m ean expansion N/ A 96 ⊕⊕ 2 studies at low risk of
(m m ) ranged across the in the f ixed appliance (2) low bias, but with serious in-
(Follow-up af ter reten- rem ovable appliance group was consistency (I 2 = 91%)
tion period, theref ore it groups f rom 1.43 to 2. 0.19 mm higher and im precision due to
was variable) 7 mm (0.47 lower to 0.85 low sam ple size
higher)
18
N/ A N/ A N/ A N/ A N/ A N/ A 1 of the 2 studies in this

com parison also m ea-
sured stability of cross-
bite correction (relapse
12 m onths af ter cor-
rection). No statisti-
cally signif icant dif f er-
ence was f ound (Addi-
tional Table 2)
The other study also
com pared the f ixed and
rem ovable appliances
to com posite onlays
f or crossbite correc-
tion, m olar expansion
and canine expansion.
All results were sta-
tistically signif icant in
f avour of f ixed and
rem ovable appliances
(Additional Table 2)
The quality of the evi-
dence (GRADE) f or all
com parisons and out-
com es in Additional
Table 2 is ⊕ very
low
* The basis f or the assumed risk is the rem ovable group event rate. The corresponding risk (and its 95% conf idence interval) is based on the assum ed risk in the com parison
group and the relative effect of the intervention (and its 95% CI).
CI: conf idence interval; N/ A: not applicable; RR: risk ratio.

19
Other comparisons for treating posterior crossbites
Settings: Public Dental Health Service and university/ hospital orthodontic/ dental clinics
Outcomes Illustrative comparative risks (95% CI) Relative effect No of participants Quality of the evidence Comments
Group A Group B
N/ A N/ A N/ A N/ A N/ A N/ A The com parisons were

all single studies (Ad-
ditional Table 3). The
quality of the evidence
(GRADE) f or all com -
parisons and outcom es
in Additional Table 3 is
⊕ very low (all at
high risk of bias with
im precision due to low
sam ple sizes)
• 1 study com pared
a rem ovable appliance
with spring-loaded
screw against a
conventional screw but
the results were
inadequately reported
• 1 study com pared
quad-helix plus m ulti-
bracket against
expansion arch plus
m ulti-bracket f or m olar/
20
canine expansion with

no statistically
signif icant results
• The f inal 2 studies
showed statistically
signif icant results
against no treatm ent
f or f ixed bonded Hyrax
appliance f ollowed by
U-bow activator (m olar/
canine expansion), and
f or grinding or grinding
plus expansion plate
(crossbite correction)

CI: conf idence interval; N/ A: not applicable.
21
DISCUSSION and expansion arch plus multi-bracket. Finally, there was no evi-
dence regarding the comparison of removable appliances with ei-
ther spring-loaded or conventional screws.
Summary of main results

The objective of this review was to evaluate the effects of different Overall completeness and applicability of
orthodontic treatments for correcting posterior crossbites. We in- evidence
cluded 15 randomised controlled trials (RCTs) that met the inclu-
sion criteria for this review. We assessed the body of evidence for The studies identified in this review are insufficient to address the
each comparison and outcome using GRADE, which takes into question of what is the best treatment for posterior crossbites. Al-
account the risk of bias of the included studies, the directness of though we were able to include 15 studies, there were many differ-
the evidence, the inconsistency of the results, the precision of the ent comparisons of appliances or other treatments and, therefore,
estimates and the risk of publication bias (GRADE 2004). The there was minimal pooling of data. This is unfortunate as one of
body of evidence for all comparisons and outcomes in this review the advantages of a systematic review is the ability to pool multiple
was very small. studies in order to increase the power to detect a difference con-
fidently, and thus to inform clinical practice better. Furthermore,
there were very limited data available for the outcome stability
Fixed appliance with mid-palatal expansion of crossbite correction, and no studies assessed signs and symp-
toms of temporomandibular joint dysfunction/respiratory disease
The body of evidence for all comparisons and outcomes in this
or quality of life. However, this was perhaps because all the stud-
group was rated as very low quality (Summary of findings for the
ies included only children. This highlights another shortcoming
main comparison). In all cases, the evidence was insufficient to
in the overall completeness of the evidence, which is that there is
determine a difference between any one type of appliance and
no evidence on orthodontic treatments for adults with posterior
another for any outcome.
crossbites. The lack of evidence regarding adults in this review is
probably because the majority of studies on adults with a poste-
Fixed versus removable appliance rior crossbite compare orthodontic treatments with orthodontic-
surgical interventions, but we excluded surgical treatments from
We found low-quality evidence to suggest that crossbite correction
this review.
is more successful when using a fixed quad-helix appliance than
when using a removable expansion plate for slow maxillary expan-
sion (Summary of findings 2). For the same comparison, mod-
erate-quality evidence suggested that molar expansion is greater Quality of the evidence
for fixed quad-helix appliances, and further low-quality evidence The body of evidence identified does not allow for any robust
was insufficient to determine a difference in canine expansion. It conclusions to be made regarding the objective of this review. The
should be noted that the two studies included children in the early sample sizes were consistently small (as low as eight participants),
mixed dentition (aged eight to 10 years) and the results may not and this fact, combined with the lack of pooling of data in meta-
be the same for people in the permanent dentition. There was analyses, meant that the power to detect statistically and clini-
also very low quality evidence that was insufficient to determine a cally significant differences, with confidence, was limited. Another
difference in stability of crossbite correction between fixed quad- problem was inconsistency as three of the four meta-analyses dis-
helix appliances and removable expansion plates. Further very low played statistically significant heterogeneity. While there were two
quality evidence suggested that fixed quad-helix appliances and low risk of bias studies that we were able to pool, the results can-
removable expansion plates are superior to composite onlays for not be relied upon due to the problems already mentioned. The
crossbite correction, molar expansion and canine expansion. remaining studies were either at high risk of bias (seven studies) or
the risk of bias was unclear (six studies). Most of the comparisons
included in the review were assessed by very small single studies,
Others interventions
which do not allow any conclusions to be drawn as to the effects
We found very low quality evidence to suggest that both tooth of the interventions studied.
grinding, with or without an expansion plate and fixed bonded
Hyrax followed by U-bow activator are superior to no treatment
for the outcomes crossbite correction and molar/canine correc-
tion respectively (Summary of findings 3). We also found very low
Potential biases in the review process
quality evidence that was insufficient to determine a difference in We made every attempt to limit bias in the review process by en-
molar or canine expansion between quad-helix plus multi-bracket suring a comprehensive search for potentially eligible studies. The

authors’ independent assessments of study eligibility and subse- Implications for research
quent data extraction and risk of bias assessment minimised the
More randomised controlled trials are required to address the ques-
potential for additional bias beyond that detailed in the ’Risk of
tion of what is the best treatment for posterior crossbites in chil-
bias’ tables in the Characteristics of included studies section. The
dren, adolescents and adults. The studies should be large enough
incompleteness of some of the reports and our inability to obtain
to detect a difference, if one exists, and should assess appropriate
clarification of certain trial details or to resolve ambiguities in the
outcomes. We believe that ’correction of crossbite’ needs to be the
reports may have contributed to some bias in their assessment,
primary outcome for all studies addressing this research question.
but where these conditions applied this was explicitly stated in the
In studies where all the crossbites were corrected (as with most
text of our review. Finally, we attempted to minimise bias further
studies in this review), ’time to correction’ and ’pain’ would be of
by changing our inclusion criteria to only include RCTs which,
increased importance as outcomes.
when performed to a high standard, should be less biased than
other study designs. High-quality work should be carried out to develop core outcome
sets for orthodontics/areas of orthodontics. Such work should be
carried out in association with the COMET (Core Outcome Mea-
Agreements and disagreements with other sures in Effectiveness Trials) Initiative (www.comet-initiative.org),
studies or reviews using robust methodology suggested by those working with the
COMET Initiative so far (Williamson 2012). These core outcome
Another systematic review of maxillary expansion arches for treat-
sets should subsequently be the minimum set of outcomes that
ing crossbites included studies published from 1999 to 2011
are measured in all clinical trials and systematic reviews (including
(Zuccati 2013). The authors of the review assessed the studies us-
this Cochrane review).
ing the Consolidated Standards of Reporting Trials (CONSORT)
statement. In similarity with our review, they argued that there Future randomised controlled trials must be well designed, well
was substantial evidence of bias, which reduced the quality of the conducted and adequately delivered with subsequent reporting,
evidence; the randomisation process was poorly described and loss including high-quality descriptions of all aspects of method-
to follow-up was unclear in many of the included studies. Their ology. Reporting should conform to the Consolidated Stan-
review also called for future trials to be carefully planned and re- dards of Reporting Trials (CONSORT) statement (www.consort-
ported using universal guidelines. statement.org), which will enable appraisal and interpretation of
results, and accurate judgements to be made about the risk of bias
and the overall quality of the evidence. Although it is uncertain
whether reported quality mirrors actual study conduct, it is note-
AUTHORS’ CONCLUSIONS worthy that studies with unclear methodology have been shown
to produce biased estimates of treatment effects (Schulz 1995).
Implications for practice
There is a very small body of low- to moderate-quality evidence
to suggest that fixed quad-helix appliances may be more successful
than removable expansion plates at correcting posterior crossbites
and expanding the inter-molar width in children with early mixed ACKNOWLEDGEMENTS
dentition (aged eight to 10 years). The remaining evidence that
we found was of very low quality and was insufficient to allow the The review authors would like to thank the Cochrane Oral Health
conclusion that any one intervention is better than another for Group and referees for their help in conducting this systematic
any of the outcomes in this review. review.

REFERENCES
References to studies included in this review Oliveira 2004 {published data only}
Ghandehari B. A Comparison of the Skeletal Effects of
Asanza 1997 {published data only} Toothborne and Tissue-Borne Rapid Palatal Expanders [thesis].
Asanza S. Comparison of Hyrax and bonded expansion Chicago: University of Illinois at Chicago, 2001.
∗
appliances. The Angle Orthodontist 1997;67(1):15–22. Oliveira NL, Da Silveira AC, Kusnoto B, Viana G. Three-
dimensional assessment of morphologic changes of the
Garib 2005 {published data only} maxilla: a comparison of 2 kinds of palatal expanders.
Garib DG, Henriques JF, Janson G, Freitas MR, Coelho American Journal of Orthodontics and Dentofacial Orthopedics
RA. Rapid maxillary expansion - tooth tissue-borne versus 2004;126(3):354–62.
tooth-borne expanders: a computed tomography evaluation
Oshagh 2012 {published data only}
of dentoskeletal effects. The Angle Orthodontist 2005;75(4):
Oshagh M, Momeni Danaei Sh, Hematiyan MR, Hajian
548–57.
Kh, Shokoohi Z. Comparison of dental arch changes and
Godoy 2011 {published and unpublished data} patients’ discomforts between newly designed maxillary
Godoy F, Godoy-Bezerra J, Rosenblatt A. Treatment of expansion screw and slow expansion procedures. Journal of
posterior crossbite comparing 2 appliances: a community- Dentistry, Shiraz University of Medical Sciences 2012;13(3):
based trial. American Journal of Orthodontics and Dentofacial 110–9.
Orthopedics 2011;139:e45–52. Petrén 2008 {published data only}
Kilic 2008 {published data only} Petrén S, Bondemark L. Correction of unilateral posterior
Kilic N, Kiki A, Oktay H. A comparison of dentoalveolar crossbite in the mixed dentition: a randomized controlled
inclination treated by two palatal expanders. European trial. American Journal of Orthodontics and Dentofacial
Journal of Orthodontics 2008;30(1):67–72. Orthopedics 2008;133:790.e7–13.
Ramoglu 2010 {published data only}
Lagravere 2010 {published and unpublished data}
Ramoglu SI, Sari Z. Maxillary expansion in the mixed
Lagravere MO, Carey J, Heo G, Toogood RW, Major PW.
dentition: rapid or semi-rapid?. European Journal of
Transverse, vertical, and anteroposterior changes from bone-
Orthodontics 2010;32:11–8.
anchored maxillary expansion vs traditional rapid maxillary
expansion: a randomized clinical trial. American Journal of Thilander 1984 {published data only}
Orthodontics and Dentofacial Orthopedics 2010;137(3):304. Thilander B, Wahlund S, Lennartsson B. The effect of early
interceptive treatment in children with posterior cross-bite.
Lamparski 2003 {published data only} European Journal of Orthodontics 1984;6:25–34.
Lamparski DG Jr, Rinchuse DJ, Close JM, Sciote JJ.
Comparison of skeletal and dental changes between 2-point References to studies excluded from this review
and 4-point rapid palatal expanders. American Journal
of Orthodontics and Dentofacial Orthopedics 2003;123(3): Petrén 2011 {published and unpublished data}
321–8. Petrén S, Bjerklin K, Bondemark L. Stability of unilateral
posterior crossbite correction in the mixed dentition: a
Lippold 2013 {published data only} randomised clinical trial with a 3-year follow-up. American
Lippold C, Stamm T, Meyer U, Végh A, Moiseenko Journal of Orthodontics and Dentofacial Orthopedics 2011;
T, Danesh G. Early treatment of posterior crossbite - a 139:e73–81.
randomised clinical trial. Trials 2013;14:20.
Weissheimer 2011 {published data only}
Martina 2012 {published data only} Weissheimer A, de Menezes LM, Mezomo M, Dias DM, de
Martina R, Cioffi I, Farella M, Leone P, Manzo P, Matarese Lima EM, Rizzatto SM. Immediate effects of rapid maxillary
G, et al. Transverse changes determined by rapid and slow expansion with Haas-type and hyrax-type expanders: a
maxillary expansion. A low-dose CT-based randomised randomized clinical trial. American Journal of Orthodontics
controlled trial. Orthodontics & Craniofacial Research 2012; and Dentofacial Orthopedics 2011;140(3):366–76.
15:159–68.
Additional references
McNally 2005 {published and unpublished data}
McNally MR, Spary DJ, Rock WP. Randomized controlled Bresolin 1983
trial comparing the quadhelix and the expansion arch for Bresolin D, Shapiro PA, Shapiro GG, Chapko MK, Dassel
the correction of crossbite. Journal of Orthodontics 2005;32 S. Mouth breathing in allergic children: its relationship to
(1):29–35. dentofacial development. American Journal of Orthodontics
Mossaz-Joelson 1989 {published and unpublished data} 1983;83:334–40.
Mossaz-Joelson K, Mossaz C. Slow maxillary expansion: Cheng 1988
a comparison between bonded and banded appliances. Cheng M-C, Enlow DH, Papsidero M, Broardbent BH,
European Journal of Orthodontics 1989;11:67–76. Oyen O, Sabat, M. Developmental effects of impaired
breathing in the face of the growing child. The Angle Malandris 2004
Orthodontist 1988;58:309–20. Malandris M, Mahoney EK. Aetiology, diagnosis and
treatment of posterior cross-bites in the primary dentition.
Egermark 1990
Egermark-Eriksson I, Carlsson GE, Magnusson T, International Journal of Paediatric Dentistry 2004; Vol. 14,
issue 3:155–66.
Thilander B. A longitudinal study on malocclusion in
relation to signs and symptoms of cranio-mandibular McNamara 1997
disorders in children and adolescents. European Journal of McNamara JA Jr, Turp JC. Orthodontic treatment and
Orthodontics 1990;12:399–407. temporomandibular disorders: is there a relationship?.
Journal of Orofacial Orthopedics 1997;58:74–89.
Egger 1997
Egger M, Davey Smith G, Schneider M, Minder C. Bias Modeer 1982
in meta-analysis detected by a simple, graphical test. BMJ Modeer T, Odenrick L, Lindner A. Sucking habits and their
1997;315(7109):629–34. relationship to posterior crossbites in 4-year-old children.
Scandinavian Journal of Dental Research 1982;90:323–8.
Gesch 2004
Gesch D, Bernhardt O, Kirbschus A. Association Ninou 1994
of malocclusion and functional occlusion with Ninou S, Stephens C. The early treatment of posterior
temporomandibular disorders (TMD) in adults: a crossbites: a review of continuing controversies. Dental
systematic review of population-based studies. Quintessence Update 1994;21:420–6.
International 2004;35(3):211–21. O’Bryn 1995
GRADE 2004 O’Bryn BL, Sadowsky C, Schneider B, BeGole EA.
GRADE Working Group. Grading quality of evidence and An evaluation of mandibular asymmetry in adults
strength of recommendations. BMJ 2004;328(7454):1490. with unilateral posterior crossbite. American Journal
of Orthodontics and Dentofacial Orthopedics 1995;107:
Heikinheimo 1987 394–400.
Heikinheimo K, Salmi K, Myllarniemi S. Long term
Ogaard 1994
evaluation of orthodontic diagnosis made at the ages of
Ogaard B, Larsson E, Lindsten R. The effects of sucking
7 and 10 years. European Journal of Orthodontics 1987;9:
habits, cohort, sex, intercanine arch widths, and breast
151–9.
or bottle feeding on posterior crossbite in Norwegian
Higgins 2011 and Swedish 3-year-old children. American Journal of
Higgins JPT, Green S (editors). Cochrane Handbook Orthodontics and Dentofacial Orthopedics 1994;106:161–6.
for Systematic Reviews of Interventions Version 5.1.0
[updated March 2011]. The Cochrane Collaboration, Pullinger 1993
2011. Available from www.cochrane-handbook.org. Pullinger AG, Seligman DA, Gornbein JA. A multiple
logistic regression analysis of the risk and relative odds of
Iodice 2013 temperomandibular disorders as a function of common
Iodice G, Danzi G, Cimino R, Paduano S, Michelotti A. occlusal factors. Journal of Dental Research 1993;72:968–79.
Association between posterior crossbite, masticatory muscle
Schulz 1995
pain, and disc displacement: a systematic review. European
Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical
Journal of Orthodontics 2013;35(6):737–44.
evidence of bias. Dimensions of methodological quality
Kennedy 2005 associated with estimates of treatment effects in controlled
Kennedy DB, Osepchook M. Unilateral posterior crossbite trials. JAMA 1995;273(5):408–12.
with mandibular shift: a review. Journal of the Canadian
Subtelny 1980
Dental Association 2005;71(8):569–73.
Subtelny JD. Oral respiration: facial maldevelopment and
Kurol 1992 corrective dentofacial orthopedics. The Angle Orthodontist
Kurol J, Berglund L. Longitudinal and cost-benefit analysis 1980;50:147–64.
of the effect of early treatment of posterior cross-bites in the Thilander 2002
primary dentition. European Journal of Orthodontics 1992; Thilander B, Rubio G, Pena L, de Mayorga C. Prevalence
14:173–9. of temporomandibular dysfunction and its association with
Leighton 1966 malocclusion in children and adolescents: an epidemiologic
Leighton BC. The early development of cross-bites. Dental study related to specified stages of dental development. The
Practitioner 1966;17:145–52. Angle Orthodontist 2002;72(2):146–54.
Lindner 1989 Thilander 2012
Lindner A. Longitudinal study on the effect of early Thilander B, Bjerklin K. Posterior crossbite and
interceptive treatment in 4-year-old children with unilateral temporomandibular disorders (TMDs): need for
cross-bite. Scandinavian Journal of Dental Research 1989; orthodontic treatment?. European Journal of Orthodontics
Vol. 97, issue 5:432–8. 2012;34(6):667–73.

Williamson 2012
Williamson PR, Altman DG, Blazeby JM, Clarke M,
Devane D, Gargon E, et al. Developing core outcome sets
for clinical trials: issues to consider. Trials 2012;13:132.
Zuccati 2013
Zuccati G, Casci S, Doldo T, Clauser C. Expansion of
maxillary arches with crossbite: a systematic review of RCTs
in the last 12 years. European Journal of Orthodontics 2013;
35(1):29–37.
References to other published versions of this review
Harrison 2001
Harrison JE, Ashby D. Orthodontic treatment for posterior
crossbites. Cochrane Database of Systematic Reviews 2001,
Issue 1. [DOI: 10.1002/14651858.CD000979
∗
Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Asanza 1997
Methods Study design: RCT (2 arms)

Location: Orthodontics Department, Albert Einstein College of Medicine and Monte-
fiore Medical Center, New York, USA
Number of centres: 1
Recruitment period: Not stated
Funding source: Not stated but study part of a Master’s thesis
Clinician experience: Not stated
Participants Inclusion criteria: Children with posterior crossbites

Exclusion criteria: None stated
Age: 8.5 to 16 years
Gender: M/F 7/7
Number randomised: 14 (Gp A: 7; Gp B: 7)
Number evaluated: 14 (Gp A: 7; Gp B: 7)
Interventions Comparison: (Fixed appliances) (rapid expansion) banded Hyrax (tooth borne)
versus bonded Hyrax (tooth/tissue borne)
Gp A (n = 7): Conventional Hyrax expander with mid-palatal jackscrew assembly and 4
rigid steel wires that were soldered to the bands on abutment teeth usually first premolars
and first molars
Gp B (n = 7): Same Hyrax expander jackscrew assembly as Gp A but wires were soldered
to 0.036 wire loops bent circumferentially at the height of contour of the abutment teeth.
The acrylic portion encased the occlusal, lingual and buccal surfaces of the abutment
teeth
Participants in both groups were instructed to turn screw twice per day (0.5 mm). After
expansion, appliances remained for a 3-month retention phase
Outcomes Lateral and posterior-anterior cephalometric assessment of angular and linear skeletal
and dental changes
Molar expansion
Notes No sample size calculation reported
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection Unclear risk Quote: “Appliances were randomly as-
bias) signed”
Comment: Insufficient information on the
method of sequence generation

Asanza 1997 (Continued)
Allocation concealment (selection bias) Unclear risk Quote: “Appliances were randomly as-
signed”
Comment: Not mentioned
Blinding of outcome assessment (detection Unclear risk Not mentioned

bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk No drop-outs reported. Data in Table 5 im-
All outcomes plied that there were no drop-outs
Selective reporting (reporting bias) High risk No measures of variance were reported, so
we were unable to analyse the data
Other bias Low risk No other sources of bias identified
Garib 2005

Location: Orthodontics Department, Bauru School of Dentistry, University of Sao Paulo,
Brazil
Funding source: Not stated
Participants Inclusion criteria: Females presenting with Class I or Class II malocclusion with unilateral
or bilateral crossbite
Exclusion criteria: age below 11 and above 14 years, persistence of any primary tooth,
absence of maxillary posterior permanent teeth, metallic restorations on the maxillary
posterior teeth, previous periodontal disease, previous orthodontic treatment and M sex
Age: Gp A: mean 12.4 years (range 11.4-13.6); Gp B: mean 12.6 years (range 11.5-13.
9)
Gender: 100% F
Number evaluated: Not stated
Interventions Comparison: (Fixed appliances) (rapid expansion) tooth-tissue borne Haas versus
tooth borne Hyrax
Gp A (n = 4): Tooth-tissue borne palatal acrylic Haas type expander
Gp B (n = 4): Tooth-borne Hyrax expander (no palatal acrylic)
Both groups had the screw activated by a complete turn after placement, followed by a
one-quarter turn morning and evening of each day (0.5 mm/day) until full expansion
on day 16 (total of 7 mm expansion). Appliance was then kept as a retainer for a further
3 months and then removed, at which point the outcomes were measured
Outcomes Transverse maxillary expansion

Maxillary posterior teeth axial inclination

Garib 2005 (Continued)
Notes Casual and systematic errors were calculated comparing the first measurement with
Dahlberg’s formula and second measurement with dependent t-test at a significance level
of 5%
No sample size calculation reported, but authors suggest that study is probably under-
powered
Risk of bias
Random sequence generation (selection Unclear risk Quote: “...sample of eight patients, who
bias) were randomly assigned to two groups”
Allocation concealment (selection bias) Unclear risk Quote: “...sample of eight patients, who
were randomly assigned to two groups”
Blinding of outcome assessment (detection Unclear risk It appears that it would have been possible
bias) to blind outcome assessors as the appliances
All outcomes were removed before final measurements
were made. However, it was not mentioned
Incomplete outcome data (attrition bias) Unclear risk No indication of whether or not there were
All outcomes any drop-outs. Unclear how many partici-
pants were included in the outcome assess-
ment
Selective reporting (reporting bias) Low risk Outcome measures described in the meth-
ods section were reported in full
Godoy 2011

Location: Dental clinic of Santo Amaro by the University of Pernambuco, Brazil
Funding source: University of Pernambuco and research grant from the Ministry of
Education of Brazil (CAPES)
Clinician experience: Specialist orthodontist with over 10 years of experience
Participants Inclusion criteria: Children had both unilateral posterior dental and functional crossbites
in the mixed dentition; all had skeletal posterior crossbite diagnosed by examining the
casts, models and anterioposterior cephalometric radiographs
Exclusion criteria: Sucking habits, previous orthodontic treatment, Class III malocclu-

Godoy 2011 (Continued)
sion
Gp A: mean age 8.00 years (SD 0.79); M/F 7/26
Gp B: mean age 7.82 years (SD 0.85); M/F 15/18
Gp C: mean age 8.09 years (SD 0.81); M/F 19/14
Number randomised: 99 (Gp A: 33; Gp B: 33; Gp C: 33)
Number evaluated: 99 (Gp A: 33; Gp B: 33; Gp C: 33)
Interventions Comparison: (Fixed versus removable appliances) (slow expansion) quad-helix ver-
sus expansion plate versus untreated control group
Gp A (n = 33): Quad-helix fixed appliance with stainless steel bands bonded to teeth
(tooth borne). Appliance was activated once a month until crossbite was corrected
Gp B (n = 33): Expansion plate removable appliance with mid-line screw and acrylic
covering (tooth-tissue borne). Appliance worn day and night and removed for teeth
brushing. Appliance was activated a one-quarter rotation of the screw once a week (0.25
mm)
Gp C (n = 33): No treatment
Gps A and B were evaluated every 4 weeks, no overcorrection was produced and once
correction was achieved each child had a retention plate to be used 24 hours/day for 3
months and then only at night for a further 3 months
Outcomes Correction of crossbite

Maxillary and mandibular inter-molar and inter-canine expansion
Length of treatment
Cost-benefit
Success rate (stability)
Number of complications
(Evaluation after crossbite correction, after 6-month retention, after retention removal)
Notes “The sample size calculation established an error of 5% and a power of 95%. To detect
any differences in length of treatment between the 2 methods, the means and standard
deviations were calculated based on the data from the study of Hermanson et al (8.00 ±
3.00 for the QH [quad-helix]; 12.00 ± 5.00 for the EP [expansion plate]). The sample
should include 27 patients per group to show a statistically significant difference”
Email sent to authors 22 November 2012, reply received 23 November 2012
Risk of bias
Random sequence generation (selection Low risk Quote: “For randomization, numbers were
bias) randomly drawn from a plastic bag. Each
child received a number from 1 to 99”
From email correspondence: “Each child
received a number according to the clini-
cal examination order. When all 99 chil-
dren had a number, a helper took the 99
pieces of papers numbering from 1 to 99
from the bag. The first number to be taken
would belong to QDH [quad-helix] group,

Godoy 2011 (Continued)
the second one to the EP [expansion plate]

group, the third one to the untreated group,
the fourth to the QDH group...”
Allocation concealment (selection bias) Low risk The method described above would not al-
low anybody involved in the study to know
their treatment allocation until they had
been allocated
Blinding of outcome assessment (detection Low risk Quote: “Palatal expansion and crossbite
bias) correction were measured on the study casts
All outcomes by 1 masked investigator... The investiga-
tor was unaware of the type of appliance
used by the patient and the length of treat-
ment (pretreatment, after expansion, after
6 months of retention, or 6 months after
removal of the retention plate)”
Incomplete outcome data (attrition bias) Low risk “Dropouts and treatments not completed
All outcomes within 12 months were classified as unsuc-
cessful”
Intention-to-treat analysis included all ran-
domised participants
Kilic 2008

Location: Department of Orthodontics, Faculty of Dentistry, Atatürk University, Erzu-
rum, Turkey
Participants Inclusion criteria: Participants with severe maxillary arch width deficiency, bilateral cross-
bite and deep palatal vault
Exclusion criteria: People with mucosal swelling during maxillary expansion
Age: Gp A: 13.75 years (SD 17 months); Gp B: 13.5 years (SD 12 months)
Gender: M/F 10/29

Kilic 2008 (Continued)
Interventions Comparison: (Fixed appliances) (rapid expansion) banded Hyrax (tooth borne)
versus bonded Hyrax (tooth/tissue borne)
Gp A (n = 21): Conventional Hyrax tooth-borne appliance for rapid maxillary expansion
Gp B (n = 18): Acrylic bonded appliance for rapid maxillary expansion
Appliances were activated twice a day, one-quarter turn each time (0.5 mm/day)
Outcomes Maxillary molar expansion

Molar crown tipping
Alveolar inclination

Email sent 22 November 2012
Risk of bias
Random sequence generation (selection Unclear risk Quote: “Randomly assigned to two groups”
bias) Comment: Insufficient information on the
Allocation concealment (selection bias) Unclear risk Quote: “Randomly assigned to two groups”
Blinding of outcome assessment (detection Unclear risk It may have been possible to blind outcome
bias) assessors if the appliances were removed be-
All outcomes fore final measurements were made. How-
ever, this was not mentioned
Incomplete outcome data (attrition bias) Low risk No drop-outs reported. Numbers of par-
All outcomes ticipants per group reported in the results
tables matches the numbers that were ran-
domised

Lagravere 2010

Location: Orthodontic clinic at the University of Alberta in Edmonton, Alberta, Canada
Recruitment period: 18-month recruitment period
Participants Inclusion criteria: People needing maxillary expansion with posterior crossbite
Number randomised: 62 (Gp A: 20; Gp B: 21; Gp C: 21)
Interventions Comparison: (Fixed appliances) (rapid expansion) Hyrax tooth-borne expander

versus bone-anchored expander versus untreated control group
Gp A (n = 20): Tooth anchored maxillary expander (TAME) Hyrax with bands on the
first permanent molars and first premolars. Activated 0.5 mm per day until posterior
dental crossbite over correction was achieved
Gp B (n = 21): Bone-anchored maxillary expander (BAME) composed of 2 custom-
milled stainless steel onplants, 2 miniscrews and an expansion screw. A healing period of
1 week was allowed before activation of the expander. Activation consisted of 0.25 mm
every other day until overcorrection was achieved
Gp C (n = 21): Treatment delayed for 12 months to serve as a control group
In Gps A and B, the appliance was removed after overcorrection was achieved and left
without retention for an additional 6 months
Outcomes Molar expansion

Inclination
Pain
Risk of bias
Random sequence generation (selection Low risk Quote: “Subjects were randomized into the
bias) groups by using a random numbers gener-
ated list”
Allocation concealment (selection bias) Unclear risk Quote: “Subjects were randomized into the
groups by using a random numbers gener-
ated list”

Lagravere 2010 (Continued)
ment
Lamparski 2003

Location: Private practice, Natrona Heights, PA, USA
Clinician experience: Board-certified orthodontist with 27 years of experience
Participants Inclusion criteria: Crossbite; mixed or permanent dentition

Exclusion criteria: Systemic disease, dental pathology; maxillary tori
Gp A: mean age 11.33 years (range 7.75-13.92); M/F 9/6
Gp B: mean age 10.8 years (range 6.58-14.58); M/F 6/9
Interventions Comparison: (Fixed appliances) (rapid expansion) 4-point expansion appliance

(Hyrax) versus 2-point expansion appliance
Gp A (n = 15): The 4-point expansion appliance consisted of a Hyrax expansion screw
with bands cemented to the maxillary first permanent molars and either the maxillary
first premolars or the maxillary deciduous first molars. Activated 0.5 mm per day until
posterior dental crossbite overcorrection was achieved
Gp B (n = 15): The 2-point expander was banded only to the maxillary first permanent
molars and had a jackscrew (a typical Hyrax appliance with both anterior wires removed)
. Activated 0.5 mm per day until posterior dental crossbite overcorrection was achieved
Outcomes Molar, canine and sutural expansion
Risk of bias
Random sequence generation (selection Unclear risk Quote: “The subjects were randomly as-
bias) signed”

Lamparski 2003 (Continued)

Allocation concealment (selection bias) Unclear risk Quote: “The subjects were randomly as-
signed”
ment
Selective reporting (reporting bias) High risk Outcomes planned in the methods sec-
tion were reported in the results. However,
means and SDs in each group were not re-
ported
Lippold 2013

Location: Orthodontics Department, Münster University’s Medical Sciences Division
and University Hospital Münster, Germany
Clinician experience: “Two specialists in orthodontics”
Participants Inclusion criteria: Functional unilateral posterior crossbite in the late deciduous or early
mixed dentition
Exclusion criteria: mid-line deviation during orthodontic treatment; persisting habits;
general diseases with permanent medication (e.g. diabetes mellitus); syndromes; cleft lip
and palate; general impairments; structural orthopaedic diseases
Age: Gp A: mean 7.3 years (SD 2.2); Gp B: mean 7.2 years (SD 2)
Gender: “The gender ratio was nearly equal at the beginning of the study”
Number randomised: 82 (Gp A: 40; Gp B: 42). However, 5 participants dropped out
after randomisation but before treatment (Gp A: 37; Gp B: 40)
Interventions Comparison: (Slow expansion) early treatment with fixed bonded Hyrax appliance
followed by U-bow activator therapy versus no treatment
Gp A (n = 37): Bonded Hyrax appliance worn 24 hours per day. Once per day activation
(0.2 mm) was mandatory and the maxillary expansion was achieved in a mean of 3.2
Lippold 2013 (Continued)
weeks (SD 1.2). This was followed by a retention period of a mean of 12.6 weeks (SD
1.8). The U-bow activator was then applied for a mean of 36.8 weeks (SD 5.4). This
was a double-plate activator combined with eponymous U-shaped wire bows on each
side (protrusive and labial bows on the upper and lower jaws). The maxillary plate had
an additional transversal expansion screw for retention of the achieved expansion
Gp B (n = 40): No treatment (after the final follow-up point, these children received the
same treatment as those in the therapy group)
Outcomes Sagittal, vertical and transversal dimensions of the maxilla and mandible
Mid-line deviation between the anterior teeth of the maxilla and mandible
Sagittal overjet and vertical overbite
Outcomes were measured 1 year after the start of treatment
Risk of bias
Random sequence generation (selection Low risk Quote: “Block randomisation with a block
bias) length of 20 and an allocation ratio of 1:1”
Allocation concealment (selection bias) Unclear risk Quote: “Block randomisation with a block
length of 20 and an allocation ratio of 1:1”
Blinding of outcome assessment (detection Unclear risk It appears that it would have been possi-
bias) ble to blind outcome assessors as the appli-
All outcomes ances could have been removed before fi-
nal measurements were made. In contrast,
the children’s group may have been obvi-
ous due to there being an untreated control
group whose crossbites would not be prop-
erly corrected. However, it was not men-
tioned
Incomplete outcome data (attrition bias) Low risk Numbers of drop-outs and reasons were
All outcomes clearly described in a study workflow (Fig-
ure 1), and were sufficiently similar in each
group
Selective reporting (reporting bias) High risk No SD for mean change from baseline re-
ported

Martina 2012

Location: Department of Oral Science, University of Naples Federico II, Italy
Recruitment period: May 2006 to October 2007
Funding source: Grant from the Italian Ministry of University and Research
Participants Inclusion criteria: Children up to 13 years old (M) and 12 years old (F), with erupted
permanent first molars and unilateral or bilateral full cusp posterior crossbite
Exclusion criteria: Severe periodontal disease (probing depth > 4 mm), congenital syn-
dromes, defects, previous orthodontic treatment
Number randomised: 50 (Gp A: 23; Gp B: 27). However, 9 children dropped out after
randomisation but before treatment (Gp A: 19; Gp B: 22)
Interventions Comparison: (Fixed appliances) slow versus rapid expansion

A 2-band palatal expander was used for both groups
Gp A (n = 12): Slow expansion, the screw was turned twice a week (0.50 mm activation
per week)
Gp B (n = 14): Rapid expansion, screw was initially turned 8 times (2.0-mm screw
activation) at chair side 2 hours after curing. Thereafter, the children’s parents were
trained to turn the screw 3 times per day (0.75 mm activation per day)
In both groups, the jackscrew was activated until a 2 mm molar transverse overcorrection
was achieved. After the required expansion was achieved, the screw was locked with light-
cure flow composite. The appliances were removed 7 months after treatment started, at
which point the outcomes were measured
Outcomes Molar expansion at molar cusp

Antero and posterior maxillary expansion
Pterygoid expansion
Molar tipping
Notes The power calculation was based upon previous estimates of rapid maxillary expansion
transverse skeletal effects. This indicated that 12 children were needed for each treatment
group (to detect 2.5 mm difference, SD = 2.0 mm, significance level = 0.05, power 80%)
Risk of bias
Random sequence generation (selection Low risk Quote: “Balanced block randomisation us-
bias) ing gender as a stratifying factor”
Allocation concealment (selection bias) Low risk Quote: “A single operator allocated the pa-
tients by means of a custom-made Java
script and was responsible for the alloca-
tion concealment, that is, the allocation was

Martina 2012 (Continued)
disclosed only when a new patient was en-

rolled in the trial”
Blinding of outcome assessment (detection Low risk Measurements were made by a single oper-
bias) ator blinded to participant allocation
All outcomes
Incomplete outcome data (attrition bias) High risk Numbers of drop-outs and reasons were
ure 4), and were similar. However, dropout
rate was very high (Gp A: 48%; Gp B: 48%)
. If the missing participants had higher
mean scores in 1 group than the other, as
the attrition rate increased, so would over/
understatement of the mean difference
McNally 2005

Location: Queen’s Hospital, Burton on Trent and The University of Birmingham, School
of Dentistry, Birmingham
Funding source: 3M Unitek supplied the quad-helix arches used in this study
Clinician experience: The authors had used expansion arches of the type tested for a
number of years
Participants Inclusion criteria: Either a unilateral or bilateral crossbite that required correction ac-
cording to the consultant orthodontist
Age: 11-16 years (not reported by group)
Gender: M/F 30/30 (not reported by group)
Number evaluated: 55 (Gp A: 28; Gp B: 27) for molar expansion; 52 (Gp A: 26; Gp B:
26) for canine expansion (the lower numbers were due to unerupted canines)
Interventions Comparison: (Slow expansion) quad-helix + multi-bracket versus expansion arch +

multi-bracket
Gp A (n = 30): Quad-helix plus multi-bracket
Gp B (n = 30): Expansion arch plus multi-bracket
In both groups the appliance was activated in order to deliver 1.8-N expansion force

McNally 2005 (Continued)
Outcomes Molar and canine expansion

Comfort
Outcomes were measured 4, 8 and 12 weeks after the start of treatment
Notes Altman nomogram for an SD of 1.5 mm at 80% power and 1% significance level suggests
a total sample size of 46 children, with 23 in each group
Risk of bias
Random sequence generation (selection High risk Quote: “Using random number tables the
bias) first 30 participants were allocated for treat-
ment with either appliance according to an
odd or even number. The next 30 were then
allocated in order to receive the alternative
treatment to those in the initial allocation”
Comment: This does not represent a truly
random sequence generation
Allocation concealment (selection bias) High risk Quote: “Using random number tables the
first 30 participants were allocated for treat-
ment with either appliance according to an
odd or even number. The next 30 were then
allocated in order to receive the alternative
treatment to those in the initial allocation”
Comment: Potential to foresee group allo-
cation
Blinding of outcome assessment (detection Unclear risk Quote: “The group of the participant was
bias) obvious from the model since the im-
All outcomes print of each type of appliance could be
seen. However, since all measurements were
made without reference to previous values,
there could be no bias”
Comment: We cannot completely rule out
the possibility of bias in this situation
Incomplete outcome data (attrition bias) Low risk Numbers of drop-outs and reasons are
ure 4), and are sufficiently similar in each
group

Mossaz-Joelson 1989
Methods Study design: Reclassified as RCT following correspondence (2 arms)

Location: Department of Orthodontics, Dental School, University of Geneva, Switzer-
land
Participants Inclusion criteria: Children with bilateral or functional unilateral crossbite. No further
definition provided
Age: Gp A: 8.6-10.8 years; Gp B: 8.7-12 years
Gender: M/F 6/4 (not reported by group)
Interventions Comparison: (Fixed appliances) (slow expansion) bonded Minne versus banded
Minne appliances
Gp A (n = 5): Conventional Minne expander embedded in acrylic and bonded to upper
deciduous first and second molars (or first and second premolars)
Gp B (n = 5): Conventional Minne expander soldered to bands to the upper first primary
molars (or first permanent premolars) and upper first molars
A continuous 2-pound (0.9-kg) force coil spring was used to obtain expansion. The
spring was re-activated every other week. The slow expansion period lasted 7-15 weeks.
After expansion was complete, the fixed appliances were removed, apart from the bonded
vertical tubes in Gp A, and the maxillary first molar bands in Gp B. Conventional
maxillary retainer worn full time for 12 weeks (retention period). There was then 12
more weeks of observation without the retainers to evaluate relapse

Angular changes
Cephalometric variables
Stability (relapse of molar and canine expansion)
Risk of bias
Random sequence generation (selection Unclear risk From correspondence with study authors:
bias) “...randomly divided into two groups...”
Allocation concealment (selection bias) Unclear risk From correspondence with study authors:
“...randomly divided into two groups...”

Mossaz-Joelson 1989 (Continued)
All outcomes any drop-outs. Unclear how many children
were included in the outcome assessment
Oliveira 2004

Location: Department of Orthodontics and the Craniofacial Center, University of Illinois
at Chicago, USA
Number of centres: 3 university orthodontic clinics and 1 private practice
Funding source: Partially funded by a grant from the American Association of Orthodon-
tists Foundation
Participants Inclusion criteria: Growing children who had maxillary permanent first premolars or
non-mobile maxillary deciduous first molar and unilateral or bilateral crossbite
Exclusion criteria: Any craniofacial anomaly
Gp A: mean age 11.9 years (range 10.7-13.4); M/F 5/4
Gp B: mean age 11.1 years (range 7.3-14.6); M/F 1/9
Interventions Comparison: (Fixed appliances) (rapid expansion) tooth-tissue-borne Haas versus

tooth-borne Hyrax
Gp A (n = 9): Tooth-tissue-borne palatal acrylic Haas type expander
Gp B (n = 10): Tooth-borne Hyrax expander (no palatal acrylic)
Appliances were activated twice a day, one-quarter turn each time (0.5 mm/day) until
overcorrection was obtained. Appliance was then kept as a retainer for a further 3 months
and then removed, at which point the outcomes were measured
Outcomes Molar expansion

Anteroposterior cephalometry
Notes “...projected sample size of 50 subjects” - sample size not met
Risk of bias

Oliveira 2004 (Continued)
Random sequence generation (selection Low risk Quote: “Randomization was carried out by
bias) using a table of random numbers”
Allocation concealment (selection bias) Low risk Quote: “A staff member in the clinic was
informed about every new patient suitable
for the study and assigned the type of ex-
pander following the list order”
Comment: It appears that allocation was
done by someone not involved in the study.
Probably done
tables matched the numbers that were ran-
domised
Oshagh 2012

Location: Orthodontic Department, School of Dentistry, Shiraz University of Medical
Sciences, Iran
Participants Inclusion criteria: Healthy children with posterior bilateral crossbites and with growth
potential
Exclusion criteria: Systemic diseases, previous orthodontic treatment, requiring headgear
or an auxiliary component, cleft palate, anterior crossbite, children with extractions

Oshagh 2012 (Continued)
Interventions Comparison: (Removable split acrylic plates) (slow expansion) conventional mid-
line expansion screw versus spring-loaded expansion screw
Gp A (n = 25): Conventional screw activated by parent with a one-quarter turn twice
per week (total 0.5 mm)
Gp B (n = 10): Spring-loaded screw activated by the orthodontist each month
Both groups were treated by the same orthodontist following the same protocol. Active
expansion continued until overcorrection (mean duration of treatment 5.3 months)

Arch size changes
Participant discomfort
Risk of bias
Random sequence generation (selection Low risk Quote: “Randomization was accomplished
bias) by a randomization table”
Allocation concealment (selection bias) Unclear risk Quote: “Randomization was accomplished
by a randomization table”
Blinding of outcome assessment (detection Unclear risk It appears that it would have been possi-
bias) ble to blind outcome assessors as the appli-
All outcomes ances were removed before casts were made.
However, it was not mentioned
All outcomes any drop-outs. Unclear how many children
were included in the outcome assessment
Selective reporting (reporting bias) High risk Poor reporting of results. Only the overall
mean monthly changes were reported. The
authors did not report the mean and SD
for changes between the baseline and final
measurement
Other bias High risk Imbalance in the numbers per group (Gp
A: 25; Gp B: 10) and gender (Gp A: M/F
6/19; Gp B: M/F 5/5) suggests a problem
with the randomisation

Petrén 2008

Location: Public Dental Health Service, Skane County Council, Sweden, and the De-
partment of Orthodontics, Faculty of Odontology, Malmö University, Malmö, Sweden
Recruitment period: 2001-2005
Funding source: Supported by the Swedish Dental Society, Skane County Council, and
the Faculty of Odontology, Malmö University, Sweden
Clinician experience: 5 experienced general practitioners under the supervision of spe-
cialist orthodontists
Participants Inclusion criteria: Mixed dentition (all incisors and first molars erupted); unilateral pos-
terior crossbite
Exclusion criteria: Sucking habits or sucking habit discontinued at less than 1 year before
the trial; previous orthodontic treatment
Gp D: mean age 8.8 years (SD 0.7); M/F 7/8
Number randomised: 60 (15 per group)
Number evaluated: 60 (15 per group)
Interventions Comparison: (Fixed versus removable appliances) (slow expansion) quad-helix ver-
sus expansion plate versus composite onlays versus untreated control group
Gp A (n = 15): The quad-helix consisted of a standard stainless steel arch with stainless
steel bands attached with glass ionomer cement on the maxillary first molars. The quad-
helix was activated 10 mm before placement and then re-activated every 6 weeks until a
crossbite correction. The treatment result was retained for 6 months
Gp B (n = 15): The expansion plate consisted of acrylic with an expansion screw and
stainless steel clasps on the deciduous and permanent first molars. The plate was activated
0.2 mm once a week by the child until a normal transverse relationship was achieved.
The treatment result was retained for 6 months
Gp C (n = 15): 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 locking the mandible in occlusion. The bite
raising was achieved by bonding composite on the occlusal surfaces on both mandibular
first molars. The composite onlay was checked every 6 weeks and removed after 1 year
Gp D (n = 15): No treatment
Outcomes Crossbite correction

Molar and canine expansion
Time to correction
Notes The sample size for each group had previously been calculated and was based on a
significance level 5% and a power of 90%, to detect a mean inter-group difference in
expansion of 2 mm (SD 1.5 mm). The sample size calculation showed that each group
needed a minimum of 12 children. The sample size target was met
Risk of bias

Petrén 2008 (Continued)
Random sequence generation (selection Low risk Quote: “The subjects were randomized as
bias) 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 first
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”
Allocation concealment (selection bias) Low risk Quote: “The envelope was in the care of 1
investigator...who was contacted and ran-
domly extracted a note and informed the
dentist which treatment strategy to use”
Blinding of outcome assessment (detection Low risk Quote: “Measurements were blinded; the
bias) examiner was unaware of which treatment
All outcomes the patients had received or which models
were taken at T0 and T1”
Incomplete outcome data (attrition bias) Low risk Quote: “Data on all patients were analyzed
All outcomes on an intention-to-treat (ITT) basis... all
patients, successful or not, were included in
the final analysis” and “all patients finished
the trial (Fig 5)”
Ramoglu 2010
Methods Study design: RCT

Location: Department of Orthodontics of Selçuk University, Turkey
Funding source: Selçuk University Research Projects (2003-2004)
Participants Inclusion criteria: Functional unilateral or bilateral posterior crossbite with transverse
deficiency; eruption of the first permanent molars
Exclusion criteria: Sagittal skeletal problem; more than 1 missing maxillary tooth in the
right and left sides of the dentition

Ramoglu 2010 (Continued)

Interventions Comparison: (Fixed appliances) semi-rapid versus rapid expansion

A splint type tooth- and tissue-borne modified bonded appliance was used for both
groups
Gp A (n = 18): Semi-rapid maxillary expansion activation was two-quarter turns per
day for the first week followed by one-quarter turn per day every other day. The mean
treatment time was 57.16 days (SD 21.52)
Gp B (n = 17): Rapid maxillary expansion activation was two-quarter turns per day
throughout treatment, and the mean treatment time was 21.23 days (SD 8.36)
Screw activation was ended when approximately 2 mm of overcorrection was achieved,
and the screw was fixed by a ligature wire

Cephalometric treatment effects
Risk of bias
Random sequence generation (selection Unclear risk Quote: “The subjects were randomly di-
bias) vided into two groups”
Allocation concealment (selection bias) Unclear risk Quote: “The subjects were randomly di-
vided into two groups”
Blinding of outcome assessment (detection Unclear risk It may have been possible to blind outcome
bias) assessors if the appliances were removed be-
All outcomes fore final measurements were made. How-
ever, this was not mentioned
tables matches the numbers that were ran-
domised

Thilander 1984
Methods Study design: RCT

Location: Public Dental Health Service, Enköping, Sweden
Recruitment period: 1965-1967
Funding source: Grant of Swedish Medical Research Council
Participants Inclusion criteria: Children with posterior crossbites. No further definition provided
Gp A: All children 5 years of age, M/F 13/20
Gp B: All children 5 years of age, M/F 11/17
Interventions Comparison: Grinding or grinding + expansion plate versus no intervention

Gp A (n = 34): Treatment procedure comprised interceptive measures in 2 steps: grinding
and, in the event of unsatisfactory results, expansion plates
Gp B (n = 34): No treatment
Gp A were treated with grinding at age 5 years. Gp B remained untreated until the
study finished 8 years later at age 13 years. Follow-up measurements to assess crossbite
correction were made at age 6, 7, 10 and 13 years
Outcomes Correction of crossbite
Risk of bias
Random sequence generation (selection Unclear risk Quote: “68 children...were randomly di-
bias) vided into two groups”
Allocation concealment (selection bias) Unclear risk Quote: “68 children...were randomly di-
vided into two groups”
Blinding of outcome assessment (detection Unclear risk Not mentioned

bias)
All outcomes
Incomplete outcome data (attrition bias) High risk The dropout rate was very different be-
All outcomes tween the treated group (3%) and the
untreated group (18%). Reasons reported
were lack of interest in the untreated group
and relocation from the town

Thilander 1984 (Continued)
F: female; Gp: group; M: male; N: number; RCT: randomised controlled trial; SD: standard deviation.
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Petrén 2011 Study including some of the participants from Petrén 2008 plus other participants and matched controls
Weissheimer 2011 Participants with maxillary deficiency, not crossbite

DATA AND ANALYSES
Comparison 1. Fixed rapid (Haas) versus fixed rapid (Hyrax)
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Molar expansion (3 months after 2 27 Mean Difference (IV, Fixed, 95% CI) 0.70 [-0.25, 1.66]
completion of expansion phase)
Comparison 2. Fixed slow (quad-helix) versus removable slow (expansion plate)
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Crossbite correction 2 96 Risk Ratio (M-H, Fixed, 95% CI) 1.20 [1.04, 1.37]
2 Molar expansion 2 96 Mean Difference (IV, Fixed, 95% CI) 1.15 [0.40, 1.90]
3 Canine expansion 2 96 Mean Difference (IV, Fixed, 95% CI) 0.19 [-0.47, 0.85]
Analysis 1.1. Comparison 1 Fixed rapid (Haas) versus fixed rapid (Hyrax), Outcome 1 Molar expansion (3
months after completion of expansion phase).
Review: Orthodontic treatment for posterior crossbites
Comparison: 1 Fixed rapid (Haas) versus fixed rapid (Hyrax)
Outcome: 1 Molar expansion (3 months after completion of expansion phase)
Mean Mean
Study or subgroup Haas Hyrax Difference Weight Difference
N Mean(SD)[mm] N Mean(SD)[mm] IV,Fixed,95% CI IV,Fixed,95% CI
Garib 2005 4 6.5 (1) 4 6.7 (0.4) 81.8 % -0.20 [ -1.26, 0.86 ]
Oliveira 2004 9 8.49 (2.33) 10 3.73 (2.64) 18.2 % 4.76 [ 2.53, 6.99 ]
Total (95% CI) 13 14 100.0 % 0.70 [ -0.25, 1.66 ]

Heterogeneity: Chi2 = 15.47, df = 1 (P = 0.00008); I2 =94%
Test for overall effect: Z = 1.45 (P = 0.15)
Test for subgroup differences: Not applicable
-20 -10 0 10 20
Favours Hyrax Favours Haas

Analysis 2.1. Comparison 2 Fixed slow (quad-helix) versus removable slow (expansion plate), Outcome 1
Crossbite correction.
Comparison: 2 Fixed slow (quad-helix) versus removable slow (expansion plate)
Outcome: 1 Crossbite correction
Study or subgroup Quad-helix Expansion plate Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Godoy 2011 33/33 30/33 74.4 % 1.10 [ 0.97, 1.24 ]
Petr n 2008 15/15 10/15 25.6 % 1.48 [ 1.02, 2.13 ]
Total (95% CI) 48 48 100.0 % 1.20 [ 1.04, 1.37 ]

Total events: 48 (Quad-helix), 40 (Expansion plate)
0.1 0.2 0.5 1 2 5 10

Favours expansion plate Favours quad-helix
Molar expansion.
Outcome: 2 Molar expansion
Mean Mean
Study or subgroup Quad-helix Expansion plate Difference Weight Difference
Godoy 2011 33 4.31 (2.4) 33 3.09 (2.4) 42.0 % 1.22 [ 0.06, 2.38 ]
Petr n 2008 15 4.6 (1.19) 15 3.5 (1.54) 58.0 % 1.10 [ 0.12, 2.08 ]
Total (95% CI) 48 48 100.0 % 1.15 [ 0.40, 1.90 ]

Heterogeneity: Chi2 = 0.02, df = 1 (P = 0.88); I2 =0.0%
-2 -1 0 1 2

Canine expansion.
Outcome: 3 Canine expansion
Mean Mean
Study or subgroup Quad-helix Expansion plate Difference Weight Difference
Godoy 2011 33 2.96 (2.48) 33 1.43 (1.78) 40.1 % 1.53 [ 0.49, 2.57 ]
Petr n 2008 15 2 (1.18) 15 2.7 (1.2) 59.9 % -0.70 [ -1.55, 0.15 ]
Total (95% CI) 48 48 100.0 % 0.19 [ -0.47, 0.85 ]

-2 -1 0 1 2
ADDITIONAL TABLES
Table 1. Fixed versus fixed with mid-palatal expansion (single study comparisons)
Study Outcome Group A Group B Results
Asanza 1997 Molar expansion (3 Hyrax banded: Mean 6 Hyrax bonded: Mean 5.9 P value = NS (as reported
months after completion mm (min 4.3 mm - max mm (min 3.2 mm - max in the study - no SD re-
of expansion phase) 7.2 mm) 7.7 mm) ported)
Kilic 2008 Molar expansion (1 week Hyrax banded: Mean 7. Hyrax bonded: Mean 7. MD 0.36 (95% CI -0.72
after completion of ex- 67 mm (SD 1.99) 31 mm (SD 1.45) to 1.44)
pansion phase) P value = 0.51
Lagravere 2010 Molar expansion (6 Hyrax tooth-borne ex- Bone-anchored ex- MD 0.08 (95% CI -1.00
months after completion pander: Mean 5.83 mm pander: Mean 5.75 mm to 1.16)
of expansion phase)

Table 1. Fixed versus fixed with mid-palatal expansion (single study comparisons) (Continued)
(SD 1.54) (SD 1.98) P value = 0.88
Molar expansion (12 Hyrax tooth-borne ex- Bone-anchored ex- MD 0.21 (95% CI -0.77
months after completion pander: Mean 4.24 mm pander: Mean 4.03 mm to 1.19)
of expansion phase) (SD 1.69) (SD 1.49) P value = 0.67
Lamparski 2003 Molar expansion (3 4-point expansion appli- 2-point expansion appli- P value = “No significant
months after completion ance (Hyrax): Not re- ance: Not reported by differences were found”
of expansion phase) ported by group group
Canine expansion (3 4-point expansion appli- 2-point expansion appli- P value = 0.331 (as re-
months after completion ance (Hyrax): Mean 3. ance: Mean 1.7 mm ported in the study - no
of expansion phase) 034 mm SD reported)
Martina 2012 Molar expan- Slow maxillary expan- Rapid maxillary expan- MD 0.60 (95% CI -0.85
sion (7 months after start sion: sion: to 2.05)
of treatment) Mean 6.3 mm (SD 2.1) Mean 5.7 mm (SD 1.6) P value = 0.42
Mossaz-Joelson 1989 Molar expansion (7-15 Bonded Minne: Mean 7. Banded Minne: Mean 8. P value = NS (as reported
weeks after start of treat- 9 mm (SD 1.5) 3* mm (SD 1.1) in the study - number of
ment) participants included in
analysis not reported)
Canine expansion (7-15 Bonded Minne: Mean 6. Banded Minne: Mean 5. P value = NS (as reported
weeks after start of treat- 4 mm (SD 1.1) 3 mm (SD 1.9) in the study - number of
ment) participants included in
analysis not reported)
Stability: relapse of molar Bonded Minne: Mean 2. Banded Minne: Mean 2. P value = NS (as reported
expansion (24 weeks after 3 mm (SD 0.8) 5 mm (SD 0.6) in the study - number of
completion of expansion participants included in
phase) analysis not reported)
Stability: relapse of ca- Bonded Minne: Mean 1. Banded Minne: Mean 1. P value = NS (as reported
nine expansion (24 weeks 6 mm (SD 0.5) 2 mm (SD 0.3) in the study - number of
after completion of ex- participants included in
pansion phase) analysis not reported)
Ramoglu 2010 Molar expansion Semi-rapid maxillary ex- Rapid maxillary expan- MD 0.60 (95% CI -0.55
pansion: Mean 5.71 mm sion: Mean 5.11 mm (SD to 1.75)
(SD 1.66) 1.81) P value = 0.31
Canine expansion Semi-rapid maxillary ex- Rapid maxillary expan- MD 0.36 (95% CI -0.64
pansion: Mean 5.13 mm sion: Mean 4.77 mm (SD to 1.36)
(SD 1.47) 1.53) P value = 0.48
CI: confidence interval; MD: mean difference; min: minimum; max: maximum; NS: not significant; RR: risk ratio; SD: standard
deviation.

* There is a discrepancy between the mean reported in Table 1 (5.3) and the text (8.3). The latter must be the actual mean as the text
reports that there is no significant difference, whereas if the mean were 5.3, the P value is < 0.05 (based on assumption of no drop-
outs).
Table 2. Fixed versus removable (single study comparisons)
Godoy 2011 Stability of crossbite correc- Quad-helix: Removable expansion RR 1 (95% CI 0.43 to 2.
tion (relapse 12 months af- 3/33 plate: 32)
ter correction) 3/33 P value = 1
Petrén 2008 Crossbite correction Quad-helix: 15/15 Composite onlays: 2/15 RR 6.20 (95% CI 1.98 to
19.43)
P value = 0.002
Molar expansion Quad-helix: Mean 4.6 mm Composite onlays: Mean 0. MD 4.10 (95% CI 3.45 to
(SD 1.19) 5 mm (SD 0.46) 4.75)
P value < 0.00001
Canine expansion Quad-helix: Mean 2 mm Composite onlays: Mean 0. MD 1.37 (95% CI 0.68 to
(SD 1.18) 63 mm (SD 0.7) 2.06)
P value = 0.0001
Crossbite correction Removable expansion Composite onlays: 2/15 RR 5 (95% CI 1.31 to 19.
plate: 10/15 07)
P value = 0.02
Molar expansion Removable expansion Composite onlays: Mean 0. MD 3.00 (95% CI 2.19 to
plate: Mean 3.5 mm (SD 1. 5 mm (SD 0.46) 3.81)
54) P value < 0.00001
Canine expansion Removable expansion Composite onlays: Mean 0. MD 2.07 (95% CI 1.37 to
plate: Mean 2.7 mm (SD 1. 63 mm (SD 0.7) 2.77)
2) P value < 0.00001
CI: confidence interval; MD: mean difference; NS: not significant; RR: risk ratio; SD: standard deviation
Table 3. Other single study comparisons
Lippold 2013 Molar expan- Fixed bonded Hyrax appli- No treatment: Mean 0.8 P value < 0.001 (as re-
sion (12 months after start ance followed by U-bow mm ported in the study - no
of treatment) activator: Mean 5.1 mm SD for mean change from
baseline reported)

Table 3. Other single study comparisons (Continued)
Canine expan- Fixed bonded Hyrax appli- No treatment: Mean 1 mm P value < 0.001 (as re-
sion (12 months after start ance followed by U-bow ported in the study - no
of treatment) activator: Mean 3.6 mm SD for mean change from
baseline reported)
McNally 2005 Molar Quad-helix + Expansion arch + multi- MD -0.55 (95% CI -1.34
expansion (12 weeks after multi-bracket: Mean 4.54 bracket: Mean 5.09 mm to 0.24)
start of treatment) mm (SD 1.27) (SD 1.67) P value = 0.17
Canine Quad-helix Expansion arch + multi- MD -0.72 (95% CI -1.52

expansion (12 weeks after + multi-bracket: Mean 1.4 bracket: Mean 2.12 mm to 0.08)
start of treatment) mm (SD 1.75) (SD 1.11) P value = 0.08
Oshagh 2012 Molar and canine expan- Removable with conven- Removable with spring- Results inadequately re-
sion tional screw loaded screw ported
Thilander 1984 Crossbite correction Grinding or grinding + ex- No treatment: RR 3.68 (95% CI 1.77 to
pansion plate: 6/28 7.64)
26/33 P value = 0.0005
CI: confidence interval; MD: mean difference; NS: not significant; RR: risk ratio; SD: standard deviation.
APPENDICES
Appendix 1. Description of appliances that can be used to treat posterior crossbite
Fixed appliances (with mid-palatal screw)

Bonded (acrylic splint)
An alternative to the banded design, this fixed expander uses posterior acrylic coverage that is bonded directly to the teeth. The posterior
bite blocks free up the occlusion by removing cuspal interferences.
Bone-anchored expander
The bone-anchored expander is composed of 2 custom-milled stainless steel onplants, 2 miniscrews and an expansion screw. The
expansion screw placed in palatal mid-line is anchored directly to the palatal surfaces of the maxilla (top jaw) with either bioglass-coated
aluminium oxide implants or osteosynthesis plates.
Expansion arch
The expansion arch is made from 1.135 mm round stainless steel wire bent into the shape of a dental arch and inserted into the extra-
oral traction tubes on the first molar bands.
Haas
A fixed maxillary expander that uses acrylic pads and heavy lingual wires to apply pressure to both the teeth and the palatal tissue during
expansion. The lingual wires are soldered to bands on the first bicuspids and the first molars and extend into the palate where they are
embedded in the acrylic pads.
Hyrax
A fixed metal expander soldered to bands on the first molars (2 points) or first molars and first bicuspids (4 points) with an 0.036-mm
lingual wire connecting the bands.
Minne expander
This is a tooth-borne appliance without any acrylic palatal covering. This design makes use of a spring loaded screw called a Minne
expander. The first premolars and molars are banded. Metal flanges are soldered onto the bands on the buccal and lingual sides. The
expander consists of a coil spring having a nut that can compress the spring. This coil spring is made to extend between the lingual
metal flanges that have been soldered. The expander is activated by closing the nut so that the spring is compressed.
Quad helix
This fixed metal expander (also available as a fixed/removable) is capable of applying forces in numerous directions depending upon
how it is activated. The 4 helical loops (2 in the first bicuspid region and 2 in the second molar region) can be activated in unison or
individually to achieve the desired results. The appliance is soldered to bands on the first molars and lingual arms run from the bands
forwards to the cuspids or first bicuspids as desired.
Removable appliances
Upper removable appliance
The upper removable appliance is an expansion plate made of acrylic, with an expansion screw and steel clasps on the first deciduous
and permanent molars.
Appendix 2. MEDLINE via OVID search strategy

1. (cross-bite$ or crossbite$).mp.
2. (posterior adj8 (teeth or tooth or dental)).mp.
3. (anteroposterior adj8 (teeth or tooth or dental)).mp.
4. “dentoalveolar inclin$”.mp.
5. ((palat$ or maxilla$) adj3 (expand$ or expansion)).mp.
6. or/1-5
7. exp Orthodontics, corrective/
8. exp Orthodontics, interceptive/
9. (expan$ and (appliance$ or device$)).mp.
10. ((transpalatal or trans-palatal) and arch$).mp.
11. (“mandibular arch$” and contract$).mp.
12. (ipomaxilla$ and (correct$ or therap$)).mp.
13. (“criss-cross elastic$” or “criss cross elastic$”).mp.
14. (occlusal and grind$).mp.
15. or/7-14
16. 6 and 15
The above subject search was linked to the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in
MEDLINE: sensitivity maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of theCochrane
Handbook for Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011] (Higgins 2011).
1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
3. randomized.ab.
4. placebo.ab.
5. drug therapy.fs.
6. randomly.ab.
7. trial.ab.
8. groups.ab.
9. or/1-8
10. exp animals/ not humans.sh.
11. 9 not 10

Appendix 3. The Cochrane Oral Health Group’s Trials Register search strategy
1 ((crossbite* or cross-bite* or “cross bite*”):ti,ab) AND (INREGISTER)
2 ((“posterior teeth” or “posterior tooth”):ti,ab) AND (INREGISTER)
3 ((posterior and dental):ti,ab) AND (INREGISTER)
4 ((anteroposterior):ti,ab) AND (INREGISTER)
5 (“dentoalveolar inclin*”:ti,ab) AND (INREGISTER)
6 (((palat* or maxilla*) AND (expand* or expansion)):ti,ab) AND (INREGISTER)
7 (#1 or #2 or #3 or #4 or #5 or #6) AND (INREGISTER)
8 ((orthodontic* or interceptive):ti,ab) AND (INREGISTER)
9 ((expan* and (appliance* or device*)):ti,ab) AND (INREGISTER)
10 (((transpalatal or trans-palatal) and arch*):ti,ab) AND (INREGISTER)
11 ((“mandibular arch*” and contract*):ti,ab) AND (INREGISTER)
12 ((ipomaxilla* and (correct* or therap*)):ti,ab) AND (INREGISTER)
13 ((“criss-cross elastic*” or “criss cross elastic*”):ti,ab) AND (INREGISTER)
14 ((occlusal and grind*):ti,ab) AND (INREGISTER)
15 (#8 or #9 or #10 or #11 or #12 or #13 or #14) AND (INREGISTER)
16 (#7 and #15) AND (INREGISTER)
Appendix 4. The Cochrane Central Register of Controlled Trials (CENTRAL) search strategy
#1 (cross-bite* in All Text or crossbite* in All Text or “cross bite*” in All Text)
#2 ((posterior in All Text near/6 teeth in All Text) or (posterior in All Text near/6 tooth in All Text) or (posterior in All Text near/6
dental in All Text))
#3 ((anteroposterior in All Text near/6 teeth in All Text) or (anteroposterior in All Text near/6 tooth in All Text) or (anteroposterior in
All Text near/6 dental in All Text))
#4 “dentoalveolar inclin*” in All Text
#5 ((palat* in All Text or maxilla* in All Text) and (expand* in All Text or expansion in All Text))
#6 (#1 or #2 or #3 or #4 or #5)
#7 MeSH descriptor Orthodontics, corrective explode all trees
#8 (orthodontic* in All Text or interceptive in All Text)
#9 (expan* in All Text and (appliance* in All Text or device* in All Text))
#10 ((transpalatal in All Text or trans-palatal in All Text) and arch* in All Text)
#11 (“mandibular arch*” in All Text and contract* in All Text)
#12 (ipomaxilla* in All Text and (correct* in All Text or therap* in All Text))
#13 (“criss-cross elastic*” in All Text or “criss cross elastic*” in All Text)
#14 (occlusal in All Text and grind* in All Text)
#15 (#7 or #8 or #9 or #10 or #11 or #12 or #13 or #14)
#16 (#6 and #15)
Appendix 5. EMBASE via OVID search strategy

1. (cross-bite$ or crossbite$).mp.
2. (posterior adj8 (teeth or tooth or dental)).mp.
3. (anteroposterior adj8 (teeth or tooth or dental)).mp.
4. “dentoalveolar inclin$”.mp.
5. ((palat$ or maxilla$) adj3 (expand$ or expansion)).mp.
6. or/1-5
7. (expan$ and (appliance$ or device$)).mp.
8. ((transpalatal or trans-palatal) and arch$).mp.
9. (“mandibular arch$” and contract$).mp.
10. (ipomaxilla$ and (correct$ or therap$)).mp.
11. (“criss-cross elastic$” or “criss cross elastic$”).mp.
12. (occlusal and grind$).mp.
13. Orthodontics/
14. or/7-13
15. 6 and 14
The above subject search was linked to the Cochrane Oral Health Group filter for identifying randomised controlled trials in EMBASE
via OVID:
1. random$.ti,ab.
2. factorial$.ti,ab.
3. (crossover$ or cross over$ or cross-over$).ti,ab.
4. placebo$.ti,ab.
5. (doubl$ adj blind$).ti,ab.
6. (singl$ adj blind$).ti,ab.
7. assign$.ti,ab.
8. allocat$.ti,ab.
9. volunteer$.ti,ab.
10. CROSSOVER PROCEDURE.sh.
11. DOUBLE-BLIND PROCEDURE.sh.
12. RANDOMIZED CONTROLLED TRIAL.sh.
13. SINGLE BLIND PROCEDURE.sh.
14. or/1-13
15. (exp animal/ or animal.hw. or nonhuman/) not (exp human/ or human cell/ or (human or humans).ti.)
16. 14 NOT 15
Appendix 6. US National Institutes of Health Trials Register and the World Health Organization
(WHO) International Clinical Trials Registry Platform search strategy
orthodontic AND posterior AND crossbite
WHAT’S NEW
Date Event Description
4 April 2014 New search has been performed Searches updated to 21 January 2014.
4 April 2014 New citation required and conclusions have changed Inclusion criteria changed to only include randomised con-
trolled trials (RCTs). Therefore we have discarded six of the
controlled clinical trials included in the previous version. To
the remaining three RCTs we have added 12 new included
RCTs in this update
All sections updated to reflect up-to-date Cochrane review
methodology and methodological expectations of Cochrane
intervention reviews (MECIR). Risk of bias assessment of
included studies carried out and summary of findings tables
added

HISTORY
Date Event Description
23 June 2008 Amended Converted to new review format.
16 November 2000 New citation required but conclusions have not Substantive amendment. A further CCT has been
changed found on two-point versus four-point expansion
(Schneiderman 1990) and follow-up data on the treat-
ment group from Lindner 1989 (Tsarapatsani 1999).
Conclusions remain largely unchanged
CONTRIBUTIONS OF AUTHORS
Jayne Harrison (JH) and Deborah Ashby wrote the protocol and previous versions of the review.
For the update:
• screening the search results and retrieving the papers: Paola Agostino (PA), Alessandro Ugolini (AU), Armando Silvestrini-
Biavati (ASB);
• data extraction and risk of bias assessment: PA, AU, ASB, Alessio Signori (AS), Philip Riley (PR);
• analysing the data and interpreting the results: PA, AU, PR, AS, Jayne Harrison (JH);
• creating the ’Summary of findings’ (GRADE) tables: PR;
• writing the results, discussion and conclusions: PA, AU, PR, JH.
DECLARATIONS OF INTEREST
Paola Agostino, Alessio Signori, Armando Silvestrini-Biavati, Alessandro Ugolini, Jayne E Harrison, Philip Riley: no interests to declare.
SOURCES OF SUPPORT
Internal sources
• Department of Surgical and Diagnostic Sciences, University of Genoa, Italy.
Provision of IT support and open access to the university library.
• Royal Liverpool and Broadgreen University Hospitals Trust (RLBUHT)/NHS, UK.
• School of Dentistry, The University of Manchester, UK.
• MAHSC, UK.
The Cochrane Oral Health Group is supported by the Manchester Academic Health Sciences Centre (MAHSC) and the NIHR
Manchester Biomedical Research Centre.

External sources
• National Health Service (NHS), UK.
Jayne Harrison received research and development grant funding support for previous versions of this review.
• Cochrane Oral Health Group Global Alliance, UK.
All reviews in the Cochrane Oral Health Group are supported by Global Alliance member organisations (British Association of Oral
Surgeons, UK; British Orthodontic Society, UK; British Society of Paediatric Dentistry, UK; British Society of Periodontology, UK;
Canadian Dental Hygienists Association, Canada; Mayo Clinic, USA; National Center for Dental Hygiene Research & Practice,
USA; New York University College of Dentistry, USA; and Royal College of Surgeons of Edinburgh, UK) providing funding for the
editorial process (http://ohg.cochrane.org/).
• National Institute for Health Research (NIHR), UK.
CRG funding acknowledgement:
The NIHR is the largest single funder of the Cochrane Oral Health Group.
Disclaimer:
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the
Department of Health.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
• The original protocol and previous versions of this review included controlled clinical trials (CCTs) and quasi-RCTs. In order to
attempt to limit bias, we only included RCTs in this update.
• We clarified that ’correction of crossbite’ is the primary outcome of this review by listing is as such in the ’Methods’ section.
INDEX TERMS
Medical Subject Headings (MeSH)

Orthodontic Appliances; Orthodontic Retainers; Orthodontics, Corrective [∗ methods]; Overbite [∗ therapy]; Palatal Expansion Tech-
nique; Randomized Controlled Trials as Topic; Temporomandibular Joint Dysfunction Syndrome [therapy]
MeSH check words

Adolescent; Child; Child, Preschool; Humans


Agostino Et Al-2014-Cochrane Database of Systematic Reviews PDF

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Agostino Et Al-2014-Cochrane Database of Systematic Reviews PDF

Transféré par

Droits d'auteur :

Formats disponibles

Cochrane Database of Systematic Reviews

Orthodontic treatment for posterior crossbites (Review)

Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P

Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison JE, Riley P.

Orthodontic treatment for posterior crossbites (Review)

Orthodontic treatment for posterior crossbites (Review) i

Orthodontic treatment for posterior crossbites

Editorial group: Cochrane Oral Health Group.

To assess the effects of orthodontic treatment for posterior crossbites.

Data collection and analysis

PLAIN LANGUAGE SUMMARY

Orthodontic treatment for posterior crossbites (Review) 3

Assumed risk Corresponding risk

M olar expansion N/ A N/ A N/ A 53 ⊕ 2 studies (1 high risk of

tooth borne (Hyrax)

N/ A N/ A N/ A N/ A N/ A N/ A The rem aining com -

CI: conf idence interval; N/ A: not applicable.

GRADE Working Group grades of evidence

Description of the condition Description of the intervention

Orthodontic treatment for posterior crossbites (Review) 6

Why it is important to do this review Primary

Search methods for identification of studies

Orthodontic treatment for posterior crossbites (Review) 7

Orthodontic treatment for posterior crossbites (Review) 8

Measures of treatment effect Subgroup analysis and investigation of heterogeneity

Orthodontic treatment for posterior crossbites (Review) 9

Orthodontic treatment for posterior crossbites (Review) 10

Orthodontic treatment for posterior crossbites (Review) 11

Orthodontic treatment for posterior crossbites (Review) 12

Risk of bias in included studies

Orthodontic treatment for posterior crossbites (Review) 13

Orthodontic treatment for posterior crossbites (Review) 14

Orthodontic treatment for posterior crossbites (Review) 15

Overall risk of bias

Effects of interventions Four-point banded (Hyrax) versus two-point banded (Hyrax)

1. Fixed appliance with mid-palatal expansion Slow expansion

Orthodontic treatment for posterior crossbites (Review) 16

Orthodontic treatment for posterior crossbites (Review) 17

Assumed risk Corresponding risk

Removable - slow Fixed - slow expansion

N/ A N/ A N/ A N/ A N/ A N/ A 1 of the 2 studies in this

GRADE Working Group grades of evidence

Other comparisons for treating posterior crossbites

Assumed risk Corresponding risk

N/ A N/ A N/ A N/ A N/ A N/ A The com parisons were

canine expansion with

GRADE Working Group grades of evidence

Summary of main results

Orthodontic treatment for posterior crossbites (Review) 22

Orthodontic treatment for posterior crossbites (Review) 23

Orthodontic treatment for posterior crossbites (Review) 25

References to other published versions of this review

Orthodontic treatment for posterior crossbites (Review) 26

Characteristics of included studies [ordered by study ID]

Methods Study design: RCT (2 arms)

Participants Inclusion criteria: Children with posterior crossbites

Notes No sample size calculation reported

Bias Authors’ judgement Support for judgement

Orthodontic treatment for posterior crossbites (Review) 27

Blinding of outcome assessment (detection Unclear risk Not mentioned

Other bias Low risk No other sources of bias identified

Methods Study design: RCT (2 arms)

Outcomes Transverse maxillary expansion