CORRECTION OF FACIAL AND

DENTAL ASYMMETRIES
SDM College of Dental Sciences,
Dharwad

Introduction:

Each person shares with the rest of the

population a great many characteristics but
there are enough differences to make each
human being a unique individual.

 Perfect bilateral body symmetry is more of

a theoretic concept that seldom exists in
living organisms

 According to
Lundstrom.A, these
asymmetries are
embryonically rooted
and are associated
with asymmetry in the
central nervous
system.

 Dorlands Medical dictionary defines

symmetry as
The similar arrangement in form and
relationships of parts around a common
axis or on each side of a plane of the
body.

 Clinically, symmetry
means balance,
where as significant
asymmetry means
imbalance.

Original

Symmetry and
Balance when applied
to facial esthetics have
been given a variety of
confirming definitions.
They refer to the state of
facial equilibrium.

Right

Left

 W.Schmid/Mongini
mentioned two types
of asymmetry
True Structural
Asymmetry
Displacement
Asymmetry

 Anthropologic investigations showed

documented evidences of right and left
sided differences in facial form.

 We, orthodontists are

often preoccupied
with the lateral facial
aspect of the patient,
where as the general
public tend to judge,
beauty, symmetry &
harmony from a
frontal projection.

 In orthodontic patients
the origin of
asymmetries can be
skeletal, dental, soft
tissue or combination
of these.

 PA Cephalograms and refined diagnostic

tools, such as computerized tomographic
images and stereophotography, allow 3
dimensional analysis of the craniofacial
complex

 However the most important diagnostic

tool for an orthodontist remains the
clinical examination of the patient.

Review of Literature
Woo in 1931 found that the human skull could
be markedly asymmetrical.
Washburn in 1946, reported the effects of
paralysis of facial muscles after unilateral
sectioning of the facial nerve.
Bjork and Bjork in 1964 noted that
compensatory asymmetric growth of maxilla
and mandible can occur when the cranial base
develops asymmetry at an early age.

 Mulick in 1965 concluded that asymmetry of

the face can be related to the functional
demands of the masticatory apparatus and
musculoskeletal system.
Sharad Shah and M.R. Joshi in 1978 observed
that pleasing and apparently symmetrical faces
do exhibit skeletal asymmetry, suggesting that
the soft tissue of the face attempts to minimize
the underlying skeletal asymmetry

 Etiology:
Genetics :

1. Clefts of the lip or

palate
2. Hemifacial
microsomia
3. Hemifacial
Hypertrophy
4. Congenital muscular
torticollis
5. Postural Scoliosis

 Etiology:
Genetics :

1. Clefts of the lip or

palate
2. Hemifacial
microsomia
3. Hemifacial
Hypertrophy
4. Congenital muscular
torticollis
5. Postural Scoliosis

 Etiology:
Genetics :

1. Clefts of the lip or

palate
2. Hemifacial
microsomia
3. Hemifacial
Hypertrophy
4. Congenital muscular
torticollis
5. Postural Scoliosis

 Etiology:
Genetics :

1. Clefts of the lip or

palate
2. Hemifacial
microsomia
3. Hemifacial
Hypertrophy
4. Congenital muscular
torticollis
5. Postural Scoliosis

Environmental factors:
Intra-Uterine pressure during pregnancy and
significant pressure at the birth canal during
parturition can have observable effects on the
bones of the fetal skull.
Trauma and infection must also be considered
when encountering facial asymmetry. Untreated
fractures of the mandible can display varying
degrees of facial disfigurement.

 Brodie concluded injury to the condylar region

results in growth arrest, and consequently, a
characteristic distortion of the mandibular form.

 Condylar fracture is not always followed by

deviant growth of the mandible however,
and many of the cases may remain
undiagnosed as shown by Proffit et al.

 It has been found that mandibular fracture may

affect the growth of the middle facial area. The
occurrence of maxillary midline shift towards the
fractured site and the degree of the deformity are
related to the site of the fracture of the mandible.

 Asymmetric muscular
potentials in the postural
positions of the mandible
have been proven
electromyographically in
patients with crossbites.

 An increased incidence of crossbite and

scissor bite is seen in children with enlarged
adenoids, tonsils and impaired nasal
breathing.
Unilateral crossbite can be also associated with
persistent intensive finger or dummy sucking
habits.

ASSESSMENT OF ASYMMETRY:
A diagnostic protocol, which includes systemic
evaluation of
The soft tissue clinical and photographic
examination.
The dentofacial skeleton PA cephalogram,
submentovertex view, TM Joint imaging.
The dentition study model casts (model
analysis), occlusograms, OPGs and occlusal xrays

1. Evaluation of the soft tissue- by means of

clinical and photographic examination
Mid-lines are assessed with upper most
condylar position and first tooth contact. If
occlusal slides alter the joint position, no
reliable midline assessment can be made.

The facial midline is defined by 3 anatomical

points:
Nasion (the root of the nose).
Subnasale ( base of the collumella)
Gnathion or Menton

Original

In normal face, the profile is oriented to the

vertical by horizontal positioning of paired
symmetrical features (endocanthions, rims
of lower eyelid, insertion point of the alae,
direction of labial fissure, and upper border
of eyebrows) .

Original

 An angle finder can be

used to confirm whether
the required position
has been achieved and
also head position
checking device can be
used.

Original

The composites of
two left sides and
two right sides
display two different
individuals.

Right

Left

2.Evaluation of the dentofacial skeleton by

means of PA cephalogram,
submentovertex view, TMJoint imaging:
The primary indication for obtaining a PA
view is the presence of facial asymmetry
(Proffit 1991).

 A PA cephalogram
can also be analyzed
so that vertical and
transverse
dimensions can be
evaluated.

 Analysis proposed by Grummons and Kappeyne

Van de Coppello 1987, describes quantitative
assessment of vertical dimensions and
proportions.
Qualitative analysis: relating the midline
landmarks to the midsagittal plane will provide
qualititative evaluation which will help to clarify
the source of asymmetry. (Sollar 1947; Grayson
et al, 1983; Proffit 1991).

Various methods of analysis:

Ricketts et al, 1972.
Hewitt 1975.
Svanholt and Solo 1977.
Grayson et al, 1983.
Chierici 1983.
Grummons and Kappeyne Van de
Coppello 1987.

LIMITATIONS OF PA CEPHALOGRAM:
Chances that apparent distances will be
affected by a tilt of the head in the head
holder. Because of this angular
measurements can be influenced in an
uncontrolled manner.
Precise measurements of the structures
are difficult.

 The conventional use of two ear rods to stabilize

the head in radiographic cephalometry is based
on the assumption that the transmeatal axis of
humans is perpendicular to the midsagittal plane.

 Thereby, the attempt to determine facial

asymmetry of a patient generally results in a
compromise rather than as an exact definition.
HOW TO OVERCOME THIS?
Any one ear rod should be used.
The other ear rod should be merely placed
against any part of the ear, or replaced by a
small soft rubber cup

3. Evaluation of the dentition, by means of study

model casts (model analysis), occlusograms,
OPGs and occlusal x- rays;

 Evaluation of dental midlines should be

done in mouth open, in centric relation, at
initial contact, and in centric occlusion.

Anders Lundstrom:
Qualitative asymmetry

Number of teeth. - oligodontia

- supernumerary teeth.
Cleft Palate

Oligodontia

Quantitative asymmetry:

Size of the teeth

Microdontia
Macrodontia
Location of the teeth in dental arch.
Antero-posterior plane
Transverse plane.
Vertical plane.

 Antero-posterior position:
Posterior segment.
Ex - Class II sub div or Class III sub div

This type of dental relation is seen in

early/delayed exfoliation of deciduous teeth.

Anterior segment:
Upper/ lower anterior midline can be deviated
because of early exfoliation of deciduous
canine, ectopic eruption or missing upper/ lower
permanent lateral incisors and peg shaped
upper lateral incisors which might lead to
abnormal canine as well as incisor relationship.

 Transverse plane:
Dental asymmetry in the transverse
plane can be due to constricted
maxillary/mandibular arch because of
digit sucking or mouth breathing habit or
abnormal posture of the tongue.

 Vertical plane:
Vertical
discrepancy in the
arches can lead to
a cant in the
occlusal plane.

 Model analysis like Boltons should be

considered in correction of midlines.
The tooth size discrepancy can be
corrected either by restoring (build up) of
small sized teeth or interproximal
reduction of larger teeth.

Asymmetry in the dental arch can be assessed

by placing a transparent ruled grid over the
dental cast so that the grid axis is on the
median palatal raphe.

CORRECTION OF ASYMMETRY
SKELETAL ASYMMETRY:

Antero-posterior
Vertical
Transverse

A-P Skeletal Asymmetry

Age of the patient.
Growing individual with
mild asymmetry
Growth modulation using
Hybrid appliances .

Functional shift of the mandible due to

maxillary constriction .
Premature contact of the occlusion
Unilateral posterior crossbite
In growing individual
Condylar spacing leads to abnormal
remodelling of glenoid fossa.

Treatment
Expansion of maxilla.
Unilateral Fixed Functional Appliances
Jasper Jumper, Churros or Fielos
appliance.

Unilateral Fixed Functional

Appliance

Moderate to severe asymmetries

Distraction osteogenesis

Orthognathic Surgery
Guidelines
More concern about transverse than
vertical asymmetry
More concern about chin position than
mandibular angles
Maxillary midline more critical than
mandibular midline

 If nose and jaw are deviated to the same

side, both should be corrected
Asymmetry of higher structures - infraorbital rims, Zygomatic arch onlay
grafts should be considered

Orthognathic surgery

Vertical Skeletal Asymmetry

Transverse skeletal asymmetries

Unilateral or bilateral constriction of the
upper arch/lower arch in conjunction with a
functional shift of the mandible.
Sutural patency
Conventional rapid palatal expansion
Surgical assisted palatal expansion

Expansion of Maxilla

A mandibular bilateral constriction can be

corrected
In growing individuals: expansion
appliances (tooth-borne appliances) can
be used.
Sympyseal distraction (bone-borne).
Orthognathic surgical procedure .

DENTAL ASYMMETRIES
Dental asymmetries can exist in solo or in
combination with a skeletal problem; but,
the rectification strategies remain the
same.

Asymmetric Midlines ( Antero-posterior /

transverse plane):
In Begg Appliance
Midline corrections can be done by placing
uprighting springs on the side to which the
midline is shifted along with Class II elastics or
Class I elastics on the opposite side.
Diagonal elastics can also be used.

In PAE:
Midline shift because of tipping of the incisors
can be corrected by ligating figure of 8 ligature
wire, which causes tipping of the engaged teeth.

 Midline corrections by bodily movement can be

achieved using PAE brackets with a combination of
open loop and a closed loop design in a rectangular
S.S wire or by using a fixed functional appliances .

 Open coil spring and closed coil spring .

A-P Corrections

Transverse Corrections

CONCLUSION:
Facial and dental asymmetries pose a
greater challenge to the clinician.
A sound diagnosis coupled with efficient
enforcement of mechanics.
A judicious use of biomechanics with
simple appliances such as cantilevers,
lingual and palatal arches can deliver
optimal forces with minimum side-effects.

Thank you