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MANAGEMENT OF FACIAL
ASYMMETRY
PRESENTED BY:
Dr. SHAZEENA QAISER
INTRODUCTION
• Facial esthetics evaluation is the most important part of the orthodontic
treatment-planning procedure.
• T...
DEFINITIONS
‘DORLAND’
•Symmetry:
The similar arrangement in form & relationship of parts
around a common axis or on each s...
Woo (1931)-
• Bones of cranium show asymmetry- rt. side being larger
• Bones of facial complex – contralateral asymmetry.
...
CLASSIFICATION OF FACIAL ASYMMETRIES
1. Skeletal
asymmetries
2. Soft tissue
asymmetries
3. Functional
asymmetries
ETIOLOGY
AJO PIRTTINIEMI 1994
A. PRENATAL CAUSES
• 1. Facial clefting syndromes
- unilateral CLCP - craniofacial clefts
I....
B. Postnatal causes
• 1.Trauma & infection
• 2. Muscle dysfunction
• 3. Functional deviations
• 4.TMJ derangements
• 5. He...
A. Malformations with abnormal developmental
processes in embryonic stage ( 1%)
1.Hemifacial microsomia
2.Congenital hemif...
B. Deformations caused by non disruptive
mechanical forces during fetal period:(2%)
1.Congenital muscular torticollis
2.Po...
C. Disruptions caused by breakdown of normal
developmental processes with onset later in life
1.Unilateral condylar hyperp...
DIAGNOSIS
1.History
2. Clinical examination
3.Radiographic examination
4.Photographic analysis
5.Digital videography
6.Art...
HISTORY:
•-Can reveal aetiology
•-Severity of deformity
CLINICAL
EXAMINATION
• Reveals asymmetry in the
vertical, antero-p...
EXTRAORAL EVALUATION
• Frontal
-Mid pupillary distance aligned with commissures
1. Inter ocular dimensions-
interpupillary-65mm
inter canthal- 35mm
2.Midfacial bony support-
lower third of iris of the e...
VERTICAL
Vertical reference plane- nasion to subnasale
•upper horizontal plane – bipupillary line
• lower horizontal line ...
Arnett and Bergman AJO1993
•The pupils are assessed for level with the horizon.
If in level - used as horizontal reference...
The pupils are not level to the horizon:
A constructed frontal horizontal reference line is
visualized as follows:
• 1. Fr...
SUBMENTOVERTEXVIEW
INTRA ORAL EXAMINATION
1. Evaluation of the dental midlines
2.Vertical occlusal evaluation
-Transverse cant of maxilla
3.T...
FUNCTIONAL EXAMINATION
1. Maximal opening
2. TMJ evaluation
•postural rest position
•-CR-CO discrepancy
•-laterocclusion/ ...
RADIOGRAPHIC EXAMINATION
Importance of head position
1.The lateral cephalogram
2.The panoramic radiograph
3. Postero-anter...
LATERAL CEPHALOGRAM
Only little useful information
In CR ,CO and initial contact permits
visualization of mand.position
OP...
PA CEPHALOGRAM
• Important adjunct for qualitative & quantitative evaluation of
dentofacial region
• Extent of deformity( ...
Various P.A Analysis:
• Rickett’s Analysis
• Svanholt and Solow Analysis
• Grummon’s Analysis
• Grayson’s Analysis
• Hewit...
• COMPUTED TOMOGRAPHY
3-D evaluation of osseous & soft tissues Complex diagnosis
•3-DIMENSIONAL CT
-Reproduces detailed sk...
PHOTOGRAPHIC ANALYSIS
• Head position, patient position, flash
• Extra oral Photographs –
Frontal - lips relaxed , smile
O...
Photographic montage/ composite
photographs
•-reveal altered facial form and disclose difference in
configuration of both ...
TREATMENT MODALITIES
SKELETAL ASYMMETRIES:
• In growing Individuals, orthopedic appliances in conjunction with
orthodontics are used to help im...
FUNCTIONAL ASYMMETRIES
• Mild deviations caused by functional shifts -minor occlusal
adjustments
• More severe deviations ...
SOFT TISSUE ASYMMETRIES
• Deformities caused by soft tissue imbalance can be treated by
either augmentation or reduction s...
AsymmetryTreatment
Growing Children
Hybrid
Functional
Appliances
Distraction
Osteogenesis
Adults
Surgical
OSTEOTOMY
Orthod...
TREATMENT POSSIBILITIES
1. MAXILLARY ARCH EXPANSION
2. ORTHODONTIC ARCH COORDINATION
3. SPLINTS
4.OCCLUSALTHERAPY
MAXILLARY EXPANSION
• 1. Slow expansion
• 2. Orthopedic rapid palatal expansion
• 3. SARPE
• 4. Segmental osteotomy
To ach...
SLOW EXPANSION:
• Can bring about skeletal expansion in primary dentition
• Lingual arch /quad helix- 50% sk. exp.
• Jack ...
RAPID PALATAL EXPANSION
• Very successful in children prior to sutural closure.
• 0.5mm day- 10 mm exp. in 20 days- 75- 80...
SARPE:
• Brown(1938)-described SARPE with midpalatal split
• Shetty(1994)-main areas of resistance to expansion
are midpal...
• Should be done after mand Decompensation
• During surgery – activated by 1- 1.5mm – 5 days of rest –0.5mm
day
• Spacing ...
Segmental Lefort I osteotomy
• Indicated in open bite cases, where SARPE is
contraindicated
•Total down fracture of maxill...
Repositioning splints AJO 1991. Schmid et.al.
• Used mainly inTMJ dysfunctions
• Indicated only when it is impossible to i...
Orthopaedic Hybrid Functional Appliances
• Hybrid /blend of several components designed to address specific problems
These...
• Functional appliances used either alone or in conjunction with
surgery for the following purposes:
• (1) to improve symm...
Herbst appliance:
• Works as an artificial joint between the maxilla and the mandible.
The appliance is fixed to the teeth...
Twin block AJO 1988 Clark
•When activated unilaterally - correct postur mand.
displacement (mid line displacement an asymm...
DISTRACTION OSTEOGENESIS
•The regeneration of bone between
vascularised bone surfaces that are separated
by gradual distra...
Surgical Osteotomy
•Maxillary hypoplasia:
Le-forte 1 osteotomy
With max.advancement.
•Maxillary hyperplasia:
maxillary seg...
mandibular hyperplasia:
1)sagital split osteotomy.
2)sub-sigmoid osteotomy.
•Mandibular hypoplasia:
1)sagital split osteo...
Orthodontic camouflage-
When skeletal deformity is very mild and any further change is
not expected, camouflage should be ...
•Normal –transverse occlusal plane – esthetic&- parallel
to the transcommisural line & a line tangent to lower lip
•Asymme...
2. Midline coordination
•Translate midline (asymmetric extractions)
•Tipping of the teeth to midline
•Altering the occlusa...
Occlusal therapy
•Selective grinding /Occlusal adjustment
-Reshaping the occlusal surfaces of the teeth to achieve a desir...
Rule of thirds
Each inner incline of posterior teeth is divided into 3 equal parts:
• If opposing centric cusp tip contact...
DENTAL COMPENSATIONS
• Midline shifts- dental compensation to make the dental midline
shift
• Axial inclination of molars
...
Surgical
•Conditions with severe skeletal asymmetries are
not able to be corrected by orthodontic camouflage
and growth mo...
1. Distraction osteogenesis
2.Maxillary surgeries - Lefort I
3. Mandibular surgeries
- BSSO
- Inferior body osteotomy
- ge...
1)Rhinoplasty.
2)Genioplasty.
3)Cheiloraphy.
COSMETIC SURGERIES
CONCLUSION
•A team approach in the management of
asymmetries always produces a high degree of
success which influences the...
Management of Facial asymmetry
Management of Facial asymmetry
Management of Facial asymmetry
Management of Facial asymmetry
Management of Facial asymmetry
Management of Facial asymmetry
Management of Facial asymmetry
Management of Facial asymmetry
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Management of Facial asymmetry

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Management of Facial asymmetry

  1. 1. MANAGEMENT OF FACIAL ASYMMETRY PRESENTED BY: Dr. SHAZEENA QAISER
  2. 2. INTRODUCTION • Facial esthetics evaluation is the most important part of the orthodontic treatment-planning procedure. • The attainment of the best facial esthetic appearance for a given patient is a primary goal of orthodontic treatment. • The evaluation of a patient’s frontal symmetry is the most critical aspect of diagnosis because this is the most appreciated view for any individual. Even the most esthetic faces are associated with mild forms of facial asymmetry. • The individuals who report for an orthodontic treatment are often associated with facial asymmetry that may be greater than the acceptable norms.
  3. 3. DEFINITIONS ‘DORLAND’ •Symmetry: The similar arrangement in form & relationship of parts around a common axis or on each side of a plane of a body. •Asymmetry Variations in the size & relationships of the two sides of a body
  4. 4. Woo (1931)- • Bones of cranium show asymmetry- rt. side being larger • Bones of facial complex – contralateral asymmetry. Vig & Hewitt (AO 1975)- • Dentoalveolar region exhibit greatest symmetry. • Allows symmetric functions even with asymmetric jaws.
  5. 5. CLASSIFICATION OF FACIAL ASYMMETRIES 1. Skeletal asymmetries 2. Soft tissue asymmetries 3. Functional asymmetries
  6. 6. ETIOLOGY AJO PIRTTINIEMI 1994 A. PRENATAL CAUSES • 1. Facial clefting syndromes - unilateral CLCP - craniofacial clefts I. GENETIC • 1. Hemi facial microsomia • 2. Neurofibromatosis • 3. Birth trauma • 4. Intra uterine pressure during preg. II . CONGENITAL
  7. 7. B. Postnatal causes • 1.Trauma & infection • 2. Muscle dysfunction • 3. Functional deviations • 4.TMJ derangements • 5. Hemi mandibular hypertrophy • 6.Pathologies ENVIRONMENTAL
  8. 8. A. Malformations with abnormal developmental processes in embryonic stage ( 1%) 1.Hemifacial microsomia 2.Congenital hemifacial hypertrophy 3.Cleft lip & palate COHEN 1982
  9. 9. B. Deformations caused by non disruptive mechanical forces during fetal period:(2%) 1.Congenital muscular torticollis 2.Postural scoliosis 3.Plagiocephaly
  10. 10. C. Disruptions caused by breakdown of normal developmental processes with onset later in life 1.Unilateral condylar hyperplasia 2.Hemifacial atrophy 3.Infections & inflammations 4.Fracture & trauma 5.Lateral malocclusion 6.Muscular dysfunction
  11. 11. DIAGNOSIS 1.History 2. Clinical examination 3.Radiographic examination 4.Photographic analysis 5.Digital videography 6.Articulated study models
  12. 12. HISTORY: •-Can reveal aetiology •-Severity of deformity CLINICAL EXAMINATION • Reveals asymmetry in the vertical, antero-posterior , lateral dimension.
  13. 13. EXTRAORAL EVALUATION • Frontal
  14. 14. -Mid pupillary distance aligned with commissures
  15. 15. 1. Inter ocular dimensions- interpupillary-65mm inter canthal- 35mm 2.Midfacial bony support- lower third of iris of the eye to be covered with lower eyelid
  16. 16. VERTICAL Vertical reference plane- nasion to subnasale •upper horizontal plane – bipupillary line • lower horizontal line - through the stomion
  17. 17. Arnett and Bergman AJO1993 •The pupils are assessed for level with the horizon. If in level - used as horizontal reference line •(1) upper canine level •(2) lower canine level •(3) chin and jaw level.
  18. 18. The pupils are not level to the horizon: A constructed frontal horizontal reference line is visualized as follows: • 1. Frontal natural head posture. • 2. Horizontal line parallel to the horizon through the pupil area • 3. Assess other structures relative to this line
  19. 19. SUBMENTOVERTEXVIEW
  20. 20. INTRA ORAL EXAMINATION 1. Evaluation of the dental midlines 2.Vertical occlusal evaluation -Transverse cant of maxilla 3.Transverse and antero-posterior occlusal evaluations • Unilateral cross bites • B-L inclination of teeth
  21. 21. FUNCTIONAL EXAMINATION 1. Maximal opening 2. TMJ evaluation •postural rest position •-CR-CO discrepancy •-laterocclusion/ laterognathia 3. Motor & sensory evaluation
  22. 22. RADIOGRAPHIC EXAMINATION Importance of head position 1.The lateral cephalogram 2.The panoramic radiograph 3. Postero-anterior projection 4. Submento vertex view 5. 3-D cephalograms
  23. 23. LATERAL CEPHALOGRAM Only little useful information In CR ,CO and initial contact permits visualization of mand.position OPG: Gross pathologies -Size &shape of condyle, ramus &body of mandible
  24. 24. PA CEPHALOGRAM • Important adjunct for qualitative & quantitative evaluation of dentofacial region • Extent of deformity( orbital/ upper facial symmetry), • Skeletal /dental involvement.
  25. 25. Various P.A Analysis: • Rickett’s Analysis • Svanholt and Solow Analysis • Grummon’s Analysis • Grayson’s Analysis • Hewitt analysis • Chierici method
  26. 26. • COMPUTED TOMOGRAPHY 3-D evaluation of osseous & soft tissues Complex diagnosis •3-DIMENSIONAL CT -Reproduces detailed skeletal pathology - Assess post treatment changes •MRI SCAN -Also provide 3-D representation of deformity -For better visualization of soft tissue
  27. 27. PHOTOGRAPHIC ANALYSIS • Head position, patient position, flash • Extra oral Photographs – Frontal - lips relaxed , smile Oblique ( rt & lt) , Profile ( rt & lt), Submental • Intra oral photographs •Impossible to assess dynamic asymmetries
  28. 28. Photographic montage/ composite photographs •-reveal altered facial form and disclose difference in configuration of both sides of the face
  29. 29. TREATMENT MODALITIES
  30. 30. SKELETAL ASYMMETRIES: • In growing Individuals, orthopedic appliances in conjunction with orthodontics are used to help improve or correct the developing imbalance. • Severe discrepancies may require a combination of surgery and orthodontics. • Abnormalities of the coronoid and condylar processes as well as in the position and shape of the articular disks should be considered when limited opening, acute mal- occlusions, or mandibular deviations are found.
  31. 31. FUNCTIONAL ASYMMETRIES • Mild deviations caused by functional shifts -minor occlusal adjustments • More severe deviations -orthodontic treatment to align the teeth • Occlusal splints may be necessary to properly evaluate the presence and extent of the functional shift by eliminating the habitual posturing and de- programming the musculature. • Because functional shift can also be the result of a skeletal asymmetry, rapid maxillary expansion, orthognathic surgery, and orthodontic treatment may be indicated in the management of these cases.
  32. 32. SOFT TISSUE ASYMMETRIES • Deformities caused by soft tissue imbalance can be treated by either augmentation or reduction surgery. • Augmentations include the use of bone grafts and silicone implants to re-contour the desired areas of the face. • With the mild dental, skeletal, and soft tissue deviations the advisability of treatment should be carefully considered.
  33. 33. AsymmetryTreatment Growing Children Hybrid Functional Appliances Distraction Osteogenesis Adults Surgical OSTEOTOMY Orthodontic camouflage Functional asymmetry Occlusal Callibration Splints
  34. 34. TREATMENT POSSIBILITIES 1. MAXILLARY ARCH EXPANSION 2. ORTHODONTIC ARCH COORDINATION 3. SPLINTS 4.OCCLUSALTHERAPY
  35. 35. MAXILLARY EXPANSION • 1. Slow expansion • 2. Orthopedic rapid palatal expansion • 3. SARPE • 4. Segmental osteotomy To achieve desired expansion with stability,it should be accomplished by sutural adjustments & not by alveolar bending dental tipping
  36. 36. SLOW EXPANSION: • Can bring about skeletal expansion in primary dentition • Lingual arch /quad helix- 50% sk. exp. • Jack screw • FR functional regulator - indirect effect
  37. 37. RAPID PALATAL EXPANSION • Very successful in children prior to sutural closure. • 0.5mm day- 10 mm exp. in 20 days- 75- 80% of sutural expansion Haas type Hyrax type Minn expander • 3:2 ratio of widening in canines & molars
  38. 38. SARPE: • Brown(1938)-described SARPE with midpalatal split • Shetty(1994)-main areas of resistance to expansion are midpalatal suture followed by pterygomaxillary buttress • Subtotal Lefort I osteotomy –except posterior and superior articulations
  39. 39. • Should be done after mand Decompensation • During surgery – activated by 1- 1.5mm – 5 days of rest –0.5mm day • Spacing between central incisors • Expansion completed within 4 weeks of surgery
  40. 40. Segmental Lefort I osteotomy • Indicated in open bite cases, where SARPE is contraindicated •Total down fracture of maxilla followed by anterior segmenting. •Maximum expansion occurs in molar area •Advantage: minimal relapse •Disadv: exp. more than 6mm
  41. 41. Repositioning splints AJO 1991. Schmid et.al. • Used mainly inTMJ dysfunctions • Indicated only when it is impossible to identify functional interferences due to neuromuscular adaptation • Superior repositioning splints are preferred • Regular wear for 2-3 mths enables compensatory changes in TMJ.
  42. 42. Orthopaedic Hybrid Functional Appliances • Hybrid /blend of several components designed to address specific problems These components produce basal and dentoalveolar changes by acting on the following: • 1. Eruption (biteplanes) • 2. Linguofacial muscle balance (shields or screens) • 3. Mandibular repositioning
  43. 43. • Functional appliances used either alone or in conjunction with surgery for the following purposes: • (1) to improve symmetry of the mandible and maxillary deficiency, • (2) to restore the dental occlusion, • (3) to expand soft tissues • (4) to lengthen the mandibular ramus
  44. 44. Herbst appliance: • Works as an artificial joint between the maxilla and the mandible. The appliance is fixed to the teeth -orthodontic bands. • The appliance is constructed to displace the mandible anteriorly and to the unaffected side for correction of the mandibular retrusion and asymmetry. • The construction bite - incisors in an edge-to-edge position , midline overcorrected by 3.5 mm.
  45. 45. Twin block AJO 1988 Clark •When activated unilaterally - correct postur mand. displacement (mid line displacement an asymmetric buccal segment relationships).
  46. 46. DISTRACTION OSTEOGENESIS •The regeneration of bone between vascularised bone surfaces that are separated by gradual distraction.
  47. 47. Surgical Osteotomy •Maxillary hypoplasia: Le-forte 1 osteotomy With max.advancement. •Maxillary hyperplasia: maxillary segmental setback. •Maxillary vertical excess: leforte-1 osteotomy with maxillary impaction.
  48. 48. mandibular hyperplasia: 1)sagital split osteotomy. 2)sub-sigmoid osteotomy. •Mandibular hypoplasia: 1)sagital split osteotomy with mandibular advancement.
  49. 49. Orthodontic camouflage- When skeletal deformity is very mild and any further change is not expected, camouflage should be considered. 1.Transverse cant correction • 2 occlusal planes : upper &lower Connects incisal edge of C.I to M-B cusp tip of I molars –important for normal intercuspation . • Natural plane of occlusion: axial inclinations of premolars to be perpendicular & that of molars mesially inclined
  50. 50. •Normal –transverse occlusal plane – esthetic&- parallel to the transcommisural line & a line tangent to lower lip •Asymmetry cases – transcommisural lines’ll not be parallel to other facial planes – treatment occlusal plane should not be parallel to facial planes
  51. 51. 2. Midline coordination •Translate midline (asymmetric extractions) •Tipping of the teeth to midline •Altering the occlusal cant
  52. 52. Occlusal therapy •Selective grinding /Occlusal adjustment -Reshaping the occlusal surfaces of the teeth to achieve a desired occlusal contact pattern -Removal of the tooth structure limited to enamel. • Restorations of teeth – crowns & FPDs
  53. 53. Rule of thirds Each inner incline of posterior teeth is divided into 3 equal parts: • If opposing centric cusp tip contacts the third closest to the central fossa – selective grinding • If opposing centric cusp tip touches the middle third – crowns FPDs • If opposing centric cusp tip contacts the cusp tip –orthodontic arch coordination
  54. 54. DENTAL COMPENSATIONS • Midline shifts- dental compensation to make the dental midline shift • Axial inclination of molars – to compensate for the developing cross bite in the contralateral side • Canting of maxillary occlusal plane
  55. 55. Surgical •Conditions with severe skeletal asymmetries are not able to be corrected by orthodontic camouflage and growth modification so surgical procedures are used to correct the deformities or asymmetries.
  56. 56. 1. Distraction osteogenesis 2.Maxillary surgeries - Lefort I 3. Mandibular surgeries - BSSO - Inferior body osteotomy - genioplasty 4.TMJ surgeries 5. Autogenous/alloplastic augmentation
  57. 57. 1)Rhinoplasty. 2)Genioplasty. 3)Cheiloraphy. COSMETIC SURGERIES
  58. 58. CONCLUSION •A team approach in the management of asymmetries always produces a high degree of success which influences the social & personal well being of these patients. •Joining hands together enlightens the future of such patients.

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