Facial Asymmetry

DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS
SEMINAR PRESENTATION
Presented by:
Dr. Deeksha Bhanotia
MDS second year
Guided by:
Dr. Mridula Trehan
Professor and Head
FACIAL ASYMMETRY
1

• Introduction
• Etiology of facial asymmetry-
1. Genetic
2. Environmental
• Classification of facial asymmetry
1. Dental
2. Skeletal
3. Functional
4. muscular
CONTENTS 2

• Diagnosis of facial asymmetry
A. Medicalhistory
B. Dentalevaluation
C. Photographforfacialevaluation
D. Radiographs:
o Lateralcephalograms
o Panoramicevaluations
o PA views
o TMJimaging
• Management of facial asymmetry
3

Introduction
◇Each person shares many characteristics with the
rest of the population.
◇Variation - provides his or her own identity.
Sándor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am.
2007 Aug;19(3):395-422
4

 No human Face – symmetric
 Goal of orthodontic treatment - create a balanced n
harmonious facial proportion
Sándor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am.
2007 Aug;19(3):395-422
5

◇Symmetry:
“Equality or correspondence in the form of parts
distributed around a centre or an axis, at the two
extremes or poles, or on the two opposite sides of
the body.”
(Steadman’s Medical dictionary)
◇Clinically, symmetry means balance, where as
asymmetry means imbalance.
Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98
Introduction 6

◇Facial Asymmetry –
“Imbalances that occur between homologous
parts of the face affecting the proportion of these
parts to one another with regard to size, form, and
position on opposite sides of a plane, line or point.”
◇ The division of normal from the abnormal –
clinician’s sense of balance and patient’s
perception of imbalance
Introduction 7

Right & left facial asymmetries Tooth size
Cleft lip
Cheong YW, Lo LJ. Facial Asymmetry: Etiology, Evaluation, and Management. Chang Gung Med J2011;34:341-51
Introduction 8

◇Asymmetry of the upper face- 5%,
◇ Middle third -36%
◇ Lower third /deviation of the chin-75%
Introduction 9

Among orthodontic patients
Mandibular midline deviation 62%
Maxillary midline deviation 39%
Molar classification asymmetry 22%
Maxillary occlusal asymmetry 20%
Mandibular occlusal
asymmetry
18%
Facial asymmetry 6%
Chin deviation 4%
Nose deviation 3%
Introduction
10

Woo (1931)–
◇Cranial bones – asymetric.
Right frontal, temporal & parital- larger.
◇Facial bones- left zygoma and maxilla– larger.
11

Peck-
◇Less asymmetry and more dimensional stability
as the cranium is approached.
◇Tendency toward right-side - not statistically
significant.
12

Vig and Hewitt 1975:
◇Cranial base - larger left side
◇Mandibular region - larger left side
◇Maxillary region -larger right side
◇Dentoalveolar symmetry - compensatory change.
13

Sharad Shah & M. R. Joshi – 1978 :
◇Pleasing & apparently symmetrical faces do exhibit
skeletal asymmetry.
◇Soft tissue of the face attempts to minimize the
underlying skeletal asymmetry.
14

According to Wool –
◇“Facial asymmetry is due to asymmetric
development of the brain, with dominance of the right
hemisphere possibly influencing an asymmetric
muscular habit, such as unilateral mastication.”
Etiology
15

Etiology Genetic Environmental
Etiology
16

1. Clefts of lip or palate –
 Facial deformity with associated
collapse of maxillary dental arch.
 Left sided :right sided – 2:
1.
Genetic
Etiology
17

Environmental
1. Intrauterine pressure
◇Parturition - Molding of parietal & facial bones
from pressures – facial asymmetry.
◇Transient effects
◇Restoration - within a few weeks to
several months.
Etiology
18

2. Trauma & infection –
◇Trauma & infection within TM joint
◇Ankylosis
◇Untreated fractures of condyle.
– compensatory growth leading to overgrowth
of condyle on affected side.
Etiology
19

1. Asymmetry according to Lundstorm in 1961
Quantitative
asymmetry -
differences in the
number
Qualitative asymmetry
-difference in size,
location of the teeth,
position of the arches.
Classification
20

1. Dental asymmetry
2. Skeletal asymmetry
3. Muscular asymmetry
4. Functional asymmetry
3. Structural Classification of
Dentofacial Asymmetry
Classification
21

1. Dental asymmetries-
 Congenitally missing tooth or teeth
 Shape and size alteration of the teeth
 Shape of dental arches.
 Midline deviations
Classification
22

2. Skeletal asymmetries –
◇Involve one or more skeletal structures on one
side of the face.
Skeletal asymmetry
Hemimandibular elongation Hemimandibular hyperplasia
Body elongation Condylar /ramus elongation
Obwegeser (1986)
Classification 23

◇Muscular asymmetry – e. g. hemifacial atrophy
◇Muscle size discrepancy – e. g. masseter hypertrophy.
◇Abnormal muscle function.
Classification 24

U v cheong
4. Functional asymmetries
–
◇Occlusal interferences.
◇Constricted maxillary arch
◇TM joint derangement - anteriorly displaced disc
without reduction
– midline shift due to interferences in mandibular
translation on affected side.
Classification
25

A. Medical history
B. Dental evaluation
C. Photograph for facial evaluation
D. Radiographs: Lateral cephalograms
Panoramic evaluations
PA views
TMJ imaging
Essential patient evaluations for facial
asymmetry
Diagnosis 26

A.Clinical examination
◇Asymmetry in the vertical,
antero-posterior or lateral
dimension
Diagnosis
27

B. Dental evaluation
◇Evaluation of dental midlines.
￭ Mouth open
￭ Initial contact
￭ Centric occlusion
￭Difference between true asymmetry &
functional asymmetry needs to be assessed.
Diagnosis
28

◇Vertical occlusal evaluation.
￭ Canted occlusal plane
￭ Can be observed by asking the patient to bite o
n
tongue blade & determine its relation to inter-
pupillary plane.
Diagnosis
29

◇Transverse & anteroposterior occlusal evaluations.
￭Careful diagnosis of unilateral posterior crossbite t
o
evaluate if it is skeletal, dental or functional.
￭ Deviation of mandible from CR to CO
￭ Occlusal view – intra-arch analysis
Diagnosis 30

C. Photograph for facial evaluation
Diagnosis
Proffit W. Contemporary Orthodontics. 3rd Ed
31

Submental view and Supracranial view
◇Patient’s head - extended to 450.
◇Useful to assess symmetry
◇Asymmetries of anterior cranial vault,
orbital areas and cheeks and Nasal
deformities
Diagnosis
32

◇The positions nasal bridge, nasal
tip, filtrum, chin point are
assessed with dental landmarks
i.e. upper incisor midline, lower
incisor midline
Diagnosis 33

◇Rule of fifth describe the
ideal transverse relationship
of the face.
Diagnosis
34

◇A well proportioned face is vertically
divided in to equal thirds
◇Subnasale to upper lip inferior - lower
lip superior to soft tissue menton - 1/3rd
and 2/3rd.
Diagnosis
35

Deficient or excess
◇Total width is compared with total
face height (ratio)
◇Zy-zy/Tr-Gn x 100
Diagnosis 36

1. Lateral cephalogram-
◇Used to assess A-P and vertical relationships
◇Limited value in diagnosing asymmetries
◇Ramal height, mandibular length & gonial angle.
Radiographs
Diagnosis
37

2. Panoramic radiograph –
◇Presence of gross pathology, missing or
supernumerary teeth.
◇Shape of mandibular ramus & condyles.
Diagnosis
38

3. Postero-anterior projection –
◇Valuable tool
◇Right & left structures are located at relatively
equal distances from the film & x-ray source.
◇Can be taken in centric occlusion & mouth open
position
Diagnosis
39

GRUMMONS ANALYSIS - 1987.
Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. JClin Orthod 1987;21:448-65.
Diagnosis 40

1. Mandibular Morphology
◇Left and right triangles – Co- -
Ag-Me.
◇These are split by the ANS-Me
line and compared.
Diagnosis 41

2. Volumetric Comparison
◇intersection with a perpendicular
from Co to MSR.
◇Two "volumes" are calculated -
Co-Ag-Me and the intersection
point
Diagnosis 42

◇Perpendiculars to MSR from Jand Ag
◇Connecting lines from Cg to Jand Ag.
◇Produces two pairs of triangles, each
pair bisected by MSR.
◇If perfect symmetry - four triangles
become two, J-Cg-J and Ag-Cg-Ag.
3. Maxillo-Mandibular Comparison of
Asymmetry -
Diagnosis 43

4. Linear Asymmetries -
◇Linear distance is measured
from MSR to Co,NC, J,Ag, and
Me.
Diagnosis 44

5. Maxillo-Mandibular Relation -
◇From buccal cusps of the upper
first molars to the Jperpendiculars.
◇Midline asymmetries of the upper
and lower incisors and Me-MSR are
also provided.
Diagnosis 45

◇Cg-Me line - divisions at ANS,A1, and B1.
◇The following ratios are calculated:
￭Upper facial ratio— Cg-ANS/Cg-Me
￭ Lower facial ratio— ANS-Me/Cg-Me
￭Maxillary ratio— ANS-A1/ANS-Me
￭ Total maxillary ratio— ANS-A1/Cg-Me
￭ Mandibular ratio— B1-Me/ANS-Me
￭ Total mandibular ratio— B1-Me/Cg-Me
￭Maxillo-mandibular ratio— ANS-A1/B1-Me
6. Frontal Vertical Proportions -
Diagnosis 46

◇Three separate acetate tracings
A.1st acetate sheet - the orbital rims,
pyriform aperture, maxillary and
mandibular incisors, and the midpoint of
the symphysis.
◇most superficial aspects of the face
Grayson’s analysis - in 1983.
Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane cephalometry. Am JOrthod 1983;84:217-24.
Diagnosis 47

B. 2nd acetate sheet - greater and lesser
wings of the sphenoid, zygomatic arch,
coronoid process, the maxillary and
mandibular first permanent molars, the
body of the mandible, and the mental
foramina
◇Represent a deeper coronal plane.
Diagnosis
48

C.3rd acetatetracing,uppersurface of the
petrousportionof thetemporalbone,
mandibular condyles,ramus,gonial angle,and
themastoid processes
Diagnosis 49

Midline for each view :
◇In the A plane –
◇Centrum of each orbit is located, - point
Mce halfway between them is marked.
◇The most lateral point on each pyriform -
halfway - point Mp.
◇maxillary and
incisors- Mi,
◇Gnathion - Mg
the mandibular central
- connect
Diagnosis 50

◇B plane - Si
◇Greater and lesser
wings of the
sphenoid- midpoint Msi
◇zygomatic arches - Mz
◇coronoid processes - Mc
◇left and right zygomas - Mx
◇Left and right mental foramina - Mf
Diagnosis 51

Plane C
◇Heads of the condyles - Md
◇Mastoid processes - Mm
◇Gonions - Mgo,
Diagnosis 52

◇Superimpose midline of A, B, and C planes -
warping within the craniofacial skeleton.
◇The midline deviate laterally as passing
from plane C, through plane B, to plane A
◇Inpatients with facial asymmetry -
posterior and middle cranial structures
appear less severely affected
Diagnosis
53

◇Plagiocephaly
◇Clefting conditions
◇Hemifacial hyperplasia
◇Hemifacial atrophy
◇Hemifacial microsomia
◇Condylar hyperplasia
◇Trauma
*Sándor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin
North Am. 2007 Aug;19(3):395-422
Skeletal Asymmetries
54

◇ Flat head syndrome
◇ Asymmetrical distortion of the skull.
◇ Two main causes: deformational plagiocephaly (DP) and
craniosynostotic plagiocephaly (CP).
◇ DP- cranial molding-helmet therapy
Plagiocephaly
*Sándor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422
55

◇Craniosynostosis - a premature fusion of cranial sutures –
reconstruction surgeries
◇Elevated intracranial pressure (ICP)
◇Without increased ICP- delay reconstruction until 12 -24 months
of age.
◇Infants with increased ICP - between the ages of 2 and 9 months
Plagiocephaly
56

Plagiocephaly
Case report 57

◇Development of a fibrous band in the sternocleidomastoid
muscle
◇Unilateral tilt of the neck
Torticollis
58

◇Myotomy and lengthening of the SCM
muscle .
◇Excision of the entire SCM muscle
and its band from its origin to its
insertion.
Torticollis
59

◇Unilateral clefts- can cause facial asymmetries - most common
cause of congenital asymmetry of the craniomaxillofacial
skeleton.
◇Depends on the location and extent of the cleft.
◇Even in the repaired state
Cleft lip and palate
60

◇Leads to facial asymmetry that grows throughout childhood.
◇Both soft tissue and hard tissue structures can be affected,
including teeth
Hemifacial hyperplasia
61

◇Main aim is -follow up until the growth has stopped.
◇Any functional corrections can be performed.
Hemifacial hyperplasia
Jagtap RR, Deshpande GS. Gingival enlargement in partial hemifacial hyperplasia. Journal of Indian Society of Periodontology.2014:18(6):772-775
62

◇Parry-Romberg syndrome.
◇Progressive condition - severe atrophy of all of the hard and
soft tissues of one side of the face
◇Silicone and fat injections, hydroxyapatite alloplastic implants
to mask the defect.
Hemifacial atrophy 63

◇The patient was treated with
autogenous fat grafting
◇Under general anesthesia -
liposuction - 50mL of fat injected the
patient’s atrophic hemiface.
Hemifacial atrophy
*Júlio César Garcia de Alencar et al. Autologous fat transplantation for the treatment of progressive hemifacial atrophy (Parry-Romberg syndrome: case report and
review of medical literatute) .An Bras Dermatol. 2011;86(4Supl1):S85-8.
64

◇Treatment strategy depends each patient’s age, physical
examination,photographs, radiographs, mounted models.
◇Treatments vary from the use of functional dentoalveolar
orthopaedic appliances to total TMJ reconstruction.
Hemifacial microsomia
65

Treatment of
hemifacial
microsomia
Functional
appliances
Surgical
intervention
Orthognathic
surgeries
Distraction
osteogenesis
Soft tissue
management
66

◇ Growth modification with Hybrid functional
appliance
◇ Bite block on normal side to prevent over
eruption
◇ Occlusal clearance on the affected
side
*El-Bialy et al. Nonsurgical treatment of hemifacial microsomia by therapeutic ultrasound and hybrid functional appliance. Open Access Journal of
Clinical Trials 2010:2:29-37
Functional appliances 67

◇ Bi-jaw orthognathic surgery - bone grafting may be required
◇ Le Fort Iosteotomy – canted occlusal plane.
◇ Concomitant mandibular osteotomies:
-Bilateral sagittal split ramus osteotomies or;
-Bilateral vertical ramus osteotomies or;
-ipsilateral vertical ramus osteotomy with contralateral sagittal split osteotomy
◇Genioplasty
Surgical intervention
68

69

70

71

72

◇ New bone formation between the
surfaces of bone segments that are
gradually separated by incremental
traction
◇ A callus forms - traction - callus
tissues are stretched inducing the
new bone formation
Distraction osteogenesis
*Amm EA. Three-year follow-up of a patient with hemifacial microsomia treatedwith distraction osteogenesis
temporary anchorage devices, and orthodontics, Am J Orthod Dentofacial Orthop 2012;142:115-2
73

*Amm EA. Three-year follow-up of a patient with hemifacial microsomia
treated with distraction osteogenesis, temporary anchorage devices, and
orthodontics, Am J Orthod Dentofacial Orthop 2012;142:115-28
74

*Amm EA. Three-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesis, temporary anchorage devices, and orthodontics, Am J
Orthod Dentofacial Orthop 2012;142:115-28
75

Predistraction
Phase
Distraction
Phase
Postdistraction
Phase
• Edgewise brackets (0.022 in) – Alignment and leveling.
• 0.020X0.025-in stainless steel
• A horizontal ramus osteotomy - left, at the level of the occlusal plane
• An angle osteotomy –right
• Advancement 18 mm along the ramus on the left and 6 mm on the right.
• Distraction at a rate of 0.5 mm twice per day for 18 days
• Eruption of the ipsilateral maxillary teeth.
• biteplane - reduced under the maxillary left second molar to allow its
gradual eruption
• first and second premolars
• Vertical traction was flanked by a mandibular miniscrew and a
hook soldered between the left canine and lateral incisor
76

77

78

79

◇Asymmetric deficiency secondary to an early fracture of the
Condylar process
1. Acute management of condyle fracture in children
- Immobilization of the jaw for 7 to 14 days
-Exercises to improve mandibular range of movement
Trauma
80

• Employa costochondralgraft
Trauma
2.ManagementofPosttraumaticasymmetry:
• Earlysurgerytoguidecondyleforsubsequent growth
• Uselocaltissue,suchasstumpoftheremainingramusor
81
3.ReconstructionoftheTMJingrowingpatient

• Asymmetric extraction sequences and asymmetric mechanics
• e.g class III elastics one side and class II elastics on the other
with oblique elastics anteriorly.
• Composite build up or prosthodontic restoration may be
indicated with pronounced tooth irregularities.
Dental Asymmetries 82

*Jung SK, Kim TW. Treatment of unilateral posterior crossbite with facial asymmetry in a female patient with transverse discrepancyAm J Orthod Dentofacial Orthop
83

2015;148:154-64
84

2015;148:154-64
85

2015;148:154-64
86

◇Midline coordination and relative symmetry are basic to an
appreciation of facial harmony and balance.
◇Lewis espouses a set of questions :
–(1) What has caused the midline deviation?
–(2) How does the deviation affect the occlusion?
–(3) Is it necessary to correct it?
The midline shift
*Jerrold L, Lowenstein LJ, The midline:Diagnosis and treatment. Am JOrthod Dentofac Orthop 1990;97:453-62
87

◇Angle:
◇tandem anterior diagonal elastic
◇Class IIIelastic OR class IIelastics
The midline shift
88

◇Strang and Thompson:
◇Double vertical spring loop auxiliary
adjusted for the mass movement of the
four incisor teeth to the left.
◇Midline- to be shifted to left.
◇Closing loop - as close to the left canine
as possible.
◇On activation- the arch rebounds to its
preactivated position,it will carry the four
incisors with it to the left.
The midline shift
89

90
Evaluation of the path of closure from postural rest to habitual
occlusion in the transverse plane.
• Clinical examination of transverse functional relationships is easy to
perform. If consists of observing the behavior of the mandibular
midline as the teeth are brought together from rest position to habitual
occlusion. Two types of crossbite cases with lateral shifting of the
mandibular midline can be differentiated.
LATEROGNATHY AND LATERO-OCCLUSION
Graber T, Rakoshi T, Petrovic A. Dentofacial Orthopaedics with Functional Appliance. 2nd ed.

91
• The first is a crossbite in which the midline shift of the mandible can be
observed only in the occlusal position. In postural rest the midlines are
coincident and well centered. The mandible slides laterally from rest
position into a crossbite in occlusion. This is called a laterocclusion, or
pseudo-crossbite, and is caused by tooth guidance.
• Treatment requires eliminating the disturbance in the intercuspation. This
often is done by widening the narrowed maxillary arch, thus improving
function.

92
• The second is a crossbite in which the midline shift is present in both
occlusal and postural rest positions (e.g., a true asymmetric facial
skeleton). This is some times referred to as laterognathy .
• Successful functional appliance treatment is not possible in such
cases; in severe cases, surgery is the only

◇ Symmetry - quintessential ingredient in facial aesthetics
◇ Inspite of being highly prevalent in the overall population,
facial asymmetry is scarcely addressed in dental literature.
◇ In the management of asymmetries – appropriate treatment
plan, force system, and the appliance is selected.
94

References
1. Sándor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry.
Oral
Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422
2. Jagtap RR, Deshpande GS. Gingival enlargement in partial hemifacial hyperplasia. Journal of Indian
Society of Periodontology.2014:18(6):772-775
3. Júlio César Garcia de Alencar et al. Autologous fat transplantation for the treatment of progressive
hemifacial atrophy (Parry-Romberg syndrome: case report and review of medical literatute) .An Bras
Dermatol. 2011;86(4Supl1):S85-8.
4. El-Bialy et al. Nonsurgical treatment of hemifacial microsomia by therapeutic ultrasound and hybrid
functional appliance. Open Access Journal of Clinical Trials 2010:2:29-37
5. Amm EA. Three-year follow-up of a patient with hemifacial microsomia treated with distraction
osteogenesis, temporary anchorage devices, and orthodontics, Am J Orthod Dentofacial Orthop
2012;142:115-28
6. Jung SK, Kim TW. Treatment of unilateral posterior crossbite with facial asymmetry in a female
patient with transverse discrepancy. Am JOrthod Dentofacial Orthop 2015;148:154-64
95

12. Grayson BH, McCarthy JG, Bookstein F
. Analysis of craniofacial asymmetry by multiplane cephalometry.
Am J Orthod 1983;84:217-24
13. Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. J Clin Orthod
1987;21:448-65
14. Graber T, Rakoshi T, Petrovic A. Dentofacial Orthopaedics with Functional Appliance. 2nd ed.
7. Jerrold L, Lowenstein LJ, The midline: Diagnosis and treatment. Am J Orthod Dentofac Orthop 1990;97:453-
62
8. Palacios P
, Uribe F
, Nanda R. Correction of an Asymmetrical Class IIMalocclusion Using Predictable Force
Systems.JClin Orthod.2007:
12(4):
211-16
9. Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98
10. Cong YW, Lo LJ. Facial Asymmetry: Etiology, Evaluation, and Management. Chang Gung Med J
2011;34:341-51
11. Proffit W. Contemporary Orthodontics. 3rd Ed
96

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