MANAGEMENT OF
FACIAL
ASYMMETRIES

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INDIAN DENTAL ACADEMY
Leader in continuing dental education

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INTRODUCTION:
Each person shares with the rest of the
population a great many characteristics.
However,there are enough di...
DEFINITIONS:
Symmetry
The similar arrangement in form &
relationships of parts around a common
axis or on each side of a ...
 Woo

(1931)Bones of cranium show asymmetry- rt.
side being larger
Bones of facial complex – contralateral
asymmetry.
 V...
CLASSIFICATION OF FACIAL
ASYMMETRIES:
1. Skeletal asymmetries
2. Soft tissue asymmetries
3. Functional asymmetries
www.ind...
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Pre natal causes:
GENETIC

AJO 1994 Pirttiniemi

1. Facial clefting syndromes
- unilateral CLCP
- craniofacial clefts

CON...
Postnatal causes:
ENVIRONMENTAL

AJO 1994 Pirttiniemi

1. Trauma & infection
2. Muscle dysfunction
3. Functional deviation...
Cohen 1982
Malformations with abnormal developmental
processes in embryonic stage ( 1%)

 Hemifacial
 Congenital

micros...
Deformations caused by non disruptive
mechanical forces during fetal period:(2%)

 Congenital

muscular torticollis

 Po...
Disruptions caused by breakdown of normal
developmental processes with onset later in life:
 Unilateral

condylar hyperpl...
www.indiandentalacademy.com




Clinical examination

Radiographic examination


Photographic analysis




History

Digital videography

Articul...


HISTORY:

-Can reveal etiology
- Severity of deformity


CLINICAL EXAMINATION:

Reveals asymmetry in the vertical,
ant...
EXTRAORAL EVALUATION:-frontal

TRANSVERSE -“Rule of fifths”

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 - Midpupillary

distance aligned with

commisures

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 -Inter

ocular dimensionsinterpupillary-65mm
inter canthal- 35mm

 Midfacial

bony supportlower third of iris of the ey...
VERTICAL
Vertical reference plane- nasion to
subnasale
line

upper horizontal plane – bipupillary
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.

F...
SUBMENTO VERTEX VIEW

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INTRA ORAL EXAMINATION

 Evaluation of the dental midlines





Vertical occlusal evaluation
-Transverse cant of maxill...
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FUNCTIONAL EXAMINATION




Maximal opening
TMJ evaluation
-postural rest position
-CR-CO discrepancy
-laterocclusion 
la...
Laterognathia / laterocclusion

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Laterocclusion

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SYSTEMATIC SEQUENCE OF
EVALUATION OF ASYMMETRY
     

Nasal tip to mid sagittal plane.

    

Maxillary Dental Midline t...
RADIOGRAPHIC EXAMINATION

Importance of head position
1.

The lateral cephalogram

2.

The panoramic radiograph

3.

Poste...
Head position:

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LATERAL CEPHALOGRAM
Only little useful information
In CR ,CO and initial contact
permits visualization of
mand.position

O...
PA CEPHALOGRAM
Important adjunct for qualitative &
quantitative evaluation of dentofacial
region
 Extent of deformity( or...
Anatomic approach
 Zygomatico

–frontal sutures and crista
galli are relatively symmetric structures

 Construction

of ...
 Perpendiculars

from bilateral structures

are constructed to this mid-sagittal
vertical reference
 The

differences be...
Bisection approach


Used in cases where it is difficult to
accurately identify Crista Galli or the
Zygomatico-frontal su...
Triangulation approach
Used to a study the relative asymmetry of
the ‘component areas’ of the facial
complex.
Following th...
Various PA analysis


Rickett’s analysis



Svanholt and solow analysis



Grummon’s analysis



Grayson’s analysis

...
Grummon’s analysis (1987)
 This

is a comparative and quantitative
PA analysis.

 Presented

in 2 forms : 1. Comprehensi...
- Horizontal plane

truction
- Mand. Morphology

ysis
- Maxillomand.

parison
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3-D CEPHALOGRAM: McCarthy
Lat.ceph & PAceph traced & digitized
X,Y,Z coordinates – integrated & establish
the exact 3-D lo...
Highlights the asymmetries of the mandible,
canting of occlusal plane,posterior
asymmetry of the orbital rim
can be rotate...
SUBMENTO VERTEX
RADIOGRAPHS:


Introduced by Berger in 1961



Pearson and Woo -found exceptional degree of
symmetry in ...
 the

submental-vertical projection is

potentially more useful than the P-A
projection.
-

allows utilization of anatom...
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Measurements to assess bilateral symmetry were
made relative to a coordinate axis system


Cranial base - interspinosum l...
COMPUTED TOMOGRAPHY
3-D evaluation of osseous & soft tissues
Complex diagnosis

3-DIMENSIONAL CT

Reproduces detailed skel...
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TMJ IMAGING








-Transcranial radiographs
-Tomographs
-CT
-Arthrography
MRI
-Video flouroscopy
-radio nucleotid...
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PHOTOGRAPHIC ANALYSIS
 Head

position, patient position, flash
 Extra oral Photographs –
Frontal - lips relaxed , smile
...
Identification of mid face deficiency:
 Zygomatic

projection
 Zygomatic prominence

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Photographic montage  composite
photographs
- reveal altered facial form and disclose
difference in configuration of both ...
DIGITAL VIDEOGRAPHY :
records lip movements during speech &
smile.
2 segments of video – frontal & oblique
dimension
fashi...
1.

2.

3.

6.

5.

4.

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ARTICULATED STUDY MODELS
3-d representation of occlusion
Improves visualisation of
static & functional
interrelationships
...
 Should

be recorded in C.R.

 Respect

the anatomical deformity in the
auditory canal during face bow transfer.

Indica...
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ETIOLOGY
 Constricted
 Single

maxillary arch

tooth interference - canines
-

premolars
SIGNIFICANCE:
 If

untreated c...
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TREATMENT
POSSIBILITIES
 MAXILLARY

ARCH EXPANSION

 ORTHODONTIC

ARCH

COORDINATION
 REPOSITIONING

SPLINTS

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MAXILLARY EXPANSION
1. Slow expansion
2. Orthopedic rapid palatal expansion
3. SARPE
4. Segmental osteotomy
To achieve des...
Slow expansion:
Can bring about skeletal
expansion in primary dentition
Lingual arch  quad helix- 50% sk.
exp.
Jack screw
...
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Rapid palatal expansion:
 Very

successful in children prior to sutural
closure.

 0.5mm

 day- 10 mm exp. in 20 days- 7...
HYRAX

HAAS

MINN
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SARPE:
 Brown(1938)-described

SARPE with

midpalatal split
 Shetty(1994)-main

areas of resistance to
expansion are mid...
Should

be done after mand.

decompensation
During

surgery – activated by 1-

1.5mm – 5 days of rest –0.5mm day
Spacin...
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Segmental Lefort I osteotomy:
 Indicated

in open bite cases, where
SARPE is contraindicated
 Total down fracture of max...
Repositioning splints AJO 1991.
Schmid et.al.
 Used mainly in TMJ dysfunctions
 Indicated

only when it is impossible to...
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Occlusal therapy
 Selective

grinding occlusal adjustment

-Reshaping the occlusal surfaces of the
teeth to achieve a des...
Rule of thirds
Each inner incline of posterior teeth is
divided into 3 equal parts:
 If opposing centric cusp tip contact...
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ETIOLOGY
1. Cleft lip- repaired
unrepaired
2. Muscular hypertrophy
atrophy
3. Scar deformities
4. Neurofibromatosis
www.in...
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TREATMENT
POSSIBILITIES


Cosmetic recontouring



Alloplastic augmentation



Prevention of wound
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Cosmetic recontouring
CLEFT LIP REPAIR –PRIMARY
CLOSURE: -Millard

procedure- incomplete clefts
 -Tennison
”
- wide clef...
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CLEFT LIP REPAIR –SECONDARY
PROCEDURES:

Deficient cupid’s bow
- excise excess scar
- free dermal grafts
Scar deformities
...
Muscle debulking:
 Stripping

of the
superficial layers of the
muscle mass with
electro cauterization

 Purely

cosmetic...
Management of burn contractures:
AJO 1987
Jack.M.Vorhies




Typical burn sitecommissure
On healing, the lips &
muscles ...






Abston Sally(1976)- uniform pressure
minimises hypertrophic scar – for 612 mths duration
Colcleugh &
Ryan(Plas.Re...
A.
B.

E.

C.

D.

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Soft tissue augmentation:
Autogenous grafts

- dermal grafts
- fat grafts

Alloplastic materials - silicones( RTV
fluid)
-...
www.indiandentalacademy.com
ETIOLOGY:
 CONGENITAL

SYNDROMES

- Craniofacial clefts
-Hemifacial microsomia
 PRENATAL

CAUSES:

Intra uterine pressur...
 POSTNATAL

CAUSES:

Hemifacial atrophy
hypertrophy
Fractures &trauma
Infections & inflammations
Established laterocclusi...
Congenital
Ramus hypoplasia

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Environmental

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DENTAL COMPENSATIONS
 Midline

shifts- dental compensation to
make the dental midline shift not so
worse compared to the ...
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Treatment objectives

PETERSON



Take advantage of growth in growing patients



Produce functional TMJs



Level the ...
TREATMENT POSSIBILITIES
 Orthodontic

-Camouflage
 Orthopedic

- hybrid functional
appliances
 Surgical

-

www.indiand...


Surgical
1. Distraction osteogenesis
2.Maxillary surgeries
- Lefort I
3. Mandibular surgeries
- BSSO
- Inferior body os...
Orthodontic camouflage-

Transverse cant correction
2

occlusal planes : upper &lower
Connects incisal edge of C.I to M-B...
 Normal

–transverse occlusal plane –

esthetic&- parallel to the transcommisural
line & a line tangent to lower lip
 As...
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Midline coordination –
 Translate

midline (asymmetric

extractions)
 Tipping
 Altering

of the teeth to midline
the oc...
Functional appliances
 Coccaro

(AJO 1969) –Used guide plane to
hold mandible forward

 Hotz(AJO

1978) –used activators...
 The

propellant unilateral magnetic
appliance.
Chate RAC. Eur J Orthod 1995

 Clinically

it has been shown that
regene...
Hybrid appliances:
 i.e.,

a hybrid  blend of several
components designed to address specific
problems

 These

can be a...
AJO 1986 Vig & Vig
 APPLIANCE

COMPONENTS AND THEIR

EXPECTED FUNCTIONS:
These components produce basal and dentoalveolar...
AJO 1998 Bärbel Kahl-Nieke et al.,
Functional appliances used either alone or
in conjunction with surgery for the
followin...
CONSTRUCTION BITE:
 The mandible is kept in a slightly forward
and overcompensated centered position establish a change i...


Buccal &Lingual shields can remove
the restricting musculature & enhance
the bone deposition on affected side
( functio...
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Herbst appliance:
AJO-DO 1982 Sarnäs, Pancherzroentgen
stereometric method.
The Herbst appliance works as an artificial
jo...
The appliance is constructed to displace the
mandible anteriorly and to the unaffected side
for correction of the mandibul...
In the pretreatment period the mandible and
the maxillary bones were displaced to the
affected side and posteriorly, incre...
Twin block AJO 1988 Clark

When activated unilaterally - correct postur
mand. displacement (mid line displacement an
asymm...
 The

occlusal inclined plane is particularly
well suited to the correction of functional
abnormalities associated with a...


A, Age 10 years 6 months. B, Age 10 years 8 months. C,
Age 11 years 3 months. D, Age 12 years 8 months.
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

PRIMARY ASYMMETRY – associated
with whole facial skeleton



SECONDARY ASYMMETRY – alveolar
hyperplastic response to m...
Nasomaxillary hypoplasia

 Lefort

II osteotomy
 Paranasal
augmentation:- onlay
grafts
 Improves soft tissue
support in...
Malar hypoplasia

 Modified

Lefort III

osteotomy

 Infra

orbital
augmentation:

 Intraoral

 Fluid

approach

silic...
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Distraction osteogenesis
Is the slow application of force to a bone
gap, resulting in the production of new
bone & soft ti...
Secondary effects:
 Oral commissure & paranasal structures –
normalise &
descend
 Mand. Condyle – increase in size & vol...
Ilizarov principles:


Bone cut- corticotomy  osteotomy



Rate – 1mm day –adults, 1.5mm- child



Rhythm – 0.5  1 0.25...
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Orthodontic considerations during
Distraction osteogenesis:
1. Occlusal interferences (based on Occlusal cant )
- apply in...
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www.indiandentalacademy.com
TMJ functional ankylosis: -AJO
1980
Any mechanical restriction of growth in the
condylar area - An ankylosis-like effect o...
AJO1980 Proffit
The treatment of patients with fractures at
the mandibular condyles can be considered
in three time frames...
Immediate postinjury treatment
in children
 surgical

intervention in young children

-aggravate growth disturbances
 If...
 If

mandible deviated toward the injured

side ( cross-bite and a distal occlusion on
that side) and a lateral open-bite...
Treatment of growing children
with a previous fracture
 Old

fractures - noticed only when the child
is brought for ortho...
 Good

postinjury growth & proportions are

maintained - conservative treatment .
 The

child translates mandible forwar...
TMJ SURGERIES
 Release

of ankylosis to provide free
movement – remove the scar tissue &
bone & coronoid process – follow...
Inverted ‘L’ osteotomy
 More

conservative –
corrects asymmetry, but
accept limited jaw
function

 Advance

the tooth
be...
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CONDYLAR HYPERPLASIA


Starts dramatically with pubertal
growth spurt



Enlarged condylar head, downward
growth of lowe...
www.indiandentalacademy.com
 Early

stages

– prior to alveolar changes –
subsigmoid osteotomy –to maintain
occlusion –no TMJ surgeries
 Late

stage...
Hemi mandibular elongation
 Increased

ramus width & body length on
affected side –midline deviation & cross
bite –undist...
www.indiandentalacademy.com
Chin surgeries
Can conceal mandibular asymmetries as
patient is more aware of the transverse
asymmetry
Considered if occlu...
Inferior border osteotomy
 Preferred

method

 Ratio

of hard &soft
tissue change is
predictable

 Permanent

results

...
www.indiandentalacademy.com
Augmentation surgeries
Done in extreme cases
 Autogenous

 allogenic bone grafts
 Autogenous  allogenic cartilage grafts...
GRAFT MATERIALS
 Used

in severe cases of asymmetries

involving wide areas – maxilla, zygoma,
condyles, mandible .
 Rep...
Reconstruction with costochondral grafts

Alternate ribs can be harvested depending on the
requirement from fifth rib onwa...
Alloplastic materials
Selection based on : 1.physical prop. &
2.Compatibility
Materials used :

Acrylic resins
Silicone ru...
3.Poly ethene & poly urethane
4.Polytetrafluoro ethylene teflon
- available in sheets

- Intra operative contouring for Na...
6. Polyamides:
Mesh forms – very technique sensitive
Onlay material for chin, nasal dorsum &
maxilla
7. Ca phosphate ceram...
Conclusion
A team approach in the
management of asymmetries always produces
a high degree of success which influences the
...
Thank you
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Management of facial asymmetries /certified fixed orthodontic courses by Indian dental academy

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Management of facial asymmetries /certified fixed orthodontic courses by Indian dental academy

  1. 1. MANAGEMENT OF FACIAL ASYMMETRIES www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. INTRODUCTION: Each person shares with the rest of the population a great many characteristics. However,there are enough differences that make each human being an unique individual. Such limitless variation in relationships of the facial structures are www.indiandentalacademy.com
  4. 4. DEFINITIONS: Symmetry The similar arrangement in form & relationships 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 www.indiandentalacademy.com
  5. 5.  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. www.indiandentalacademy.com
  6. 6. CLASSIFICATION OF FACIAL ASYMMETRIES: 1. Skeletal asymmetries 2. Soft tissue asymmetries 3. Functional asymmetries www.indiandentalacademy.com
  7. 7. www.indiandentalacademy.com
  8. 8. Pre natal causes: GENETIC AJO 1994 Pirttiniemi 1. Facial clefting syndromes - unilateral CLCP - craniofacial clefts CONGENITAL 1. 2. 3. 4. Hemi facial microsomia Neurofibromatosis Birth trauma Intra uterine pressure during preg. www.indiandentalacademy.com
  9. 9. Postnatal causes: ENVIRONMENTAL AJO 1994 Pirttiniemi 1. Trauma & infection 2. Muscle dysfunction 3. Functional deviations 4. TMJ derangements 5. Hemi mandibular hypertrophy 6.Pathologies www.indiandentalacademy.com
  10. 10. Cohen 1982 Malformations with abnormal developmental processes in embryonic stage ( 1%)  Hemifacial  Congenital microsomia hemifacial hypertrophy  Cleft lip & palate www.indiandentalacademy.com
  11. 11. Deformations caused by non disruptive mechanical forces during fetal period:(2%)  Congenital muscular torticollis  Postural scoliosis  Plagiocephaly www.indiandentalacademy.com
  12. 12. Disruptions caused by breakdown of normal developmental processes with onset later in life:  Unilateral condylar hyperplasia  Hemifacial  Infections & inflammations  Fracture  Lateral atrophy & trauma malocclusion  Muscular dysfunction www.indiandentalacademy.com
  13. 13. www.indiandentalacademy.com
  14. 14.    Clinical examination Radiographic examination  Photographic analysis   History Digital videography Articulated study models www.indiandentalacademy.com
  15. 15.  HISTORY: -Can reveal etiology - Severity of deformity  CLINICAL EXAMINATION: Reveals asymmetry in the vertical, antero-posterior or lateral dimension. www.indiandentalacademy.com
  16. 16. EXTRAORAL EVALUATION:-frontal TRANSVERSE -“Rule of fifths” www.indiandentalacademy.com
  17. 17.  - Midpupillary distance aligned with commisures www.indiandentalacademy.com
  18. 18.  -Inter ocular dimensionsinterpupillary-65mm inter canthal- 35mm  Midfacial bony supportlower third of iris of the eye to be covered with lower eyelid www.indiandentalacademy.com
  19. 19. VERTICAL Vertical reference plane- nasion to subnasale line upper horizontal plane – bipupillary lower horizontal line - thru’ the stomion www.indiandentalacademy.com
  20. 20. 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. www.indiandentalacademy.com
  21. 21. 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 www.indiandentalacademy.com
  22. 22. SUBMENTO VERTEX VIEW www.indiandentalacademy.com
  23. 23. INTRA ORAL EXAMINATION  Evaluation of the dental midlines   Vertical occlusal evaluation -Transverse cant of maxilla Transverse and antero-posterior occlusal evaluations -Unilateral cross bites www.indiandentalacademy.com
  24. 24. www.indiandentalacademy.com
  25. 25. FUNCTIONAL EXAMINATION   Maximal opening TMJ evaluation -postural rest position -CR-CO discrepancy -laterocclusion laterognathia  Motor & sensory evaluation www.indiandentalacademy.com
  26. 26. Laterognathia / laterocclusion www.indiandentalacademy.com
  27. 27. Laterocclusion www.indiandentalacademy.com
  28. 28. SYSTEMATIC SEQUENCE OF EVALUATION OF ASYMMETRY       Nasal tip to mid sagittal plane.      Maxillary Dental Midline to Midsagittal plane      Maxillary Dental midline to mandibular Dental midline.      Mandibular dental midline to Midsymphysis. www.indiandentalacademy.com
  29. 29. 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 www.indiandentalacademy.com
  30. 30. Head position: www.indiandentalacademy.com
  31. 31. 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 www.indiandentalacademy.com
  32. 32. PA CEPHALOGRAM Important adjunct for qualitative & quantitative evaluation of dentofacial region  Extent of deformity( orbital upper facial symmetry), Skeletal dental invlovement. www.indiandentalacademy.com
  33. 33. Anatomic approach  Zygomatico –frontal sutures and crista galli are relatively symmetric structures  Construction of the horizontal line through the zygomatico frontal sutures the horizontal axis. A vertical line perpendicular to the horizontal axis passing through and bisect the base of the crista galli - approximates the anatomic midsagittal plane of the www.indiandentalacademy.com
  34. 34.  Perpendiculars from bilateral structures are constructed to this mid-sagittal vertical reference  The differences between the the projections from the two sides - compared to quantify discrepancies (height & distances between the bilateral structures www.indiandentalacademy.com
  35. 35. Bisection approach  Used in cases where it is difficult to accurately identify Crista Galli or the Zygomatico-frontal sutures  Bilateral landmarks are located and bisected. A reference line is then constructed through as many of the midpoints of these bilateral landmarks.  If a mid-point is obviously off www.indiandentalacademy.com
  36. 36. Triangulation approach Used to a study the relative asymmetry of the ‘component areas’ of the facial complex. Following the identification of bilateral structures and the midline, triangles are constructed to divide the face in to various components. The right and left triangles are then www.indiandentalacademy.com
  37. 37. Various PA analysis  Rickett’s analysis  Svanholt and solow analysis  Grummon’s analysis  Grayson’s analysis  Hewitt analysis  Chierici method www.indiandentalacademy.com
  38. 38. Grummon’s analysis (1987)  This is a comparative and quantitative PA analysis.  Presented in 2 forms : 1. Comprehensive analysis www.indiandentalacademy.com
  39. 39. - Horizontal plane truction - Mand. Morphology ysis - Maxillomand. parison www.indiandentalacademy.com
  40. 40. 3-D CEPHALOGRAM: McCarthy Lat.ceph & PAceph traced & digitized X,Y,Z coordinates – integrated & establish the exact 3-D location in space www.indiandentalacademy.com
  41. 41. Highlights the asymmetries of the mandible, canting of occlusal plane,posterior asymmetry of the orbital rim can be rotated in atypical views to assess the skeletal pathology www.indiandentalacademy.com
  42. 42. SUBMENTO VERTEX RADIOGRAPHS:  Introduced by Berger in 1961  Pearson and Woo -found exceptional degree of symmetry in the sphenoid bone.  Moss(1971) - the passage and location of neurovascular bundles during orofacial growth cannot be violated  Ritucci and Burstone(1981) - developed a cephalometric system for assessment of www.indiandentalacademy.com
  43. 43.  the submental-vertical projection is potentially more useful than the P-A projection. - allows utilization of anatomic landmarks on the cranial base, remote www.indiandentalacademy.com
  44. 44. www.indiandentalacademy.com
  45. 45. www.indiandentalacademy.com
  46. 46. Measurements to assess bilateral symmetry were made relative to a coordinate axis system  Cranial base - interspinosum line, ( x axis), and the interspinosum axis( z axis).  The zygomaxillary complex - PTM line, ( x axis), and the PTM axis, ( z axis).  The mandible - condylion line( x axis) and the condylion axis www.indiandentalacademy.com
  47. 47. 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 www.indiandentalacademy.com
  48. 48. www.indiandentalacademy.com
  49. 49. TMJ IMAGING        -Transcranial radiographs -Tomographs -CT -Arthrography MRI -Video flouroscopy -radio nucleotide imaging www.indiandentalacademy.com
  50. 50. www.indiandentalacademy.com
  51. 51. 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 www.indiandentalacademy.com
  52. 52. Identification of mid face deficiency:  Zygomatic projection  Zygomatic prominence www.indiandentalacademy.com
  53. 53. Photographic montage composite photographs - reveal altered facial form and disclose difference in configuration of both sides of the face www.indiandentalacademy.com
  54. 54. DIGITAL VIDEOGRAPHY : records lip movements during speech & smile. 2 segments of video – frontal & oblique dimension fashion 30 frames /sec.- in standardized “Chelsea eats cheese cake on Chesapeake” – video clip is taken (5 sec ) www.indiandentalacademy.com
  55. 55. 1. 2. 3. 6. 5. 4. www.indiandentalacademy.com
  56. 56. ARTICULATED STUDY MODELS 3-d representation of occlusion Improves visualisation of static & functional interrelationships of teeth www.indiandentalacademy.com
  57. 57.  Should be recorded in C.R.  Respect the anatomical deformity in the auditory canal during face bow transfer. Indications for articular mounting :  1. TMJ signs  2. CR-CO discrepancy  3. Treatment planning - diagnostic setup - mock surgery - selective grinding www.indiandentalacademy.comrestorative
  58. 58. www.indiandentalacademy.com
  59. 59. ETIOLOGY  Constricted  Single maxillary arch tooth interference - canines - premolars SIGNIFICANCE:  If untreated can lead to true skeletal asymmetry www.indiandentalacademy.com
  60. 60. www.indiandentalacademy.com
  61. 61. TREATMENT POSSIBILITIES  MAXILLARY ARCH EXPANSION  ORTHODONTIC ARCH COORDINATION  REPOSITIONING SPLINTS www.indiandentalacademy.com
  62. 62. 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. www.indiandentalacademy.com
  63. 63. Slow expansion: Can bring about skeletal expansion in primary dentition Lingual arch quad helix- 50% sk. exp. Jack screw FR functional regulator - indirect effect www.indiandentalacademy.com
  64. 64. www.indiandentalacademy.com
  65. 65. Rapid palatal expansion:  Very successful in children prior to sutural closure.  0.5mm day- 10 mm exp. in 20 days- 7580% of sutural expansion Haas type Hyrax type Minn expander  3:2 ratio of widening in canines & molars www.indiandentalacademy.com
  66. 66. HYRAX HAAS MINN www.indiandentalacademy.com
  67. 67. 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 www.indiandentalacademy.com
  68. 68. 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 wks. www.indiandentalacademy.com
  69. 69. www.indiandentalacademy.com
  70. 70. 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 is www.indiandentalacademy.com
  71. 71. Repositioning splints AJO 1991. Schmid et.al.  Used mainly in TMJ 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 www.indiandentalacademy.com
  72. 72. www.indiandentalacademy.com
  73. 73. 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 teeths –crowns & FPDs Diagnostic casts on articulator- reveal www.indiandentalacademy.com
  74. 74. 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 www.indiandentalacademy.com
  75. 75. www.indiandentalacademy.com
  76. 76. ETIOLOGY 1. Cleft lip- repaired unrepaired 2. Muscular hypertrophy atrophy 3. Scar deformities 4. Neurofibromatosis www.indiandentalacademy.com
  77. 77. www.indiandentalacademy.com
  78. 78. TREATMENT POSSIBILITIES  Cosmetic recontouring  Alloplastic augmentation  Prevention of wound www.indiandentalacademy.com
  79. 79. Cosmetic recontouring CLEFT LIP REPAIR –PRIMARY CLOSURE: -Millard procedure- incomplete clefts  -Tennison ” - wide clefts Both are modified Z-plasties www.indiandentalacademy.com
  80. 80. www.indiandentalacademy.com
  81. 81. CLEFT LIP REPAIR –SECONDARY PROCEDURES: Deficient cupid’s bow - excise excess scar - free dermal grafts Scar deformities - scar revision - Z-plasty www.indiandentalacademy.com
  82. 82. Muscle debulking:  Stripping of the superficial layers of the muscle mass with electro cauterization  Purely cosmetic , usually without complications  Indicated in cases of www.indiandentalacademy.com
  83. 83. Management of burn contractures: AJO 1987 Jack.M.Vorhies   Typical burn sitecommissure On healing, the lips & muscles scarifycentripetel scar contraction – microstomia- 5 days – www.indiandentalacademy.com
  84. 84.    Abston Sally(1976)- uniform pressure minimises hypertrophic scar – for 612 mths duration Colcleugh & Ryan(Plas.Recons.Surg.1976)described the procedure of splinting to prevent wound contractures -made an acrylic splint that protrudes past the commisures to hold the stoma www.indiandentalacademy.com
  85. 85. A. B. E. C. D. www.indiandentalacademy.com
  86. 86. Soft tissue augmentation: Autogenous grafts - dermal grafts - fat grafts Alloplastic materials - silicones( RTV fluid) - teflon - poly amides urethanes www.indiandentalacademy.com
  87. 87. www.indiandentalacademy.com
  88. 88. ETIOLOGY:  CONGENITAL SYNDROMES - Craniofacial clefts -Hemifacial microsomia  PRENATAL CAUSES: Intra uterine pressure Birth trauma Congenital torticollis Craniosynostosis www.indiandentalacademy.com
  89. 89.  POSTNATAL CAUSES: Hemifacial atrophy hypertrophy Fractures &trauma Infections & inflammations Established laterocclusion Muscular function www.indiandentalacademy.com
  90. 90. Congenital Ramus hypoplasia www.indiandentalacademy.com
  91. 91. Environmental www.indiandentalacademy.com
  92. 92. DENTAL COMPENSATIONS  Midline shifts- dental compensation to make the dental midline shift not so worse compared to the underlying skeletal shift  Axial inclination of molars – to compensate for the developing cross bite in the contralateral side  Canting of maxillary occlusal plane- to www.indiandentalacademy.com
  93. 93. www.indiandentalacademy.com
  94. 94. Treatment objectives PETERSON  Take advantage of growth in growing patients  Produce functional TMJs  Level the maxilla & mandible  Adjust the symmetry – rhinoplasty - genioplasty - bone recontouring - autogenous alloplastic - adjunctive soft tissue www.indiandentalacademy.com
  95. 95. TREATMENT POSSIBILITIES  Orthodontic -Camouflage  Orthopedic - hybrid functional appliances  Surgical - www.indiandentalacademy.com
  96. 96.  Surgical 1. Distraction osteogenesis 2.Maxillary surgeries - Lefort I 3. Mandibular surgeries - BSSO - Inferior body osteotomy - genioplasty 4. TMJ surgeries 5. Autogenousalloplastic augmentation www.indiandentalacademy.com
  97. 97. Orthodontic camouflage- 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  Esthetic plane of occlusion: a line www.indiandentalacademy.com
  98. 98.  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 www.indiandentalacademy.com
  99. 99. www.indiandentalacademy.com
  100. 100. Midline coordination –  Translate midline (asymmetric extractions)  Tipping  Altering of the teeth to midline the occlusal cant www.indiandentalacademy.com
  101. 101. Functional appliances  Coccaro (AJO 1969) –Used guide plane to hold mandible forward  Hotz(AJO 1978) –used activators  Proffit(AJO1980) –prefers Frankel appliance  When mandibular growth is nearly completed ( all permanent teeth erupted), conventional fixed appliance therapy to www.indiandentalacademy.com
  102. 102.  The propellant unilateral magnetic appliance. Chate RAC. Eur J Orthod 1995  Clinically it has been shown that regeneration of a normal muscle balance is possible even in absence of a condyle Melson etal., AJO 1986  Radiologically it has been demonstrated that bone apposition, required to obtain www.indiandentalacademy.com
  103. 103. Hybrid appliances:  i.e., a hybrid blend of several components designed to address specific problems  These can be activator bionator Frankel with modifications  Using these, the patient can translate the mandible & any remodelling in the condyle occurs in the unloaded , forward www.indiandentalacademy.com
  104. 104. AJO 1986 Vig & Vig  APPLIANCE COMPONENTS AND THEIR EXPECTED FUNCTIONS: 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 (construction or www.indiandentalacademy.com
  105. 105. AJO 1998 Bärbel Kahl-Nieke et al., 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, www.indiandentalacademy.com
  106. 106. CONSTRUCTION BITE:  The mandible is kept in a slightly forward and overcompensated centered position establish a change in muscle activity that could lead to enhanced bone apposition and optimal growth direction of the condyle www.indiandentalacademy.com
  107. 107.  Buccal &Lingual shields can remove the restricting musculature & enhance the bone deposition on affected side ( functional matrix)  Differential eruption can be permitted by adequate trimming of the bite blocks – allow correction of the transverse occlusal cant of the maxilla www.indiandentalacademy.com
  108. 108. www.indiandentalacademy.com
  109. 109. www.indiandentalacademy.com
  110. 110. Herbst appliance: AJO-DO 1982 Sarnäs, Pancherzroentgen stereometric method. The Herbst appliance works as an artificial joint between the maxilla and the mandible The appliance is fixed to the teeth -orthodontic bands. www.indiandentalacademy.com
  111. 111. 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. www.indiandentalacademy.com
  112. 112. In the pretreatment period the mandible and the maxillary bones were displaced to the affected side and posteriorly, increasing the degree of asymmetry and retrognathia. In the treatment period this development was reversed or arrested, but at the same time the tilt of the mandible to the www.indiandentalacademy.com
  113. 113. Twin block AJO 1988 Clark When activated unilaterally - correct postur mand. displacement (mid line displacement an asymmetric buccal segment relationships). www.indiandentalacademy.com
  114. 114.  The occlusal inclined plane is particularly well suited to the correction of functional abnormalities associated with asymmetric mandibular development.  For correction of asymmetry, the lower appliance requires maximum retention in the lower arch to minimize dental movement and to encourage asymmetric www.indiandentalacademy.com
  115. 115.  A, Age 10 years 6 months. B, Age 10 years 8 months. C, Age 11 years 3 months. D, Age 12 years 8 months. www.indiandentalacademy.com
  116. 116. www.indiandentalacademy.com
  117. 117. www.indiandentalacademy.com
  118. 118.  PRIMARY ASYMMETRY – associated with whole facial skeleton  SECONDARY ASYMMETRY – alveolar hyperplastic response to mandibular asymmetries  Cant in orbital plane along with occlusal tilt indicates primary asymmetry  Usually, camouflage treatment rather www.indiandentalacademy.com
  119. 119. Nasomaxillary hypoplasia  Lefort II osteotomy  Paranasal augmentation:- onlay grafts  Improves soft tissue support in lateral & inferior alar bases  Allogenic catilage is excellent  1:1 ratio of change www.indiandentalacademy.com
  120. 120. Malar hypoplasia  Modified Lefort III osteotomy  Infra orbital augmentation:  Intraoral  Fluid approach silicone allogenic www.indiandentalacademy.com
  121. 121. www.indiandentalacademy.com
  122. 122. Distraction osteogenesis Is the slow application of force to a bone gap, resulting in the production of new bone & soft tissues. Unique features:  Functional matrix – soft tissue hyperplasia  Bone & stretched periosteum – template for bone synthesis.  Adequate stability – direct ossification www.indiandentalacademy.com
  123. 123. Secondary effects:  Oral commissure & paranasal structures – normalise & descend  Mand. Condyle – increase in size & volume  Airway –increases in volume. 2 types of distraction devices: 1. Monofocal 2. Multiplanar Mandible should be expanded till www.indiandentalacademy.com
  124. 124. Ilizarov principles:  Bone cut- corticotomy osteotomy  Rate – 1mm day –adults, 1.5mm- child  Rhythm – 0.5 1 0.25 mm advancement  Presence of cortical outline in OPG lat. ceph –best indicator of osseous healing  if treatment initiated in early stages- max. deformity & occlusal cant auto correct www.indiandentalacademy.com
  125. 125. www.indiandentalacademy.com
  126. 126. Orthodontic considerations during Distraction osteogenesis: 1. Occlusal interferences (based on Occlusal cant ) - apply interarch elastics 2. Post distraction cross bite –contralat. Side -RPE & Intermax. elastics to settle occlusion -reinforce lower anchorage - levelling of occlusal plane 3. Post distraction open bite – same side www.indiandentalacademy.com
  127. 127. www.indiandentalacademy.com
  128. 128. www.indiandentalacademy.com
  129. 129. TMJ functional ankylosis: -AJO 1980 Any mechanical restriction of growth in the condylar area - An ankylosis-like effect on growth (the mandible can move, but is restricted.) - "FUNCTIONAL MANDIBULAR ANKYLOSIS. '' -Restriction of the child's ability to translate the mandible forward out of the www.indiandentalacademy.com
  130. 130. AJO1980 Proffit The treatment of patients with fractures at the mandibular condyles can be considered in three time frames:  (1) immediately following the accident,  (2) during the postinjury stages of mandibular growth, and  (3) at the completion or near completion of growth. www.indiandentalacademy.com
  131. 131. Immediate postinjury treatment in children  surgical intervention in young children -aggravate growth disturbances  If occlusion is normal, - close observation & exercises to maintain www.indiandentalacademy.com
  132. 132.  If mandible deviated toward the injured side ( cross-bite and a distal occlusion on that side) and a lateral open-bite on the uninjured side- Minimal immobilisation followed by active physiotherapy & appliance therapy  Mouth-opening exercises are encouraged, but interarch elastics should be worn to www.indiandentalacademy.com
  133. 133. Treatment of growing children with a previous fracture  Old fractures - noticed only when the child is brought for orthodontic consultation  ascertain whether the deformity is progressive proportions of the jaws are relatively stable.  Progressive deformity - mechanical limitations on growth – results in "functional ankylosis.'' -requires early www.indiandentalacademy.com
  134. 134.  Good postinjury growth & proportions are maintained - conservative treatment .  The child translates mandible forward in reasonably normal occlusion (the shortened ramus is evident only in a strained retruded position) – encourage the child to function with the mandible forward www.indiandentalacademy.com
  135. 135. TMJ SURGERIES  Release of ankylosis to provide free movement – remove the scar tissue & bone & coronoid process – followed by physiotherapy.  Reconstruction of damaged condylar process – grafts ( pseudo arthrosis)  Followed by functional appliance to guide subsequent growth – as soon as possible after surgery-to control any www.indiandentalacademy.com
  136. 136. Inverted ‘L’ osteotomy  More conservative – corrects asymmetry, but accept limited jaw function  Advance the tooth bearing portion – defects filled with autogenous bone www.indiandentalacademy.com
  137. 137. www.indiandentalacademy.com
  138. 138. CONDYLAR HYPERPLASIA  Starts dramatically with pubertal growth spurt  Enlarged condylar head, downward growth of lower border till midline , secondary upward alveolar growth  Lateral open bite ,no midline deviation, tilted occlusal plane www.indiandentalacademy.com
  139. 139. www.indiandentalacademy.com
  140. 140.  Early stages – prior to alveolar changes – subsigmoid osteotomy –to maintain occlusion –no TMJ surgeries  Late stages- -Lefort I to level occlusal plane - Subcondylar osteotomy BSSO -Trimming of lower border www.indiandentalacademy.com
  141. 141. Hemi mandibular elongation  Increased ramus width & body length on affected side –midline deviation & cross bite –undisturbed occlusal plane  Surgery preceded by RPE for 4 months –to match the intercanine width  Subcondylar BSSO –unilateral side & allow rotation of contra lateral angle www.indiandentalacademy.com
  142. 142. www.indiandentalacademy.com
  143. 143. Chin surgeries Can conceal mandibular asymmetries as patient is more aware of the transverse asymmetry Considered if occlusion is satisfactory – less complex & considerable esthetic benefit 1.  Alloplastic augmentation www.indiandentalacademy.com
  144. 144. Inferior border osteotomy  Preferred method  Ratio of hard &soft tissue change is predictable  Permanent results  Less traumatic decrease morbidity  Done on out patient www.indiandentalacademy.com
  145. 145. www.indiandentalacademy.com
  146. 146. Augmentation surgeries Done in extreme cases  Autogenous allogenic bone grafts  Autogenous allogenic cartilage grafts -Calvarial intramembranous bones are more predictable  Alloplasts -sialastic, proplast, hydroxyl apatite  Disadvantages: unpredictable effects on soft tissue contours, underlying bone www.indiandentalacademy.com
  147. 147. GRAFT MATERIALS  Used in severe cases of asymmetries involving wide areas – maxilla, zygoma, condyles, mandible .  Repeated surgeries are needed to attain adequate results  COSTOCHONDRAL GRAFTS –very ideal in reconstruction of missing facial parts – www.indiandentalacademy.com
  148. 148. Reconstruction with costochondral grafts Alternate ribs can be harvested depending on the requirement from fifth rib onwards www.indiandentalacademy.com
  149. 149. Alloplastic materials Selection based on : 1.physical prop. & 2.Compatibility Materials used : Acrylic resins Silicone rubber 1. 2. Craniofacial applications :   Major contour alterations Augment frontal, zygomatic, nasal, chin deficiencies www.indiandentalacademy.com
  150. 150. 3.Poly ethene & poly urethane 4.Polytetrafluoro ethylene teflon - available in sheets - Intra operative contouring for Nasomaxillary& malar hypoplasia,orbital floor reconstruction, continuity defects 5.Proplast – tissue ingrowth for uptake Customised formswww.indiandentalacademy.com for chin, premaxilla,
  151. 151. 6. Polyamides: Mesh forms – very technique sensitive Onlay material for chin, nasal dorsum & maxilla 7. Ca phosphate ceramics: Hydroxy apatite & related materials Become integral part of living bone tissue 8. Autoalloplasts: Alloplasts implanted insecure area of the body, incorporated with fibrous tissue in 6 www.indiandentalacademy.com
  152. 152. 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 handicapped www.indiandentalacademy.com
  153. 153. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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