Facial Asymmetry Guide

FACIAL ASYMMETRY
Guided By:
Dr. Suresh Kangne
Dr. Anand Ambekar
Dr. Pravinkumar Marure
Dr. Yatishkumar Joshi
Dr. Chaitanya Khanapure
Dr. Rashmi Dhanashetti
Presented By:
Dr. Abhidnya Madansure

CONTENT
◇Introduction
◇Review of literature
◇Etiology of facial asymmetry
◇Classification of facial asymmetry
◇Diagnosis of facial asymmetry
◇Management of facial asymmetry

“
“The study of orthodontia is indissolubly
connected with the art related to the
human face.”
-Dr. Edward H. Angle.

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.

Attractiveness
Averageness
Sexual
dimoarphism
Youthfulness
Asymmetry
 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

◇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

◇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

Right & left facial asymmetries
Cleft lip
Tooth size
Cheong YW, Lo LJ. Facial Asymmetry: Etiology, Evaluation, and Management. Chang Gung Med J 2011;34:341-51
Introduction

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

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

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

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

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

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.
Review of
literature

Etiology of facial
asymmetry
3.

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

Etiology Genetic Environmental
Etiology

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

2. Hemifacial microsomia –
 Defect in proliferation & migration of early
embryonic neural crest cells.
 Affects craniofacial region
 Mandibular asymmetry
 Dental
Etiology

3. Hemifacial hypertrophy –
 Due to asymmetry in primary distribution of neural
crest cells.
 Both soft & calcified tissues.
 Commonly seen on right side.
Etiology

4. Congenital muscular torticollis –
 Shortening of at least one of the
cervical muscles.
 Usually - sternocleidomastoid muscle.
5. Postural scoliosis –
 Deformity outside the spine
 High incidence of lateral malocclusion.
Etiology

b
6. Hemifacial atrophy –
 Perrie-Romberg syndrome.
 Slowly progressing atrophy
of subcutaneous tissues, fat &
bone.
 Females > males. Left > right.
 Roots – underdeveloped -
Failure of eruption - openbite
on affected side.
Etiology

bishara
7. Mandibulofacial dysostosis.
 Treacher Collins syndrome
 Ears, eyes, cheekbones, jaws.
8. Plagiocephaly.
 Flat head syndrome
 Asymmetrical distortion of
the skull.
Etiology

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

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

3. Rheumatoid arthritis
4. Neuromuscular disturbances – damage to
nerve – loss of muscle function & tone –
asymmetry.
Etiology

U v cheong
5. Sucking habits or asymmetrical chewing habits
6. Various pathologic conditions – osteochondroma
of condyle.
◇Facial asymmetry, open bite on involved side, &
mandibular deviation.
Etiology

Classification of facial
asymmetry3.

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

VERTICAL ASYMMETRY TRANSVERSE ASYMMETRY
SAGITTAL ASYMMETRY
2. According to the involvement of facial plane
Classification

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

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

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

Hemimandibular elongation Hemimandibular hyperplasia
Midline deviation Opposite side Same side
Gonial angle Flattening on affected side Normal or more acute
Midline notching Absent Present

Body elongation
Condyle / ramus
elongation
Plane of discrepancy Horizontal/ transverse Vertical
Gonial angle Flattening Acute
Mandibular & occlusal
Planes
No vertical Difference Vertical Difference
Unilateral openbite Absent Present

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

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

◇Developmental
￭Agenesis.
￭Hypoplasia of condyle, neck, ramus, body
￭Hyperplasia of condyle, neck, ramus, body
￭Combinations
4. Classification of mandibular
asymmetry
Classification

◇Acquired
￭ Trauma – ankylosis
￭ Tumors
￭ Infections
￭ Functional mandibular displacement
Classification

Diagnosis of facial
asymmetry3.

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

A. Medical history
◇Prenatal / natal history
◇Forceps delivery
◇Rule out any underlying medical condition or
syndrome which can present as a facial
asymmetry.
eg. Treacher Collins syndrome, torticollis,
scoliosis, plagiocephaly etc.
Diagnosis

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

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

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

Intra-arch Analysis
 Antero-posterior reference plane -
mid palatal raphae
 Transverse reference plane -
Tuberosity plane (drawn
perpendicular to AP plane)
 The position of teeth and arch
symmetry - measured with respect
to these plane
Diagnosis

 The anterior point - lingual frenum
 The posterior point - a
perpendicular, which runs from the
posterior edge of the raphe from the
maxillary to the mandibular cast
Diagnosis

Symmetrograph
Asymmetrical arch shape in transverse
and anteroposterior direction, -
assessed using a template, oriented to
mid-palatal raphe and tuberosity plane
Diagnosis

◇Soft tissue evaluation
￭Deviations in dorsum & tip of nose, philtrum & chin
point.
￭Asymmetry of mandible is characterized by:
1) Deviation of chin to one side
2) Dentoskeletal midline discrepancies
3) Crossbite
4) Canting of occlusion plane may also be seen.
Diagnosis

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

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

◇Compare full face photograph with composites
consisting of two right or two left Sides.
Diagnosis
Left symmetry Original Right symmetry

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

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

◇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

Deficient or excess
◇Total width is compared with total
face height (ratio)
◇Zy-zy/Tr-Gn x 100= 75%
◇Zy-zy =0.75x facial height
Diagnosis

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

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

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

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

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

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

◇Perpendiculars to MSR from J and Ag
◇Connecting lines from Cg to J and 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

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

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

◇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

 Using the MSR plane
 Nasal cavity width,
 Mandibular width,
 Maxillary width,
 Intermolar and intercuspid width
 Construction of midsagittal plane. - A transverse
plane - center of the zygomatic arches, a
perpendicular from crista galli.
Ricketts AnalysisDiagnosis

◇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 J Orthod 1983;84:217-24.
Diagnosis

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

C. 3rd acetate tracing, upper surface of
the petrous portion of the temporal bone,
mandibular condyles, ramus, gonial
angle, and the mastoid processes
Diagnosis

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 the mandibular central
incisors- Mi,
◇Gnathion - Mg - connect
Diagnosis

◇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

◇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
◇In patients with facial asymmetry -
posterior and middle cranial structures
appear less severely affected
Diagnosis

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

◇Basilar view- key triangles are constructed
◇Superpositioning of the triangles- demonstrates
the warping of the craniofacial complex.
Diagnosis

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. Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod
1994;64(2):89-98
3. Cheong YW, Lo LJ. Facial Asymmetry: Etiology, Evaluation, and Management. Chang Gung Med J
2011;34:341-51
4. Proffit W. Contemporary Orthodontics. 3rd Ed
5. Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. J Clin Orthod
1987;21:448-65.
6. Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane
cephalometry. Am J Orthod 1983;84:217-24.
7. Burke PH. Stereophotogrammetric measurement of normal facial asymmetry in children. Hum Biol
1971;4:536.
8. Cohen MM Jr. Perspectives of craniofacial asymmetry. Part I. The biology of asymmetry. Int J Oral
Maxillofac Surg 1995;24:2-7.
9. Haraguchi S, Iguchi Y, Takada K. Asymmetry of the face in orthodontic patients. Angle Orthod
2008;78:421-6.
10. Severt TR, Proffit WR. The prevalence of facial asymmetry in the dentofacial deformities population
at the University of North Carolina. Int J Adult Orthodon Orthognath Surg 1997;12:171-6.
11. Proffit WR, Turvey TA. Dentofacial asymmetry. In: Proffit WR, White RP Jr, eds. Surgical Orthodontic
Treatment. St Louis: Mosby, 1991:483-549.

Management of
facial asymmetry
7.

Facial
Asymmetry
Skeletal
Dental

◇Plagiocephaly
◇Clefting conditions
◇Hemifacial hyperplasia
◇Hemifacial atrophy
◇Hemifacial microsomia
◇Condylar hyperplasia
◇Trauma
In previous seminar…..
* 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

◇ Flat head syndrome
◇ Asymmetrical distortion of the skull.
◇ Two main causes: deformational plagiocephaly (DP) and
craniosynostotic plagiocephaly (CP).
◇ DP- cranial molding-helmet therapy
* 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
Plagiocephaly

◇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

Plagiocephaly
Case report

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

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

◇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

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

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

◇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

◇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.

◇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

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

◇ Growth modification with Hybrid functional
appliance
◇ Bite block on normal side to prevent over
eruption
◇ Buccal and lingual shield on the affected
side - vertical development
* 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

◇ Bi-jaw orthognathic surgery - bone grafting may be required
◇ Le Fort I osteotomy – 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

◇ McCarthy et al-
◇ 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 treated with distraction osteogenesi
temporary anchorage devices, and orthodontics, Am J Orthod Dentofacial Orthop 2012;142:115-2

*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

*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

Predistraction
Phase
• Edgewise brackets (0.022 in) – Alignment and leveling.
• 0.020X0.025-in stainless steel
Distraction
Phase
• 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
Postdistraction
Phase
• Eruption of the ipsilateral maxillary teeth.
• biteplane - reduced under the maxillary left second molar to allow its
gradual eruption
• first and second premolars
• sectional wires were hinged between the right canine and lateral incisor
- hook soldered - vertical
• traction by a mandibular miniscrew
*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

Soft tissue management:
◇Contour modification is done to enhance the contour of the
skeletal and soft tissue
◇Accomplished by adding fat to the affected side

◇It is a developmental malformation characterized by
excessive growth of the condyle.
◇Treatment varies according to age, overall skeletal growth,
presence or absence of active hyperplasia, and degree of facial
asymmetry
◇Treatment - surgical and can entail high condylectomy,
orthognathic surgery, or both.
* Choi YJ, Lee SH, Baek MS, Kim JY, Park YC. Consecutive condylectomy and molar intrusion using temporary anchorage devices as an alternative for correcting facial
asymmetry with condylar hyperplasia. Am J Orthod Dentofacial Orthop 2015;147:S109-21
Condylar hyperplasia

asymmetry with condylar hyperplasia. Am J Orthod Dentofacial Orthop 2015;147:S109-21

asymmetry with condylar hyperplasiaAm J Orthod Dentofacial Orthop 2015;147:S109-21

◇ 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

3. Reconstruction of the TMJ in growing patient
◇Use local tissue, such as stump of the remaining ramus or
◇Employ a costochondral graft
Trauma
2. Management of Post traumatic asymmetry:
• Early surgery to guide condyle for subsequent growth

* Hossein Behnia, Azita Tehranchi and Farnaz Younessian. Comprehensive Management of Temporomandibular Joint Ankylosis — State of the Art. A Textbook of
Advanced Oral and Maxillofacial Surgery Volume 2: 411-32
Trauma

Dental Asymmetries
divided into 4 groups –
1. Occlusal cants
2. Asymmetric arch form
3. Unilateral crossbite
4. Asymmetric left to right buccal occlusion, with or without
midline deviation.

A. Canted anterior occlusal plane
◇Vertical interarch elastics – extrusion
◇0.017 x 0.025-inch TMA - intrusion arch
◇0.017 x 0.025-inch TMA -extrusion
1. Canted occlusal plane
Canted occlusal plane

◇Posterior occlusal cant
-Cantilever with hook
◇A lingual arch
-with a tip-back activation on the steep side
-tip forward activation on the contralateral side
corrects a cant of the mandibular occlusal plane
Canted occlusal plane

◇ Asymmetrically shaped arch wire
◇ Cantilever (.017 x .025 TMA), from the first molar, with a hook
that is attached in the area where the arch needs to be
expanded.
-TPA / lingual arch-to prevent rotation of the anchor molar
2. Asymmetric arch form

◇ Crossbite-elastics
◇ Arch expansion
◇ A compensated dentition is found in patients with a unilateral
posterior crossbite. - Torque or 3rd order movement has to be
carried out
3. Unilateral crossbite

4. Asymmetric left to right buccal occlusion, with or without
midline deviation.
Unilateral
class II elastics
Open-coil
springs
Unilateral fixed
functional
appliance
Pendulum
appliance

◇Class II malocclusions
◇Distally positioned mandibular molars on the
Class II side
◇midline deviation is severe
◇ASYMMETRIC EXTRACTION

*Jung SK, Kim TW. Treatment of unilateral posterior crossbite with facial asymmetry in a female patient with transverse discrepancyAm J Orthod Dentofacial Orthop
2015;148:154-64

◇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 J Orthod Dentofac Orthop 1990;97:453-62

What others see What Orthodontists see
Treatment of Midline shift...
?
The midline shift

◇Angle:
◇tandem anterior diagonal elastic
◇Class III elastic OR class II elastics
The midline shift

◇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

The midline shift
Palacios P, Uribe F, Nanda R. Correction of an Asymmetrical Class II Malocclusion Using Predictable Force Systems. J Clin Orthod. 2007:12(4):211-16

Palacios P, Uribe F, Nanda R. Correction of an Asymmetrical Class II Malocclusion Using Predictable Force Systems. J Clin Orthod. 2007:12(4):211-16
The midline shift

◇ Symmetry - quintessential ingredient in facial aesthetics
◇ In spite 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.

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 J Orthod Dentofacial Orthop 2015;148:154-64
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 II Malocclusion Using Predictable Force
Systems. J Clin 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.Cheong YW, Lo LJ. Facial Asymmetry: Etiology, Evaluation, and Management. Chang Gung Med J
2011;34:341-51
11.Proffit W. Contemporary Orthodontics. 3rd Ed

Facial Asymmetry Guide

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