Tells us about all the facial asymmetries and their treatment

1. MANAGEMENT OF FACIAL
ASYMMETRY
PRESENTED BY:
Dr. SHAZEENA QAISER

2. INTRODUCTION
• Facial esthetics evaluation is the most important part of the orthodontic
treatment-planning procedure.
• The attainment of the best facial esthetic appearance for a given patient is a
primary goal of orthodontic treatment.
• The evaluation of a patient’s frontal symmetry is the most critical aspect of
diagnosis because this is the most appreciated view for any individual. Even
the most esthetic faces are associated with mild forms of facial asymmetry.
• The individuals who report for an orthodontic treatment are often
associated with facial asymmetry that may be greater than the acceptable
norms.

3. DEFINITIONS
‘DORLAND’
•Symmetry:
The similar arrangement in form & relationship 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

4. 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.

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

6. ETIOLOGY
AJO PIRTTINIEMI 1994
A. PRENATAL CAUSES
• 1. Facial clefting syndromes
- unilateral CLCP - craniofacial clefts
I. GENETIC
• 1. Hemi facial microsomia
• 2. Neurofibromatosis
• 3. Birth trauma
• 4. Intra uterine pressure during preg.
II . CONGENITAL

7. B. Postnatal causes
• 1.Trauma & infection
• 2. Muscle dysfunction
• 3. Functional deviations
• 4.TMJ derangements
• 5. Hemi mandibular hypertrophy
• 6.Pathologies
ENVIRONMENTAL

8. A. Malformations with abnormal developmental
processes in embryonic stage ( 1%)
1.Hemifacial microsomia
2.Congenital hemifacial hypertrophy
3.Cleft lip & palate
COHEN 1982

9. B. Deformations caused by non disruptive
mechanical forces during fetal period:(2%)
1.Congenital muscular torticollis
2.Postural scoliosis
3.Plagiocephaly

10. C. Disruptions caused by breakdown of normal
developmental processes with onset later in life
1.Unilateral condylar hyperplasia
2.Hemifacial atrophy
3.Infections & inflammations
4.Fracture & trauma
5.Lateral malocclusion
6.Muscular dysfunction

11. DIAGNOSIS
1.History
2. Clinical examination
3.Radiographic examination
4.Photographic analysis
5.Digital videography
6.Articulated study models

12. HISTORY:
•-Can reveal aetiology
•-Severity of deformity
CLINICAL
EXAMINATION
• Reveals asymmetry in the
vertical, antero-posterior ,
lateral dimension.

13. EXTRAORAL EVALUATION
• Frontal

14. -Mid pupillary distance aligned with commissures

15. 1. Inter ocular dimensions-
interpupillary-65mm
inter canthal- 35mm
2.Midfacial bony support-
lower third of iris of the eye to be covered
with lower eyelid

16. VERTICAL
Vertical reference plane- nasion to subnasale
•upper horizontal plane – bipupillary line
• lower horizontal line - through the stomion

17. 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.

18. 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

19. SUBMENTOVERTEXVIEW

20. INTRA ORAL EXAMINATION
1. Evaluation of the dental midlines
2.Vertical occlusal evaluation
-Transverse cant of maxilla
3.Transverse and antero-posterior occlusal evaluations
• Unilateral cross bites
• B-L inclination of teeth

21. FUNCTIONAL EXAMINATION
1. Maximal opening
2. TMJ evaluation
•postural rest position
•-CR-CO discrepancy
•-laterocclusion/ laterognathia
3. Motor & sensory evaluation

23. 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

24. 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 mandible

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

26. Various P.A Analysis:
• Rickett’s Analysis
• Svanholt and Solow Analysis
• Grummon’s Analysis
• Grayson’s Analysis
• Hewitt analysis
• Chierici method

27. • 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

28. 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

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

30. TREATMENT MODALITIES

31. SKELETAL ASYMMETRIES:
• In growing Individuals, orthopedic appliances in conjunction with
orthodontics are used to help improve or correct the developing
imbalance.
• Severe discrepancies may require a combination of surgery and
orthodontics.
• Abnormalities of the coronoid and condylar processes as well as in
the position and shape of the articular disks should be considered
when limited opening, acute mal- occlusions, or mandibular
deviations are found.

32. FUNCTIONAL ASYMMETRIES
• Mild deviations caused by functional shifts -minor occlusal
adjustments
• More severe deviations -orthodontic treatment to align the teeth
• Occlusal splints may be necessary to properly evaluate the
presence and extent of the functional shift by eliminating the
habitual posturing and de- programming the musculature.
• Because functional shift can also be the result of a skeletal
asymmetry, rapid maxillary expansion, orthognathic surgery, and
orthodontic treatment may be indicated in the management of
these cases.

33. SOFT TISSUE ASYMMETRIES
• Deformities caused by soft tissue imbalance can be treated by
either augmentation or reduction surgery.
• Augmentations include the use of bone grafts and silicone
implants to re-contour the desired areas of the face.
• With the mild dental, skeletal, and soft tissue deviations the
advisability of treatment should be carefully considered.

34. AsymmetryTreatment
Growing Children
Hybrid
Functional
Appliances
Distraction
Osteogenesis
Adults
Surgical
OSTEOTOMY
Orthodontic
camouflage
Functional asymmetry
Occlusal
Callibration
Splints

35. TREATMENT POSSIBILITIES
1. MAXILLARY ARCH EXPANSION
2. ORTHODONTIC ARCH COORDINATION
3. SPLINTS
4.OCCLUSALTHERAPY

36. 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

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

39. RAPID PALATAL EXPANSION
• Very successful in children prior to sutural closure.
• 0.5mm day- 10 mm exp. in 20 days- 75- 80% of sutural
expansion
Haas type
Hyrax type
Minn expander
• 3:2 ratio of widening in canines & molars

41. 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

43. • 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 weeks of surgery

44. 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

45. Repositioning splints AJO 1991. Schmid et.al.
• Used mainly inTMJ 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 compensatory changes in
TMJ.

47. Orthopaedic Hybrid Functional Appliances
• Hybrid /blend of several components designed to address specific problems
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

48. • 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
• (4) to lengthen the mandibular ramus

49. 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.

50. Twin block AJO 1988 Clark
•When activated unilaterally - correct postur mand.
displacement (mid line displacement an asymmetric
buccal segment relationships).

51. DISTRACTION OSTEOGENESIS
•The regeneration of bone between
vascularised bone surfaces that are separated
by gradual distraction.

53. Surgical Osteotomy
•Maxillary hypoplasia:
Le-forte 1 osteotomy
With max.advancement.
•Maxillary hyperplasia:
maxillary segmental setback.
•Maxillary vertical excess:
leforte-1 osteotomy with maxillary impaction.

54. mandibular hyperplasia:
1)sagital split osteotomy.
2)sub-sigmoid osteotomy.
•Mandibular hypoplasia:
1)sagital split osteotomy with mandibular
advancement.

55. Orthodontic camouflage-
When skeletal deformity is very mild and any further change is
not expected, camouflage should be considered.
1.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

56. •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

58. 2. Midline coordination
•Translate midline (asymmetric extractions)
•Tipping of the teeth to midline
•Altering the occlusal cant

59. 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 teeth –
crowns & FPDs

60. 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

61. DENTAL COMPENSATIONS
• Midline shifts- dental compensation to make the dental midline
shift
• Axial inclination of molars
– to compensate for the developing cross bite in the contralateral
side
• Canting of maxillary occlusal plane

62. Surgical
•Conditions with severe skeletal asymmetries are
not able to be corrected by orthodontic camouflage
and growth modification so surgical procedures
are used to correct the deformities or asymmetries.

63. 1. Distraction osteogenesis
2.Maxillary surgeries - Lefort I
3. Mandibular surgeries
- BSSO
- Inferior body osteotomy
- genioplasty
4.TMJ surgeries
5. Autogenous/alloplastic augmentation

64. 1)Rhinoplasty.
2)Genioplasty.
3)Cheiloraphy.
COSMETIC SURGERIES

65. 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 patients.