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

MANAGEMENT OF
FACIAL
ASYMMETRIES

www.indiandentalacademy.com

INDIAN DENTAL ACADEMY
Leader in continuing dental education



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

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

 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.

CLASSIFICATION OF FACIAL
ASYMMETRIES:
1. Skeletal asymmetries
2. Soft tissue asymmetries
3. Functional asymmetries

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.

Postnatal causes:
ENVIRONMENTAL

AJO 1994 Pirttiniemi

1. Trauma & infection
2. Muscle dysfunction
3. Functional deviations
4. TMJ derangements
5. Hemi mandibular hypertrophy
6.Pathologies


Cohen 1982
Malformations with abnormal developmental
processes in embryonic stage ( 1%)

 Hemifacial
 Congenital

microsomia

hemifacial hypertrophy

 Cleft

lip & palate


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

 Congenital

muscular torticollis

 Postural

scoliosis

 Plagiocephaly

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





Clinical examination

Radiographic examination


Photographic analysis




History

Digital videography

Articulated study models



HISTORY:

-Can reveal etiology
- Severity of deformity


CLINICAL EXAMINATION:

Reveals asymmetry in the vertical,
antero-posterior or lateral
dimension.


EXTRAORAL EVALUATION:-frontal

TRANSVERSE -“Rule of fifths”


 - Midpupillary

distance aligned with

commisures


 -Inter

ocular dimensionsinterpupillary-65mm
inter canthal- 35mm

 Midfacial

bony supportlower third of iris of the eye
to be covered with lower
eyelid

VERTICAL
Vertical reference plane- nasion to
subnasale
line

upper horizontal plane – bipupillary
lower horizontal line - thru’ the stomion


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.

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

SUBMENTO VERTEX VIEW


INTRA ORAL EXAMINATION

 Evaluation of the dental midlines





Vertical occlusal evaluation
-Transverse cant of maxilla
Transverse and antero-posterior occlusal
evaluations
-Unilateral cross bites

FUNCTIONAL EXAMINATION




Maximal opening
TMJ evaluation
-postural rest position
-CR-CO discrepancy
-laterocclusion
laterognathia



Motor & sensory evaluation

Laterognathia / laterocclusion


Laterocclusion


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.

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


Head position:


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


PA CEPHALOGRAM
Important adjunct for qualitative &
quantitative evaluation of dentofacial
region
 Extent of deformity( orbital upper facial symmetry),
Skeletal dental invlovement.

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

 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

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

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

Various PA analysis


Rickett’s analysis



Svanholt and solow analysis



Grummon’s analysis



Grayson’s analysis



Hewitt analysis



Chierici method

Grummon’s analysis (1987)
 This

is a comparative and quantitative
PA analysis.

 Presented

in 2 forms : 1. Comprehensive

analysis

- Horizontal plane

truction
- Mand. Morphology

ysis
- Maxillomand.

parison

3-D CEPHALOGRAM: McCarthy
Lat.ceph & PAceph traced & digitized
X,Y,Z coordinates – integrated & establish
the exact 3-D location in space


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


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

 the

submental-vertical projection is

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

allows utilization of anatomic

landmarks on the cranial base, remote

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

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

TMJ IMAGING








-Transcranial radiographs
-Tomographs
-CT
-Arthrography
MRI
-Video flouroscopy
-radio nucleotide imaging

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

Identification of mid face deficiency:
 Zygomatic

projection
 Zygomatic prominence


Photographic montage composite
photographs
- reveal altered facial form and disclose
difference in configuration of both sides of
the face


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 )

1.

2.

3.

6.

5.

4.


ARTICULATED STUDY MODELS
3-d representation of occlusion
Improves visualisation of
static & functional
interrelationships
of teeth


 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

ETIOLOGY
 Constricted
 Single

maxillary arch

tooth interference - canines
-

premolars
SIGNIFICANCE:
 If

untreated can lead to true
skeletal asymmetry

TREATMENT
POSSIBILITIES
 MAXILLARY

ARCH EXPANSION

 ORTHODONTIC

ARCH

COORDINATION
 REPOSITIONING

SPLINTS


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.

Slow expansion:
Can bring about skeletal
expansion in primary dentition
Lingual arch quad helix- 50% sk.
exp.
Jack screw
FR functional regulator - indirect
effect

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

HYRAX

HAAS

MINN

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

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.

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

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

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

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

ETIOLOGY
1. Cleft lip- repaired
unrepaired
2. Muscular hypertrophy
atrophy
3. Scar deformities
4. Neurofibromatosis

TREATMENT
POSSIBILITIES


Cosmetic recontouring



Alloplastic augmentation



Prevention of wound

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

procedure- incomplete clefts
 -Tennison
”
- wide clefts
Both are modified Z-plasties

CLEFT LIP REPAIR –SECONDARY
PROCEDURES:

Deficient cupid’s bow
- excise excess scar
- free dermal grafts
Scar deformities
- scar revision
- Z-plasty

Muscle debulking:
 Stripping

of the
superficial layers of the
muscle mass with
electro cauterization

 Purely

cosmetic ,
usually without
complications

 Indicated

in cases of


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



Typical burn sitecommissure
On healing, the lips &
muscles scarifycentripetel scar
contraction –
microstomia- 5 days –








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

A.
B.

E.

C.

D.


Soft tissue augmentation:
Autogenous grafts

- dermal grafts
- fat grafts

Alloplastic materials - silicones( RTV
fluid)
- teflon
- poly amides
urethanes

ETIOLOGY:
 CONGENITAL

SYNDROMES

- Craniofacial clefts
-Hemifacial microsomia
 PRENATAL

CAUSES:

Intra uterine pressure
Birth trauma
Congenital torticollis
Craniosynostosis

 POSTNATAL

CAUSES:

Hemifacial atrophy
hypertrophy
Fractures &trauma
Infections & inflammations
Established laterocclusion
Muscular function

Congenital
Ramus hypoplasia


Environmental


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

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


TREATMENT POSSIBILITIES
 Orthodontic

-Camouflage
 Orthopedic

- hybrid functional
appliances
 Surgical

-




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

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

 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

Midline coordination –
 Translate

midline (asymmetric

extractions)
 Tipping
 Altering

of the teeth to midline
the occlusal cant

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

 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

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

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

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,

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




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

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.

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.


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

Twin block AJO 1988 Clark

When activated unilaterally - correct postur
mand. displacement (mid line displacement an
asymmetric buccal segment relationships).


 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



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



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

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


Malar hypoplasia

 Modified

Lefort III

osteotomy

 Infra

orbital
augmentation:

 Intraoral

 Fluid

approach

silicone allogenic


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

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

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

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

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

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.

Immediate postinjury treatment
in children
 surgical

intervention in young children

-aggravate growth disturbances
 If

occlusion is normal, - close

observation & exercises to maintain

 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

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

 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

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

Inverted ‘L’ osteotomy
 More

conservative –
corrects asymmetry, but
accept limited jaw
function

 Advance

the tooth
bearing portion –
defects filled with
autogenous bone


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

 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

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

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

Inferior border osteotomy
 Preferred

method

 Ratio

of hard &soft
tissue change is
predictable

 Permanent

results

 Less

traumatic
decrease morbidity

 Done

on out patient


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

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 –

Reconstruction with costochondral grafts

Alternate ribs can be harvested depending on the
requirement from fifth rib onwards

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

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,

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

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

Thank you
Leader in continuing dental education


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

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