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