CRANIOFACIAL
ASYMMETRY
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INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

www.indiandentalacademy.com
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Introduction & Definitions
Epidemiology of Asymmetries
Etiology a nd Development of
Asymmetries
Cra niofacial
Den...
Introduction to Facial
Asymmetries

www.indiandentalacademy.com




Human beings like any other creation of god
display bilateral symmetry except for some
minor negligible variations.
...






By strict definition a mirror
image of right to left is
referred to as symmetry.
Due to various environmental or
...






Asymmetry in the craniofacial region was
first recognized by an artist Hasse in 1887.
Since then many anatomists,...






Orthodontists are usually preoccupied with
lateral facial aspect while general public judge
beauty, symmetry & ha...


Stedman's Medical Dictionary
defines Symmetry as

“equality or correspondence
in form of parts distributed
around a cen...


American College Dictionary
defines symmetry as
“the correspondence in size,
form, and arrangement of parts
on opposite...
Epidemiology of
Asymmetries

www.indiandentalacademy.com




In most individuals the right side of the
face is slightly larger than the left ,and
usually there is some asymmetry...






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Asymmetry of the upper face
was seen in only 5%,
36% had a middle third
asymmetry, usually just the
nose but s...


Prevalence of orthodontic asymmetries:
Peck & Peck. 1991: studied bilaterally facial asymm. In 52 adult
white people wi...
www.indiandentalacademy.com


According to LUNDSTROM in 1961

QUANTITATIVE
ASYMMETRY

QUALITATIVE
ASYMMETRY

includes differences in
the no. of teeth...




A. Dental Asymmetries:
can be due to Local factors such as loss of
deciduous teeth, congenitally missing teeth,
habi...




C) Muscular Asymmetries :
Hemifacial atrophy or cerebral palsy,
abnormal muscle functional
D) Functional Asymmetry:
...
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

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Eyes : unilateral micropthalmia , anopthalmia
Nose : unilateral arhinia, heminasal aplasia, absence
of one nost...
Based on Morphology
www.indiandentalacademy.com

:-Derek Henderson et al
Tessier’s Clefts (1976)

www.indiandentalacademy.com
Subramani & Murthy
Indian J Plast Surg: Dec :2005

www.indiandentalacademy.com
www.indiandentalacademy.com
Etiology & Development
of Asymmetries

www.indiandentalacademy.com


Two main cause of asymmetries are
Genetic
imperfections

www.indiandentalacademy.com

Environmental
factors


Hemifacial microsomia,



Retinoic acid and thalidomide teratology,



Clefting syndromes,



Craniosynostoses.



...


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Intra –uterine pressure during pregnancy and
significant pressure in the birth canal during
parturition.
Pathologic:...


Clinically significant asymmetry is etiologically and pathologically
heterogeneous and may be localised or generalised
...
Skeletal Asymmetries

www.indiandentalacademy.com
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CHIN
MANDIBLE
MANDIBLE + CHIN
MAXILLA + MANDIBLE
MAXILLA + MANDIBLE + CHIN
ZYGOMA + NOSE + FRONTAL
www.indian...


To visualize the 3
dimensional alteration of
mid facial and mandiblular
complex to specifically
identify the asymmetry....
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Transverse asymmetry
Cant of lower border of chin
AP asymmetry

www.indiandentalacademy.com
Acc to Souyris et al. 1983:
1.
Infections :
2.
Trauma and fractures
3.
Defective musculature
4.
Cysts and tumors
5.
Fibro-...




Usually is a resultant
of mandibular defects
or a defect in itself or
associated structures.
These are usually seen
...
Dental Asymmetries

www.indiandentalacademy.com
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
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Midline deviations
Sub division cases
Unilateral posterior cross bites
Unilateral impacted teeth
 Resulting in m...

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Arch form deviation
Frontal dental cants
Unilateral mesial movement of
posterior teeth
Missing teeth
Shape and ...
www.indiandentalacademy.com
• A thorough clinical examination and radiographic examination are
necessary to determine the extent of the Soft tissue, S...




It revels asymmetry in vertical, AP &
lateral dimension.
STEPS IN CLINICAL EVALUATION:
i.
Evaluation of the dental m...
RULE OF FIFTHS AND THIRDS

www.indiandentalacademy.com




A no. of projections are available to properly identify the
causes and location of the asymmetry
Lateral cephalogram...
CRANIOFACIAL ASYMMETRY BY MULTIPLANE CEPHALOMETRY

-Barry H. Grayson, Joseph G. McCarthy, Fred Bookstein,

1. Lateral ceph...
Grummon’s frontal analysis

www.indiandentalacademy.com
CRITERIA

RIGHT

LEFT

DIFFERENCE

HORIZONTAL PLANE
ZA line to MSR
(angular)
ZA to MSR (linear)
ZA to outer cranium
(linea...
LINEAR ASSYMETRY
MSR – Co
MSR – NC
MSR – J
MSR – Ag
MSR – Me
MAXILLO – MANDIBULAR ASSYMETRY
A1 offset
B1 offset
A6 to J
(p...
www.indiandentalacademy.com


Jug Handle projection: sub-mento vertex view




The exact position of the chin and rest of the mandible to
the maxil...
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CT scans
CBCT (cone beam CT)
CAT scan (computer axial tomography)
Laser scanning
OrthoCAD and E-Model...
Treatment of Asymmetries

www.indiandentalacademy.com




These conditions are heterogeneous and require
extensive multi speciallity approach to achieve
comprehensive treatme...
Treatment is divided into 3 stages:
stages




Preadolescent children
Adolescent
Adults

www.indiandentalacademy.com


Principles of treatment:
In pre-adolescent children , 2 major problems
cause severe asymmetry:
A) Hemifacial Microsomia...






In both conditions the maxilla is affected
secondarily as deficient vertical growth of
the mandible leads to dist...




The major reason for early surgical
intervention would be to improve the
chances of subsequent favorable growth
Surg...
Treatment options

A) Growth modification with Asymmetric
functional appliance
 Asymmetric (Hybrid) functional appliance
...
Hybrid appliance

www.indiandentalacademy.com



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Complex congenital condition with
an extremely variable phenotype
Incidence: 1: 5600 birth
Male: Female = 3:2
...
Clinical Features:
 Represented by the acronym: “OMENS”

 O- orbital dysphasia
 M- mandibular hypoplasia
 E- ear defec...
BJ Plast Surg: 1997: 536 – 551
Proffit & White 580 – 587
J P Reyneke : 233
www.indiandentalacademy.com
Bishara

et al AO 1...
Three grades
1)
Grade I: The soft tissue and mandible are
present but deficient on the affected side
2)
Grade II: the mand...




In general, children with grade I AND mild
grade II problems may respond favorably to
functional appliance therapy a...
Principle

stages & techniques
applicable to treatment of HFM

B J Plast Surg: 1997: 536 – 551
www.indiandentalacademy.co...


Surgical correction:
correction
Three stage of surgical intervention
described by Converse et al
1) Stage I : Tissue au...
2) Stage II: Orthognathic surgery
3) Stage III: contour modification is done to
III
enhance the contour of the skeletal an...
By far the most frequent growth problem due
to trauma in a child is asymmetric deficiency
secondary to an early fracture o...
2) Post treatment asymmetry:
early surgery to make translation of condyle
possible to guide subsequent
growth
3) Reconstru...
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3rd major cause of asymmetry

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Affected in an multi articular form

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Treatment with functional appliance is not
...
Excessive verses deficient mandibular growth
•

Functional appliance until growth is complete or all
complete, to prevent ...
Clinical management of
Hemi- Mandibular Hypertrophy

• Remove the growth site at the head of the affected

condyle
• Hybri...
Hemimandibular hypertrophy
www.indiandentalacademy.com


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In adults skeletal asymmetry can not be managed
orthodontically.
Initial alignment followed by jaw surgery
MAXILLAR...

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BSSO
BSSRO
CONDYLECTOMY
CONDYLAR
AUGMENTATION

www.indiandentalacademy.com
Surgery to improve asymmetry
www.indiandentalacademy.com


LE FORT 1 WITH OR
WITHOUT ROTATION
CORRECTION &
ASSOCIATED STRUCTURAL
CORRECTION

www.indiandentalacademy.com


GENIOPLASTIES
 AUGMENTATION
 REDUCTION
 ROTATION

OR


COMBINED WITH
MAXILLARY OR
MANDIBULAR
PROCEDURES

www.indian...
•Often treated only with orthodontics
•Asymmetric extraction sequence and asymmetric mechanics such as
•Class III elastics...
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Proper diagnosis & treatment planning is must.
A detailed and precise evaluation of the force systems
to be used.
O...
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In severe cases - to provide space necessary to
correct pronounced asymmetries.
This is done in order to overc...
www.indiandentalacademy.com
Sem Orthod 1998 :3




To correct asymmetries due to
unilateral extrusions or intrusion
or mild skeletal defects
producing occlusal cants.
...
Conclusions

www.indiandentalacademy.com
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Although a myriad of factors contribute to
facial aesthetics, symmetry may be the
quintessential ingredient.
In t...


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A primary goal of surgical orthodontics is to
eliminate the dental compensations for the
skeletal deformity in all t...
KEY TO TREATMENT
SUCCESS
“RIGHT DIAGNOSIS AND TREATMENT AT
THE RIGHT TIME TO GET RIGHT
RESULT”.

www.indiandentalacademy.c...
References

www.indiandentalacademy.com
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BJ Plast Surg: 1997: 536 – 551
Proffit & White 580 – 587
J P Reyneke : 233
Facial asymmetry : A Review :...
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AJO 1981 Sep 263 - 288 Tridimensional planning for
surgical/orthodontic treatment of mandibular excess - ...
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AJODO 1991 Jul 19 - 34 Assessment of structural and
displacement mandibular asymmetries - Schmid, Mongini,...
www.indiandentalacademy.com
Leader in continuing dental education

www.indiandentalacademy.com
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Facial asymmetry /certified fixed orthodontic courses by Indian dental academy

  1. 1. CRANIOFACIAL ASYMMETRY www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3.    Introduction & Definitions Epidemiology of Asymmetries Etiology a nd Development of Asymmetries Cra niofacial Dentofacial     Classification of Asymmetries Diagnosis & Treatment Pla nning Treatment Conclusions www.indiandentalacademy.com
  4. 4. Introduction to Facial Asymmetries www.indiandentalacademy.com
  5. 5.   Human beings like any other creation of god display bilateral symmetry except for some minor negligible variations. Concern of symmetry dates back to the ancient civilizations which are evident in their paintings and sculptures. www.indiandentalacademy.com
  6. 6.    By strict definition a mirror image of right to left is referred to as symmetry. Due to various environmental or developmental imperfections :ASYMMETRIES develop Asymmetries within some reasonable range cannot be considered abnormal and doesn’t need to be treated. www.indiandentalacademy.com
  7. 7.    Asymmetry in the craniofacial region was first recognized by an artist Hasse in 1887. Since then many anatomists, anthropologists and biologists like Hilton, Huxley, Woodger, Leibrich, Hellman, Woo, etc have found asymmetry of form, function, and proportions in animals and humans……… Classical concept of facial symmetry was depicted in the paintings of Leonardo da Vinci and Albercht Durer in 1507 www.indiandentalacademy.com
  8. 8.    Orthodontists are usually preoccupied with lateral facial aspect while general public judge beauty, symmetry & harmony from frontal aspect Thompson: “normal asymmetry is not very evident, whereas abnormal asymmetry is quiet obvious ” Alton Moore: “In some cases what is pleasing esthetically to some one is displeasing to other.” www.indiandentalacademy.com
  9. 9.  Stedman's Medical Dictionary defines Symmetry as “equality or correspondence in form of parts distributed around a centre or an axis, at the two opposite sides of the body”. Asymmetry is defined as any deviation from normal or difference in size or relationship between two sides of the body www.indiandentalacademy.com
  10. 10.  American College Dictionary defines symmetry as “the correspondence in size, form, and arrangement of parts on opposite sides of a plane , line, or point”. SYMMETRY = BALANCE ASYMMETRY = IMBALANCE www.indiandentalacademy.com
  11. 11. Epidemiology of Asymmetries www.indiandentalacademy.com
  12. 12.   In most individuals the right side of the face is slightly larger than the left ,and usually there is some asymmetry in facial animation. In persons with asymmetry, the lower face is affected much more frequently than the middle or upper thirds. www.indiandentalacademy.com
  13. 13.     Asymmetry of the upper face was seen in only 5%, 36% had a middle third asymmetry, usually just the nose but sometimes including the zygoma 75% had lower third especially a deviation of the chin. About half of the patients with asymmetry in the upper or middle third also had mandibular asymmetry. www.indiandentalacademy.com
  14. 14.  Prevalence of orthodontic asymmetries: Peck & Peck. 1991: studied bilaterally facial asymm. In 52 adult white people with exceptionally well- balanced facial appearance  Decrease in asymmetry occurrence as approached cranially  Deformities were very mild and were identified by clinicians sense of balance and patients perception of imbalance  Woo 1931: evaluated ancient Egyptian skulls and found cranial asymmetry  Vig and Hewitt 1975 evaluated 63 PA cephs. Of 9 year old children clinically normal  They had mild degrees of unnoticeable asymmetries  Melnik et al 1991 noted significant gender differences in the occurrence of asymmetries  www.indiandentalacademy.com
  15. 15. www.indiandentalacademy.com
  16. 16.  According to LUNDSTROM in 1961 QUANTITATIVE ASYMMETRY QUALITATIVE ASYMMETRY includes differences in the no. of teeth on each side or the presence of a cleft lip and palate. could be difference in size of the teeth, their location in the arches or the position of the arches in the head. Proffit & White : Pg: 574 - 644 www.indiandentalacademy.com
  17. 17.   A. Dental Asymmetries: can be due to Local factors such as loss of deciduous teeth, congenitally missing teeth, habits and lack of exactness in genetic expression. B. Skeletal Asymmetries: Their deviation may involve one bone such as maxilla or mandible or it may involve a no. of skeletal and muscular structures on one side of the face. Bishara et al AO 1994:64:2 www.indiandentalacademy.com
  18. 18.   C) Muscular Asymmetries : Hemifacial atrophy or cerebral palsy, abnormal muscle functional D) Functional Asymmetry: can result from the mandible being deflected laterally or antero - posteriorly, if occlusal interferences prevent proper intercuspation in centric relation. Bishara et al AO 1994:64:2 www.indiandentalacademy.com
  19. 19.     Eyes : unilateral micropthalmia , anopthalmia Nose : unilateral arhinia, heminasal aplasia, absence of one nostril, blind dimple, skin tag, proboscides, nasal coloboma, etc Mouth : supernumerary mouth, ectopically placed mouth, teeth, etc Ears : dimorphism, hypoplastic, angulated, Low set, with tissue tags, pits, sinuses, etc. Bishara et al AO 1994:64:2 www.indiandentalacademy.com
  20. 20. Based on Morphology www.indiandentalacademy.com :-Derek Henderson et al
  21. 21. Tessier’s Clefts (1976) www.indiandentalacademy.com
  22. 22. Subramani & Murthy Indian J Plast Surg: Dec :2005 www.indiandentalacademy.com
  23. 23. www.indiandentalacademy.com
  24. 24. Etiology & Development of Asymmetries www.indiandentalacademy.com
  25. 25.  Two main cause of asymmetries are Genetic imperfections www.indiandentalacademy.com Environmental factors
  26. 26.  Hemifacial microsomia,  Retinoic acid and thalidomide teratology,  Clefting syndromes,  Craniosynostoses.  Multiple Neurofibromatosis www.indiandentalacademy.com (dominant gene)
  27. 27.   Intra –uterine pressure during pregnancy and significant pressure in the birth canal during parturition. Pathologic:  Osteochondroma of the mandibular condyle  Trauma and infection  Untreated fracture of mandible  Trauma and infection of TMJ  Ankylosis of TMJ  Damage to nerve www.indiandentalacademy.com
  28. 28.  Clinically significant asymmetry is etiologically and pathologically heterogeneous and may be localised or generalised MALFORMATIONS GENE MUTATION EMBRYOPATHIES CRANIOSYNOSTOSIS DISRUPTIONS FETOPATHIES CAUSES HAMARTOSES TRAUMA PATHOLOGIES INFECTIONS CYSTS TUMORS FIBRO OSSEOUS HEMI-ASYMMETRIES HEMI HYPERPLASIA HEMI HYPOPLASIA HEMI ATROPY
  29. 29. Skeletal Asymmetries www.indiandentalacademy.com
  30. 30.       CHIN MANDIBLE MANDIBLE + CHIN MAXILLA + MANDIBLE MAXILLA + MANDIBLE + CHIN ZYGOMA + NOSE + FRONTAL www.indiandentalacademy.com
  31. 31.  To visualize the 3 dimensional alteration of mid facial and mandiblular complex to specifically identify the asymmetry. www.indiandentalacademy.com
  32. 32.    Transverse asymmetry Cant of lower border of chin AP asymmetry www.indiandentalacademy.com
  33. 33. Acc to Souyris et al. 1983: 1. Infections : 2. Trauma and fractures 3. Defective musculature 4. Cysts and tumors 5. Fibro-osseous lesions Resulting in: 1. Hemi hyperplasia 2. Hemi hypoplasia 3. Hemi atropy 4. Ankylosis  www.indiandentalacademy.com
  34. 34.   Usually is a resultant of mandibular defects or a defect in itself or associated structures. These are usually seen as defects in transverse dimension, AP or vertical resulting in cant of the occlusal plane. www.indiandentalacademy.com
  35. 35. Dental Asymmetries www.indiandentalacademy.com
  36. 36.     Midline deviations Sub division cases Unilateral posterior cross bites Unilateral impacted teeth  Resulting in mesial migration of distal teeth www.indiandentalacademy.com
  37. 37.      Arch form deviation Frontal dental cants Unilateral mesial movement of posterior teeth Missing teeth Shape and size alteration of the teeth www.indiandentalacademy.com
  38. 38. www.indiandentalacademy.com
  39. 39. • A thorough clinical examination and radiographic examination are necessary to determine the extent of the Soft tissue, Skeletal, Dental and Functional involvement. Guidelines to achieve a specific diagnosis: www.indiandentalacademy.com
  40. 40.   It revels asymmetry in vertical, AP & lateral dimension. STEPS IN CLINICAL EVALUATION: i. Evaluation of the dental midlines ii. Vertical occlusal evaluation: The presence of a canted occlusal plane could be the result of a unilateral increase in the vertical length of the condyle and ramus. iii. Transverse and antero posterior occlusal evaluations . iv. Transverse skeletal evaluation v. Soft tissue evaluation. www.indiandentalacademy.com
  41. 41. RULE OF FIFTHS AND THIRDS www.indiandentalacademy.com
  42. 42.   A no. of projections are available to properly identify the causes and location of the asymmetry Lateral cephalogram:   To find ramal height, mandibular length and gonial angle. Postero anterior projections:   Hewitt (1975)  Svanholt & Solo (1977)  Chierici (1983)  Multi planar ceph. Analysis – Grayson and Bookstein (1983)  Grummons & Kappeyene analysis(1987)   Rocky mountain analysis- Ricketts (1972) Proffit (1991) Panoramic radiograph:  To find presence of gross pathology, missing or supernumerary teeth. www.indiandentalacademy.com
  43. 43. CRANIOFACIAL ASYMMETRY BY MULTIPLANE CEPHALOMETRY -Barry H. Grayson, Joseph G. McCarthy, Fred Bookstein, 1. Lateral ceph tracing 2. PA ceph tracing 3. Basal cranium tracing www.indiandentalacademy.com
  44. 44. Grummon’s frontal analysis www.indiandentalacademy.com
  45. 45. CRITERIA RIGHT LEFT DIFFERENCE HORIZONTAL PLANE ZA line to MSR (angular) ZA to MSR (linear) ZA to outer cranium (linear) MANDIBULAR MORPHOLOGY TRIANGLE- Co- Ag- Me Co – Me (linear) Co – Ag (linear) Ag – Me (linear) Co – Ag – Me (angular) VOLUMETRIC COMPARISON POLYGON – Co – Ag – Me –MSR Co – MSR Area of polygon MAXILLO – MANDIBULAR COMPARISON Cg – J Cg – Ag J – MSR Ag – MSR J on MSR Ag on MSR Area of Cg – J - MSR Area of Cg – Ag – MSR www.indiandentalacademy.com
  46. 46. LINEAR ASSYMETRY MSR – Co MSR – NC MSR – J MSR – Ag MSR – Me MAXILLO – MANDIBULAR ASSYMETRY A1 offset B1 offset A6 to J (perpendicular) FRONTAL VERTICAL PROPORTIONS Cg – ANS : Cg – Me ANS – Me : Cg – Me ANS – A1 : ANS – Me ANS – A1 : Cg – Me B1 – Me : ANS – Me B1 – Me : Cg – Me ANS – A1 : B1 – Me www.indiandentalacademy.com
  47. 47. www.indiandentalacademy.com
  48. 48.  Jug Handle projection: sub-mento vertex view   The exact position of the chin and rest of the mandible to the maxilla , zygoma and the cranium can be analysed. Occlusal radiograph:  To analyse dental malocclusion and its co-relation with the adjacent bony structures. www.indiandentalacademy.com
  49. 49.           CT scans CBCT (cone beam CT) CAT scan (computer axial tomography) Laser scanning OrthoCAD and E-Models 3 D occlusograms MRI for soft tissue asymmetry Stercophotogrammetry Digital photography Skeletal Scintigraphy www.indiandentalacademy.com
  50. 50. Treatment of Asymmetries www.indiandentalacademy.com
  51. 51.   These conditions are heterogeneous and require extensive multi speciallity approach to achieve comprehensive treatment results. The team include: www.indiandentalacademy.com
  52. 52. Treatment is divided into 3 stages: stages    Preadolescent children Adolescent Adults www.indiandentalacademy.com
  53. 53.  Principles of treatment: In pre-adolescent children , 2 major problems cause severe asymmetry: A) Hemifacial Microsomia B) Growth deficiency secondary to trauma www.indiandentalacademy.com
  54. 54.    In both conditions the maxilla is affected secondarily as deficient vertical growth of the mandible leads to distortion of the alveolar process. In Hemifacial Microsomia, both soft and hard tissue elements are missing and growth potential is likely to be deficient because of the missing soft tissue. Condylar fracture may produce partial ankylosis that restricts what otherwise would been normal growth. www.indiandentalacademy.com
  55. 55.   The major reason for early surgical intervention would be to improve the chances of subsequent favorable growth Surgery should be growth neutral ( no deleterious effects on growth) www.indiandentalacademy.com
  56. 56. Treatment options A) Growth modification with Asymmetric functional appliance  Asymmetric (Hybrid) functional appliance Eg: Bite block on normal side to prevent over eruption and buccal and lingual shield on the affected side where vertical development is desired with out bite blocks. In major defects soft and hard tissue simply do not have the potential and are less likely to respond favorably. B) Progressive asymmetry is an indication for early surgical intervention  www.indiandentalacademy.com
  57. 57. Hybrid appliance www.indiandentalacademy.com
  58. 58.      Complex congenital condition with an extremely variable phenotype Incidence: 1: 5600 birth Male: Female = 3:2 Right : Left = 3:2 10 – 30% of cases have bilateral defects www.indiandentalacademy.com BJ Plast Surg: 1997: 536 – 551
  59. 59. Clinical Features:  Represented by the acronym: “OMENS”  O- orbital dysphasia  M- mandibular hypoplasia  E- ear defects  N- cranial nerve defects  S- soft tissue defects BJ Plast Surg: 1997: 536 – 551 www.indiandentalacademy.com
  60. 60. BJ Plast Surg: 1997: 536 – 551 Proffit & White 580 – 587 J P Reyneke : 233 www.indiandentalacademy.com Bishara et al AO 1994:64:2
  61. 61. Three grades 1) Grade I: The soft tissue and mandible are present but deficient on the affected side 2) Grade II: the mandibular condyle, ramus and glenoid fossa may be present or absent but when present are severly hypoplastic and displaced. The soft tissue, including the muscle of mastication, also are hypoplastic. 3) Grade III: there is complete absence of the condyle and ramus and a commensurate soft tissue defect BJ Plast Surg: 1997: 536 – 551 Proffit & White 580 – 587 J P Reyneke : 233 Bishara et al AO 1994:64:2 www.indiandentalacademy.com
  62. 62.   In general, children with grade I AND mild grade II problems may respond favorably to functional appliance therapy and this conservative approach should be tried before surgery Pt with severe grade II and Grade III problems are candidates for early surgery either to lengthen the ramus on the affected side or to construct a condyle/ramus unit. BJ Plast Surg: 1997: 536 – 551 Proffit & White 580 – 587 J P Reyneke : 233 Bishara et al AO 1994:64:2 www.indiandentalacademy.com
  63. 63. Principle stages & techniques applicable to treatment of HFM B J Plast Surg: 1997: 536 – 551 www.indiandentalacademy.com
  64. 64.  Surgical correction: correction Three stage of surgical intervention described by Converse et al 1) Stage I : Tissue augmentation Augmenting deficiencies in the mandible, reconstructing missing skeletal elements & improving three-dimensional symmetry www.indiandentalacademy.com BJ Plast Surg: 1997: 536 – 551 Proffit & White 580 – 587 J P Reyneke : 233 Bishara et al AO 1994:64:2
  65. 65. 2) Stage II: Orthognathic surgery 3) Stage III: contour modification is done to III enhance the contour of the skeletal and soft tissue.  Newer Trends: Distraction Osteogenesis !! www.indiandentalacademy.com BJ Plast Surg: 1997: 536 – 551 Proffit & White 580 – 587 J P Reyneke : 233
  66. 66. By far the most frequent growth problem due to trauma in a child is asymmetric deficiency secondary to an early fracture of the Condylar process. 1) Acute management of condyle # in children Immobilization of the jaw for 7 to 14 days www.indiandentalacademy.com BJ Plast Surg: 1997: 536 – 551 Proffit & White 580 – 587 J P Reyneke : 233 Bishara et al AO 1994:64:2
  67. 67. 2) Post treatment asymmetry: early surgery to make translation of condyle possible to guide subsequent growth 3) Reconstruction of the TMJ in growing pt: a) use local tissue, such as stump of the remaining ramus or b) Employ a costochondral graft www.indiandentalacademy.com BJ Plast Surg: 1997: 536 – 551 Proffit & White 580 – 587 J P Reyneke : 233 Bishara et al AO 1994:64:2
  68. 68.  3rd major cause of asymmetry  Affected in an multi articular form   Treatment with functional appliance is not recommended for JRA Surgery to lengthen the mandible, either with conventional Orthognathic surgery or distraction osteogenesis. www.indiandentalacademy.com BJ Plast Surg: 1997: 536 – 551 Proffit & White 580 – 587 J P Reyneke : 233 Bishara et al AO 1994:64:2
  69. 69. Excessive verses deficient mandibular growth • Functional appliance until growth is complete or all complete, to prevent the development of maxillary as well as mandibular asymmetry if possible . This is followed by corrective surgery as necessary. www.indiandentalacademy.com
  70. 70. Clinical management of Hemi- Mandibular Hypertrophy • Remove the growth site at the head of the affected condyle • Hybrid appliance to block further eruption of teeth on affected side and allowing teeth to erupt on the unaffected side www.indiandentalacademy.com
  71. 71. Hemimandibular hypertrophy www.indiandentalacademy.com
  72. 72.    In adults skeletal asymmetry can not be managed orthodontically. Initial alignment followed by jaw surgery MAXILLARY PROCEDURES:  LE FORT 1 WITH ASYMMETRIC CORRECTION WITH OR WITHOUT NASAL AND OTHER MIDFACIAL PROCEDURES  MANDIBULAR PROCEDURES:  BSSO WITH ASYMMETRY CORRECTION  SURICAL REMOVAL OF THE POTENTIAL GROWTH CENTER ESPECIALLY IN CONDITIONS LIKE HEMI FACIAL HYPERTROPHY DUE TO CONDYLAR OVERGROWTH.  CHIN PROCEDURES:  ASYMMETRIC GENIOPLASTIES  DISTRACTION OSTEOGENESIS www.indiandentalacademy.com BJ Plast Surg: 1997: 536 – 551 Proffit & White 580 – 587 J P Reyneke : 233 Bishara et al AO 1994:64:2
  73. 73.     BSSO BSSRO CONDYLECTOMY CONDYLAR AUGMENTATION www.indiandentalacademy.com
  74. 74. Surgery to improve asymmetry www.indiandentalacademy.com
  75. 75.  LE FORT 1 WITH OR WITHOUT ROTATION CORRECTION & ASSOCIATED STRUCTURAL CORRECTION www.indiandentalacademy.com
  76. 76.  GENIOPLASTIES  AUGMENTATION  REDUCTION  ROTATION OR  COMBINED WITH MAXILLARY OR MANDIBULAR PROCEDURES www.indiandentalacademy.com
  77. 77. •Often treated only with orthodontics •Asymmetric extraction sequence and asymmetric mechanics such as •Class III elastics on one side and Class II elastics on other with oblique anterior elastics •Unilateral headgears / jasper jumper etc •Unilateral tipback bends •Composite buildups and prosthodontic restorations in pronounced asymmetries •In arch constructions due to dental causes SME and RME can be used with appliances like HYRAX, HASS, Quad helix, etc •Distalization of molars with appliances like pendulum appliance, distal jet, implants, etc. www.indiandentalacademy.com
  78. 78.    Proper diagnosis & treatment planning is must. A detailed and precise evaluation of the force systems to be used. Orders of correction:  Molar rotation : 1st order  Correct mesial migration and mesial in rotations due to premature loss of decidious counterpart  Molar tipping : 2nd order  To correct abnormal mesial angulation and migration; ectopic eruptions  Posterior crossbite : 3rd order  CO- CR discrepancies  Achieved by:  Asymmetric extractions  Differential anchorage preparation  Asymmetric space closure mechanics www.indiandentalacademy.com Sem Orthod 1998 :3
  79. 79.     In severe cases - to provide space necessary to correct pronounced asymmetries. This is done in order to overcome the side effects of asymmetric mechanics Before proceeding, it is crucial to determine whether the observed asymmetry is genuine & not the product of a functional or habitual shift of mandible. Anchorage must be critically reviewed www.indiandentalacademy.com Sem Orthod 1998 :3
  80. 80. www.indiandentalacademy.com Sem Orthod 1998 :3
  81. 81.   To correct asymmetries due to unilateral extrusions or intrusion or mild skeletal defects producing occlusal cants. Here the brackets are positioned progressively gingivally / occlusally to correct the canted occlusal plane. Sem www.indiandentalacademy.com Orthod 1998 :3
  82. 82. Conclusions www.indiandentalacademy.com
  83. 83.    Although a myriad of factors contribute to facial aesthetics, symmetry may be the quintessential ingredient. In the management of dental arch asymmetries, the clinician should select the appropriate force system and the appliance design necessary to address the asymmetry while minimizing undesirable side effects. Surgical correction of Dentofacial asymmetries necessitates corresponding orthodontic treatment. www.indiandentalacademy.com
  84. 84.   A primary goal of surgical orthodontics is to eliminate the dental compensations for the skeletal deformity in all three planes of space. The three-dimensional skeletal, dental, and soft-tissue alterations required for the surgical and orthodontic correction of dento facial asymmetries are among of the most challenging and rewarding treatments to plan and accomplish. www.indiandentalacademy.com
  85. 85. KEY TO TREATMENT SUCCESS “RIGHT DIAGNOSIS AND TREATMENT AT THE RIGHT TIME TO GET RIGHT RESULT”. www.indiandentalacademy.com
  86. 86. References www.indiandentalacademy.com
  87. 87.        BJ Plast Surg: 1997: 536 – 551 Proffit & White 580 – 587 J P Reyneke : 233 Facial asymmetry : A Review :Bishara et al AO 1994:64:2 Asymmetries : diagnosis and treatment : Sem Orthod 1998 :3 : 133 -198 A classification of cranio facio cervical clefts: Subramani & Murthy :Indian J Plast Surg: Dec :2005 Use of triangular analysis: K W Butow Peter van der Walt: J Max Fac Surg 12 1984 62- 70 www.indiandentalacademy.com
  88. 88.        AJO 1981 Sep 263 - 288 Tridimensional planning for surgical/orthodontic treatment of mandibular excess - Bell and Jacobs AJO 1981 May 535 - 548 Dental arch shape - Sampson AJO 1982 Jul 68 - 74 Hemifacial microsomia treated with Herbst appliance - Sarnäs, Pancherz, Rune, and Selvik AJO 1983 May 382 - 390 Analysis of errors in orthodontic measurements - Houston AJO 1984 Mar 224 - 237 Diagnosis and treatment planning of skeletal asymmetry with submental-vertical radiograph Forsberg, Burstone, and Hanley AJO 1985 Mar 240 - 246 Progressive facial asymmetry Arvystas, Antonellis, and Justin AJODO 1988 Jan 38 - 46 Facial and dental arch asymmetries Alavi, BeGole, and Schneider www.indiandentalacademy.com
  89. 89.       AJODO 1991 Jul 19 - 34 Assessment of structural and displacement mandibular asymmetries - Schmid, Mongini, and Felisio AJODO 1994Aug 191 - 200 mand and facial asymmetrys REVIEW ARTICLE - Pirttiniemi AJODO 1994 May 489 - 495 Mandibular skeletal and dental asymmetry in Class II malocclusions - Rose, Sadowsky, BeGole, and Moles AJODO 1994 Jan 73 - 77 Prepubertal trauma and mandibular asymmetry - Skolnick, Iranpour, Westesson, and Adair AJODO 1994 Sep 250 - 256 Assessment of craniofacial asymmetry with S-V radiographs - Arnold, Anderson, and Lilyemark AJODO 1995 Apr 394 - 400 Unilateral crossbite and mandibular asymmetry in adults O'Bym, Sadowsky,Schneider, and BeGole www.indiandentalacademy.com
  90. 90. www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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