management of facial asymmetry Management of facial a symmetry Prepared by: Dr Mohammed Alruby القلق لا يمنع الم الغد ولكنه يسرق متعه اليوم Definition: A symmetry means balance in facial dimension but a symmetry means imbalance in facial dimension = perfect bilateral body symmetry is more theoretic concept that seldom exist in living organisms = Bjork 1964 noted that compensatory a symmetric growth of maxilla and mandible can occur when the cranial base develops a symmetry at an early age = the period at which normal a symmetry becomes abnormal cannot easily defined and is often determined by the clinician’s sense of balance and patient perception of imbalance Classification: The facial a symmetry can classified according to: - I origin: skeletal, functional, muscular, soft tissue - II site: upper third, middle third, lower third - III etiology: congenital, developmental, acquired, functional Etiology 1- Congenital: Hemi-facial microsomia Craniosynostosis Torticollis: wryneck: it is stiff neck associated with muscle spasm (condition in which the head is tilted to one side, the muscles affected especially sternocleidomastoid muscle 2- Developmental: a- Intrinsic jaw growth disturbance: = excessive unilateral growth of mandible is responsible for facial a symmetry; it is described as: hemi-mandibular hyperplasia ---- obwegeser = this a symmetry due to continued growth of mandible on one side after growth on the other side has stopped, it is usually become appears at late teens b- Secondary growth disturbance: Unilateral paralysis of mandibular elevator muscle as a result of birth injury or de-innervation, lead to defect in growth of maxilla and mandible that in turn cause facial a symmetry Excessive muscle tone as in case of torticollis, that cause mechanical restriction of growth 3- Acquired facial a symmetry: a- Condylar trauma: = one of the most common causes of mandibular a symmetry in c= one of the most common causes of mandibular a symmetry in children that inhibit the growth of mandible at the affected side = the trauma may be followed by ankylosis of mandible at the site of trauma that lead to subsequent facial a symmetry b- Surgical trauma: The open reduction of condylar fracture in children should be avoided because the scar tissue that produced after surgery may be increased the restriction of normal anterior and downward growth as a result of decreased translatory movement of condyle c- Habits: rest on hand d- Degenerative joint disease e- Pathology as osteo-chondoma 4- Functional a symmetry: = as a result of deflection of mandible laterally or anterior posterior, these functional deviations may be caused by constricted maxillary arch or malposed tooth -------- the abnormal initial contact in centric relation may result in subsequent mandibular displacement in centric occlusion = in case of TMJ derangement has anterior displaced disc without reduction that lead to translation of mandible t

1. 1
Dr. Mohammed Alruby
Management of facial a symmetry
Prepared by:
Dr Mohammed Alruby
‫ال‬ ‫متعه‬ ‫يسرق‬ ‫ولكنه‬ ‫الغد‬ ‫الم‬ ‫يمنع‬ ‫ال‬ ‫القلق‬
‫ي‬
‫وم‬
Definition:

2. 2
Dr. Mohammed Alruby
A symmetry means balance in facial dimension but a symmetry means imbalance in facial
dimension
= perfect bilateral body symmetry is more theoretic concept that seldom exist in living organisms
= Bjork 1964 noted that compensatory a symmetric growth of maxilla and mandible can occur
when the cranial base develops a symmetry at an early age
= the period at which normal a symmetry becomes abnormal cannot easily defined and is often
determined by the clinician’s sense of balance and patient perception of imbalance
Classification:
The facial a symmetry can classified according to:
- I origin: skeletal, functional, muscular, soft tissue
- II site: upper third, middle third, lower third
- III etiology: congenital, developmental, acquired, functional
Etiology
1- Congenital:
Hemi-facial microsomia
Craniosynostosis
Torticollis: wryneck: it is stiff neck associated with muscle spasm (condition in which the head is
tilted to one side, the muscles affected especially sternocleidomastoid muscle
2- Developmental:
a- Intrinsic jaw growth disturbance:
= excessive unilateral growth of mandible is responsible for facial a symmetry; it is described as:
hemi-mandibular hyperplasia ---- obwegeser
= this a symmetry due to continued growth of mandible on one side after growth on the other side
has stopped, it is usually become appears at late teens
b- Secondary growth disturbance:
Unilateral paralysis of mandibular elevator muscle as a result of birth injury or de-innervation,
lead to defect in growth of maxilla and mandible that in turn cause facial a symmetry
Excessive muscle tone as in case of torticollis, that cause mechanical restriction of growth
3- Acquired facial a symmetry:
a- Condylar trauma:
= one of the most common causes of mandibular a symmetry in c= one of the most common causes
of mandibular a symmetry in children that inhibit the growth of mandible at the affected side
= the trauma may be followed by ankylosis of mandible at the site of trauma that lead to subsequent
facial a symmetry
b- Surgical trauma:
The open reduction of condylar fracture in children should be avoided because the scar tissue that
produced after surgery may be increased the restriction of normal anterior and downward growth
as a result of decreased translatory movement of condyle
c- Habits: rest on hand
d- Degenerative joint disease
e- Pathology as osteo-chondoma
4- Functional a symmetry:

3. 3
Dr. Mohammed Alruby
= as a result of deflection of mandible laterally or anterior posterior, these functional deviations
may be caused by constricted maxillary arch or malposed tooth -------- the abnormal initial contact
in centric relation may result in subsequent mandibular displacement in centric occlusion
= in case of TMJ derangement has anterior displaced disc without reduction that lead to
translation of mandible to affected side
Diagnosis of facial a symmetry
1- History:
The history of patient should include:
- Age of patient
- Age at which a symmetry is first noted
- Is a symmetry worse by time or not?
- Family history
2- Clinical examination:
- Frontal face analysis and profile analysis
- Palpate the face to detect the soft and hard tissue defect
- Examine TMJ function
- Examination of the cant of occlusal plane: the presence of canted occlusal plane could be
due to unilateral increase or decrease in the vertical height of condyle and ramus
Clinically: is achieved by asking the patient to bite on tongue plate to determine how it
relate to the inter-pupillary line
- Evaluate of dental midline at: mouth opening, centric relation, initial contact, centric
occlusion
True skeletal or dental a symmetry will be exhibit similar midline discrepancies
A symmetry due to occlusal interferences may result in mandibular functional shift
following initial tooth contact
- Evaluate the transverse and anterior posterior occlusion, also unilateral cross bite should
carefully have diagnosed to determine if it is skeletal or dental
3- Radiographic examination:
a- Posterior anterior cephalometric radiograph to evaluate the:
Dental and skeletal midline deviation
Canting of the jaws and occlusal planes
Upper facial a symmetry
b- Panoramic radiograph:
Show condyle
Body length
Ramus height
Anti-gonial notch and teeth
c- Lateral cephalometric radiograph:
Lack of superimposition of bilateral structure
d- Submento-vertex radiograph:
Used for examination of:
Mandibular ramus deformity
Facial-lingual width of mandible
Zygoma and zygomatic arch region
e- TMJ radiograph:

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Dr. Mohammed Alruby
To detect the abnormalities at condyle either hypoplastic or hyperplastic
f- Computed tomography:
CT scan of cranio-facial region, three dimensional evaluations by software
g- Magnetic resonance imaging:
It is good for examination of soft tissue abnormalities
4- Diagnostic cast:
It is important to examine the dentition and plane of treatment
5- Photographs:
Physio-print method that recommended by Sassoni
N: B:
== as a general: skeletal deviation must be equal to or greater than 4mm in order to render a
symmetry but if the degree is lower than 4mm it considered as mild
== use of symmetrograph: using a templet oriented to mid palatal raphe and tuberosity using
symmetrograph
== for extra-oral clinical evaluation, use the rule of fifth to evaluate the transverse relationship
of the face
Treatment of facial a symmetry
1- Management of functional shift:
= mild deviation due to functional shift corrected with minor occlusal adjustment
= more severe deviation corrected by orthodontic alignment to align the teeth and to obtain proper
function
= occlusal splints necessary to evaluate the presence and extent of functional shift by eliminate
habitual posturing and deprogramming the musculature and can treated by: RME, orthognathic
surgery, orthodontic treatment
2- Management of skeletal a symmetry:
= in growing individuals’ orthopedic appliance and orthodontic treatment used to improve and
correct the development of skeletal imbalance
= in severe cases the combination of orthodontic treatment and orthognathic surgery is used in
these cases
3- Management of soft tissue a symmetry:
Treated by augmentation or reduction surgery, augmentation occurs by bone graft to recontour
the desired area of face
Burston 1998: the treatment options include:
- Orthognathic surgery
- Orthopedic and orthodontic either extraction or non-extraction therapy, the treatment plane
depends on differentiating the skeletal from dental problem
Factors considered during using functional appliances in cases of facial a symmetry

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Dr. Mohammed Alruby
1- Must be used in growing individuals
2- Teeth in the unaffected site must be prevented from eruption
3- Teeth in the underdeveloped side must be allowed to erupt to level the cant of occlusal plane
4- Appliance must displace the mandible to unaffected side