MANAGEMENT OF FACIAL
Dr. SHAZEENA QAISER
• Facial esthetics evaluation is the most important part of the orthodontic
• 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
The similar arrangement in form & relationship of parts
around a common axis or on each side of a plane of a body.
Variations in the size & relationships of the two sides of a
• 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.
A. Malformations with abnormal developmental
processes in embryonic stage ( 1%)
2.Congenital hemifacial hypertrophy
3.Cleft lip & palate
B. Deformations caused by non disruptive
mechanical forces during fetal period:(2%)
1.Congenital muscular torticollis
C. Disruptions caused by breakdown of normal
developmental processes with onset later in life
1.Unilateral condylar hyperplasia
3.Infections & inflammations
4.Fracture & trauma
-Mid pupillary distance aligned with commissures
1. Inter ocular dimensions-
inter canthal- 35mm
2.Midfacial bony support-
lower third of iris of the eye to be covered
with lower eyelid
Vertical reference plane- nasion to subnasale
•upper horizontal plane – bipupillary line
• lower horizontal line - through the stomion
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.
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
• 3. Assess other structures relative to this line
• In growing Individuals, orthopedic appliances in conjunction with
orthodontics are used to help improve or correct the developing
• Severe discrepancies may require a combination of surgery and
• 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.
• Mild deviations caused by functional shifts -minor occlusal
• 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
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.
• 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
• Can bring about skeletal expansion in primary dentition
• Lingual arch /quad helix- 50% sk. exp.
• Jack screw
• FR functional regulator - indirect effect
RAPID PALATAL EXPANSION
• Very successful in children prior to sutural closure.
• 0.5mm day- 10 mm exp. in 20 days- 75- 80% of sutural
• 3:2 ratio of widening in canines & molars
• Brown(1938)-described SARPE with midpalatal split
• Shetty(1994)-main areas of resistance to expansion
are midpalatal suture followed by pterygomaxillary
• Subtotal Lefort I osteotomy –except posterior and
• Should be done after mand Decompensation
• During surgery – activated by 1- 1.5mm – 5 days of rest –0.5mm
• Spacing between central incisors
• Expansion completed within 4 weeks of surgery
Segmental Lefort I osteotomy
• Indicated in open bite cases, where SARPE is
•Total down fracture of maxilla followed by anterior
•Maximum expansion occurs in molar area
•Advantage: minimal relapse
•Disadv: exp. more than 6mm
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
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
• 1. Eruption (biteplanes)
• 2. Linguofacial muscle balance (shields or screens)
• 3. Mandibular repositioning
• Functional appliances used either alone or in conjunction with
surgery for the following purposes:
• (1) to improve symmetry of the mandible and maxillary
• (2) to restore the dental occlusion,
• (3) to expand soft tissues
• (4) to lengthen the mandibular ramus
• 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.
Twin block AJO 1988 Clark
•When activated unilaterally - correct postur mand.
displacement (mid line displacement an asymmetric
buccal segment relationships).
•The regeneration of bone between
vascularised bone surfaces that are separated
by gradual distraction.
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
•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
2. Midline coordination
•Translate midline (asymmetric extractions)
•Tipping of the teeth to midline
•Altering the occlusal cant
•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
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
• If opposing centric cusp tip contacts the cusp tip –orthodontic
• Midline shifts- dental compensation to make the dental midline
• Axial inclination of molars
– to compensate for the developing cross bite in the contralateral
• Canting of maxillary occlusal plane
•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.
•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.