Diagnosis and Treatment Planning of

Patients With Asymmetries

CharlesJ. Burstone
The diagnosis, treatment planning, and design of mechanics for the asymmetric patient requires the differentiation between problems of dental and
skeletal origin. Although much information can be gleaned from a cephalometric analysis, the clinical examination and study models offer important
clues in establishing the diagnosis of skeletal discrepancy. Abnormal and
asymmetric axial inclinations can either produce a dental asymmetry or, if
compensatory in nature, may mask an underlying skeletal problem. The role
of axial inclination in diagnosis is applied to the following situations:
subdivision cases, unilateral crossbites, midline discrepancies, arch form
deviations, and frontal cants to the occlusal plane.
The management of axial inclination asymmetries depends on the treatment
plan. Nonextraction patients may require maintenance of asymmetric compensatory axial inclinations. Surgical and extraction patients can be treated
to a more ideal symmetry. (Semin Orthod 1998;4:153-164.) Copyright 1998

by W,B. Saunders Company

t is c o m m o n to find asymmetric occlusal relationships in patients requiring o r t h o d o n t i c treatment.

Examples include a Class II occlusion on one side of
the arch with a Class I or Class III occlusion on the
other. T h e r e may be lack of midline c o r r e s p o n d e n c e
between the u p p e r and lower arches or both midlines
may n o t be symmetrically placed in the face. Unilateral crossbites can exist and arch f o r m may n o t be
symmetric, or u p p e r and lower arches may n o t be
congruent.
T h e cause of these asymmetries can be multivariate. In some patients, the p r o b l e m originated with
a b n o r m a l dental eruption, p r e m a t u r e loss of primary
teeth, or loss of p e r m a n e n t teeth; however, in o t h e r
patients, the origin may be primarily skeletal in nature
in which an asymmetric maxilla or, m o r e likely, an
asymmetric m a n d i b l e is present. T h e first step in the
diagnosis and t r e a t m e n t p l a n n i n g of all patients is to
identify these asymmetries and to differentiate be-

From the Department of Orthodontics, School of Dental Medicine, University of Connecticut Health CentG Farmington, CT.
Address correspondence to Charles J. Burstone, DDS, MS,
Professor, Department of' Orthodontics, School of Dental Medicine,
University of Connecticut Health Cent~ Farmington, CT 06030.
Copyright 1998 by W.B. Saunders Company
1073-8746/98/0403-000558. 00/0

tween those that are of a dental or a skeletal cause. It is

only t h e n that the clinician can make a valid decision
c o n c e r n i n g the n e e d for surgery or a nonsurgical
a p p r o a c h and, if the a p p r o a c h is nonsurgical, if
extraction or n o n e x t r a c t i o n is the t r e a t m e n t of choice.
The diagnosis of skeletal or dental asymmetry can be
accomplished by an overall evaluation of the patient's
skeletal and soft-tissue facial pattern. Radiographs,
such as the posteroanterior (PA) and submental views,
are particularly useful in making this type of diagnosis.
T h e submental vertex view helps to m o r e precisely
diagnose the nature of the asymmetry, particularly if it
is a m a n d i b u l a r problem. Specialized radiographs,
such as c o m p u t e d t o m o g r a p h i c scans and the use of
stereometry with or without implants, offer m u c h
i n f o r m a t i o n but are too d e m a n d i n g for the average
patient. T h e soft tissues of the face also offer a clue to
any existing skeletal problem. Close observation during the clinical examination, both f r o m a frontal and
inferior aspect, along with o r i e n t e d facial photographs, is a necessary r e q u i r e m e n t for p r o p e r diagnosis. T h e cephalometric a p p r o a c h to the differentiation
of skeletal asymmetries regarding both their nature
and m a g n i t u d e is b e y o n d the scope of this article. The
emphasis here is on the use of teeth as markers to
make this determination. By evaluating parameters
such as axial inclinations of teeth and the a m o u n t of
space available, valid j u d g m e n t s can be m a d e to assist
in developing an appropiate t r e a t m e n t plan.

Seminars in Orthodontics, Vol 4, No 3 (September), 1998: pp 153-164

153

154

Charles J. Burstone

Differential Diagnosis Based on Tooth

Position: The Posterior Teeth
T h e starting position of any evaluation of asymmetric
occlusion is centric relation. A l t h o u g h there may be
some a r g u m e n t about what is the correct position of
the m a n d i b l e and the condyle in occlusion, a g o o d
reference is centric relation rather than centric occlusion. Centric occlusion can be confusing because
many patients show m a n d i b u l a r shifts that can make
the asymmetry appear either m o r e or less severe. A
patient with asymmetric occlusion in centric occlusion
is shown in Figure 1, in which the right side is in Class
II and the left side is in Class I occlusion. During the
initial stages of treatment, in which simple leveling
occurred, the occlusion c h a n g e d to a m o r e symmetric
Class II occlusion as the m a n d i b l e was repositioned
close to centric relation. If the t r e a t m e n t plan was
based on the original improperly t r i m m e d models in
centric occlusion, subsequent t r e a u n e n t could lead to
significant errors in t r e a t m e n t planning, such as
asymmetric extraction and the use of asymmetric
mechanics. For this reason, it is r e c o m m e n d e d that all
models be t r i m m e d in centric relation. Centric relation can be established by manipulation of the mandible, the use of splints where tight musculature

prevents easy m a n d i b u l a r manipulation, or, as in the

case shown, therapeutic diagnosis can be helpful. In
therapeutic diagnosis, some tooth m o v e m e n t is accomplished, such as crossbite correction by expansion
dentally or by skeletal expansion with rapid maxillary
expansion or o t h e r m i n o r tooth m o v e m e n t before the
final treatment plan is established. After this initial
m i n o r t r e a t m e n t stage, it is usually easier to establish a
correct centric relation.
An occlusal plane should be established that is the
t r e a t m e n t plane of occlusion. T h e emphasis is on the
word " p l a n e , " which is three-dimensional in nature so
an occlusal line can be evaluated either as a lateral or a
frontal line. T h e occlusal plane and dental axial
inclinations m e a s u r e d to this plane can t h e n be used
to establish the presence of either a dental or skeletal
asymmetry. This supplements the previous database of
the facial bones that was established from the clinical
examination, photographs, and radiographs.
Figure 2 shows a Class I occlusion on the right side
and Class II occlusion on the left. The u p p e r left first
molar is mesially inclined. Simulation of what a simple
single force could accomplish can be p e r f o r m e d by
mentally uprighting the tooth a r o u n d a p o i n t a little
below the center of resistance (near the center of the

Figure 1. Pseudoasymmetry. Centric occlusion. (A) Right-side Class II. (B) Left-side Class I.
After initial leveling, the m o l a r relationship is m o r e symmetric (C, D). Mandible repositioned to centric relation.

Diagnosis and TreatmentPlanning

root). A couple would also a p p r o a c h rotating the

tooth a r o u n d this point. With single forces, there is
little d e m a n d on a n c h o r a g e and, because teeth migrate usually by tipping, visualization of u p r i g h t i n g
can help differentiate a dental p r o b l e m from a skeletal
problem. In Figure 2, it can be seen that such
u p r i g h t i n g of the u p p e r first m o l a r would place the
left side into Class I; hence, the diagnosis is a dental
asymmetry. C o m p a r e this asymmetry to Figure 3, in
which the axial inclinations of the u p p e r molars are
n o r m a l and a skeletal Class II is present. If the u p p e r
left molar had a distal axial crown inclination, equalizing axial inclinations so that both sides are identical
would make the Class II left side even m o r e asymmetric.
Observation of mesiodistal axial inclinations of
posterior teeth c a n n o t always differentiate dental
from skeletal origins of asymmetry because migration
of a tooth may have o c c u r r e d early in its eruption,
p r o d u c i n g little tipping. O t h e r dental guides m i g h t be
helpful, including the rotation (mesial-in) of the
u p p e r m o l a r and the a m o u n t of r o o m posteriorly
either in the tuberosity or the ramus. In c o m p a r i n g
the differences of axial inclination between the right
and left sides, it is i m p o r t a n t to maintain a constant
plane o f occlusion. T h e relevant differentiation to
make is the difference in axial inclination between the
right and left sides and, only secondarily, which axial
inclinations m i g h t be m o r e correct for the patient.
T h e same a p p r o a c h can be used to evaluate unilateral posterior crossbites. In Figure 4, a dental crossbite
is shown. Mentally u p r i g h t i n g the u p p e r left m o l a r
would correct the crossbite. Conversely, in Figure 5,
uprighting the u p p e r left m o l a r so that its axial
inclination would be the same as the right side would
make the crossbite worse; hence, this is a skeletal
crossbite.

155

t
Right

Left

Figure 3. Class II subdivision. Skeletal asymmetry. All

molars have n o r m a l axial inclinations.
Asymmetric Class I occlusion is shown in Figure 6
where the axial inclinations are not symmetric and the
u p p e r left m o l a r is compensating. U p r i g h t i n g the
tooth a r o u n d the center of the root would p r o d u c e
Class II occlusion o f the left side; indicating a skeletal
discrepancy that is masked.
In some patient.s, there may be a difference in
buccolingual axial inclinations f r o m right to left with
no crossbite. In Figure 7, the teeth have c o m p e n s a t e d
for a skeletal discrepancy, and equalizing the axial
inclinations on the left side with the right would
p r o d u c e a crossbite. T h e clinician should carefully
evaluate the mesiodistal and buccolingual axial inclinations o f all the posterior teeth, and n o t only the molar
teeth, because this allows for differentiation of skeletal
f r o m dental problems. This a p p r o a c h provides the

!
Right

Left

Figure 2. Class II subdivision. Dental asymmetry. Left

u p p e r molar is tipped mesially.

Right

Left

Figure 4. Unilateral crossbite of dental origin. U p p e r

left molar leans toward the lingual.

Charles J. Burstone

156

Right

Left

Figure 5. Unilateral crossbite of skeletal origin. Molars have n o r m a l axial inclinations. U p p e r left m o l a r
leans slightly toward the buccal.
p r o p e r b a c k g r o u n d to d e t e r m i n e later, during treatm e n t planning, w h e t h e r c o m p e n s a t o r y axial inclinations should be m a i n t a i n e d or produced.

Differential Diagnosis of Midline

Discrepancies
O n e of the challenges in treatment p l a n n i n g and
t r e a t m e n t is the correct p l a c e m e n t of the u p p e r and
lower dental midlines. Not only must the dental
midlines correspond, but they must be in a p r o p e r
relationship to the face. A n u m b e r of criteria have
b e e n used to establish the positioning of the u p p e r
and lower dental midlines. S o m e of these are some-

Right

Left

Figure 7. C o m p e n s a t o r y axial inclination on the left

side. Potential unilateral crossbite.
what arbitrary and can lead to i m p r o p e r diagnosis and
treatment. A skeletal midline can be established using
the PA head film. F r o m horizontal planes in cranial
base, perpendiculars are drawn through crista galli or
some o t h e r midline point. T h e fallacy o f establishing a
midsagittal plane in this m a n n e r lies in the fact that
the horizontal planes may n o t be parallel to each
o t h e r and are often difficult to establish. Also, any

!
Right

Left

Figure 6. C o m p e n s a t o r y axial inclination gives Class I

occlusion. Potential unilateral Class II occlusion on
the left side.

Figure 8. Facial midline is d e t e r m i n e d by soft-tissue

factors: the p h i h r u m and distance of the canine to the
corners of the mouth.

Diagnosis and Treatment Planning

157

Figure 11. Upper dental ntidline to the right of the

lower midline. Skeletal problem with apical base
discrepancy.

Figure 9. Incisor apical base discrepancy between

upper and lower arches. Arbitrary skeletal midsagittal
plane passes through the lower apical base midline.

Figure 10, Upper midline to the right without an

apical base discrepancy. Upper incisors are tipped
toward the right.

deviation in the horizontal plane and the perpendicular drawn to it can lead to large errors in establishing a
dental midline. Others have tried to establish a midline by bisecting the distance between bilateral points
on the greater wing of sphenoid or the orbits or other
lateral points on the outside of the skull. Even in the
most symmetric individuals, there are differences in
width between right and left sides; hence, bisecting
the distance between two corresponding points can
lead to an erroneous midline. Sometimes the median
palatal raphe is used as a guide. The raphe may be
misleading because of error in establishing a perpen-

Figure 12. Dental midlines correspond. Apical base

discrepancy is masked by compensatory tipping of the
upper incisors to the left side.

158

Charles]. Burstone

Figure 13. Dental midline discrepancy without apical base discrepancy. Lower incisors are easily tipped to the left
with a single force. Before (A) After (B).

Figure 14. U p p e r dental midline to right. No apical base discrepancy. Only simple tipping of the u p p e r incisors is
required. Before (A) After (B).
dicular to the raphe and because many raphes are
not linear, but display curvature. T h e arbitrary planes
that have b e e n discussed are n o t based on realities
that can benefit the patient. Two o t h e r concepts can
be used that are m o r e realistic for establishing a plane
on which the dental midlines should be placed;
namely, the facial midline and the apical base midlines.
A c o m m o n p r o c e d u r e to establish the facial midline is to take a piece of dental floss and c o n n e c t
points at glabella or nasion, subnasale and p o g o n i o n .
This can lead to e r r o n e o u s results because of inaccuracy in identifying the points and the parallax required in visualizing the points. In addition, if there is
any type of m a n d i b u l a r asymmetry, the three points
would not correspond. The facial midline is an aesthetic midline; and a midline that the patient can
easily identify as the correct midline for the tace.
Patients do n o t take dental floss and place it in front of
their face to evaluate the midline. They look at o t h e r
factors, and it is these factors that will now be discussed as a better guide to midline placement. T h e
center of the p h i l t r u m is a g o o d guide to the placem e n t of the maxillary dental midline. T h e "V" at the

Right

Left

Figure 15. Greater condylar growth on the right side

should p r o d u c e buccal crossbite of the mandibular
arch on the left side.

Diagnosis and TreatmentPlanning

159

Figure 16. Severe skeletal asymmetry Class III right

(A), Class II left (B). Lower dental midline to left (C).
Good arch harmony with little crossbite. Other details
in Figures 17 and 18.

Figure 17. Compensatory axial inclinations. Canine

leans buccally on left side, frontal view (A). Upper left
molar leans toward buccal more than the right molar,
viewed from posterior (B). Lower left molar leans
toward lingual, viewed from posterior (C).

160

Charles J. Burstone

vermillion b o r d e r forms a g o o d landmark that is easily

identified by orthodontists and patients (Fig 8). Ano t h e r guide is to look at the distance between the
canine or first p r e m o l a r and the c o r n e r of the mouth.
If the midline is properly positioned, the patient will
see the same a m o u n t of tooth exposure on the right
and left side. T h e patient is m o r e apt to look at
soft-tissue guides, such as the p h i l t r u m and the corners of the mouth, in evaluating the dental midline,
than any arbitrary string that is placed in front of the
face.
In addition to the facial midline, skeletal asymmetry as viewed from the front of the patient should be

studied carefully. A tracing is m a d e of the PA head

film. A t r e a t m e n t occlusal plane is established, and to
that occlusal plane, the midlines of the maxilla and
m a n d i b l e are evaluated. Unfortunately, there are no
g o o d landmarks to accurately p i n p o i n t these midlines.
A g o o d c o m p r o m i s e is to use the teeth as markers, as
was previously d o n e to evaluate the posterior occlusion. Points are identified approximately at the center
of the roots of the u p p e r incisors and the lower
incisors. This m e d i a n p o i n t of the roots is called the
apical base point. Perpendiculars are drawn to the
occlusal plane f r o m these points to evaluate if an
apical base midline discrepency exists. Apical base

Figure 18. Occlusal view of models. The wider u p p e r

arch (A) and the narrower lower arch (B) on the left
side compensating for the crossbite tendency. PA tracing showing the skeletal asymmetry and dental compensations (C).

Diagnosis and TreatmentPlanning

discrepancies imply some type of skeletal asymmetry

with either an asymmetric maxilla or, most likely, an
asymmetric mandible. It is possible, however, to have
early drift of teeth, particularly with a unilaterally
missing lateral incisor where an apical base discrepancy exists without any skeletal asymmetry showing on
the face. In Figure 9, a patient with an apical base
midline discrepancy is shown. T h e lower incisor midline lies on an arbitrary skeletal midline t h r o u g h
m e d i a n structures. The lower apical base also lies on
this line, and the u p p e r apical base p o i n t is to the
patient's right. W h e n there is an apical base discrepancy, t r e a t m e n t becomes m o r e difficult because translation of teeth across the midline may be required.
With translation, a n c h o r a g e loss can p r o d u c e skewing
or rotation of the arches with undesirable side effects.
F r o m the clinical examination or the study casts,
axial inclinations can be used to d e t e r m i n e if an apical
base discrepancy exists. This can be accomplished by
mentally uprighting teeth so the axial inclinations on
the right and left side are equalized, or visualizing
where the centers of the roots might be so that a
p e r p e n d i c u l a r can be d r o p p e d to the occlusal plane.
Figure 10 shows a midline discrepancy with the
u p p e r incisors to the right of the lowers. By mentally
uprighting the incisors to equalize their axial inclinations, midlines would c o r r e s p o n d and a dental midline discrepancy therefore exists. In contrast, in Figure
11, a skeletal discrepancy is shown. Equalizing axial
inclinations would not help the midline. The midlines
b e c o m e further apart as the teeth are uprighted. This
is an example of a skeletal or apical base discrepancy.
T h e r e are patients who may have no discrepancy
between the u p p e r and lower dental midlines, and yet
a skeletal apical base discrepancy could exist. Such a
situation is shown in Figure 12, in which the u p p e r
teeth have tipped to the left. U p r i g h t i n g these teeth
would p r o d u c e a midline discrepancy with the u p p e r
midline to the patient's right. In many t r e a t m e n t
plans, compensatory axial inclinations should be mainrained at least in part to ensure p r o p e r correction in
apical base discrepancies for which no surgery is
planned.
If a midline discrepancy between the u p p e r and
lower is present and no apical base discrepancy is
observed, t r e a t m e n t is simplified because simple single
forces can be used to tip teeth to correct the midlines
so they properly correspond. The mechanics are
simple, and they usually will n o t p r o d u c e major side
effects if p e r f o r m e d appropriately. Conversely, where
there is a true apical base discrepancy, the translatory
mechanics r e q u i r e d b e c o m e m o r e difficult and are a
limitation to the a m o u n t of mesiodistal m o v e m e n t
possible.
In Figure 13A, the lower dental midline is to the
right of the facial midline, and no apical base discrepancy exists. Even without a head film, the lower

161

Figure 19. C o r r e c t i o n of right and left mesiodistal

occlusal differences requires m o v e m e n t a r o u n d the
arch. Arrows show possible direction of tooth movement.
incisors can be mentally u p r i g h t e d to see the midlines
correspond. T h e finished case is shown in Figure 13B,
in which simple tooth m o v e m e n t by tipping allowed
the midlines to correspond. In Figure 14, the u p p e r
midline is to the patient's right. No apical base
discrepancy exists, so the incisors very easily tipped to
the left after extraction therapy. No wires or appli-

Figure 20. Crisscross elastics and or c o m b i n e d Class II

and Class IIl elastics can p r o d u c e rotation of the
entire arch, which is n o t usually desirable,

Cha~tes J. Burstone

162

ance's were used on the incisors because the incisors

followed the canines and were self-correcting by means
of the transeptal fibers.

Arch Form Symmetry and Arch

Correspondence
Because skeletal asymmetries are common, it is important to review the role of compensations in the dental
arch that occur naturally. If a skeletal asymmetry is
produced by a mandible that has grown more horizontally on one side than the otheL a crossbite would
normally be expected. In the diagram shown in Figure
15, the added mandibular growth on the right side is
responsible not only for Class III occlusion on the
right side and Class II occlusion on the left, but a
dental midline shift with the mandibular midline
moving to the left. Also, a crossbite would be expected
with mandibular buccal overjet appearing on the
patient's left side. Although crossbites can be observed, usually the magnitude of the crossbite is
minimized by compensatory movement and axial
inclinations of the teeth.
A patient with this asymmetric relationship is shown
in Figure 16. The right side is Class III and the left side
approaches Class II. The lower midline is to the left of
the upper midline. Nevertheless, the amount of overjet and crossbite tendency is relatively small. It is
important to look in greater detail to see why dental
compensations have minimized this crossbite tendency. Looking from the frontal view, it is noted that
the left canine leans more toward the buccal than the
right canine (Fig 17A). Looking from the posterior,
the upper left molar leans more toward the buccal
than the upper fight molar (Fig 17B). In the lower

arch, the left molar leans toward the lingual more

than the right molar (Fig 17C). These compensations
are produced by muscle forces that have effectively
eliminated most of the crossbite that would have been
expected. The occlusal view of both the upper and
lower arches shows that, relative to the median palatal
raphe, arch width is not symmetric right to left. In the
upper, the left side is wider (Fig 18A) and, in the lower
arch, the width relative to the median palatal raphe is
smaller on the left side (Fig 18B). The tracing of the
PA head film confirms the skeletal asymmetry and the
compensatory migration of the teeth that minimized
the crossbite (Fig 18C).
What is the significance of these buccolingual axial
inclination compensations? The patient shown has an
extreme skeletal discrepancy that requires orthognathic surgery. In preparation for tile surgery, for the
bones to be positioned correctly, the axial inclinations
should be equalized so that no asymmetry will be
present at the end of treatment. There are many
patients who have skeletal problems that are not so
extreme or in whom the treatment of choice or
preference would be nonsurgical. In these patients, it
is necessary to maintain the asymmetry of the axial
inclinations. It would be an error to correct the axial
inclinations by placing symmetric brackets with straight
wires that produce torque on the individual teeth.
Such mechanics, of course, would lead to the production of a crossbite. It should be recognized that
compensation in the form of changes in the axial
inclinations of teeth as in arch width has resulted from
muscular activity. Idealistically, orthodontists have been
taught that the most desirable arch form is symmetric.
In some patients this may be true; however, in nonskel-

OP
FH

-%

FH

Left

Right

Figure 21. Some skeletal

asymmetries may have one
ramus longer with a cant to
the occlusal plane (OP).
Axial inclinations that are
compensatory will appear
more symmetric to OP than
to Frankfort horizontal (FH).

Diagnosis and TreatmentPlanning

etal t r e a t m e n t of a patient with skeletal asymmetry,

these compensations should be m a i n t a i n e d to treat to
an asymmetric arch.
T h e malocclusion of a patient who presents with
Class II occlusion on one side and Class III or Class I
occlusion on the o t h e r side can either be of skeletal or
dental origin or of both. If the origin is dental, it is
clear that the tooth m o v e m e n t r e q u i r e d is m o v e m e n t
a r o u n d the arch. This is n o t an en masse m o v e m e n t of
the entire arch but, rather, m o v e m e n t of the teeth
a r o u n d the arch like pearls on a chain. To reach this
goal, distal m o v e m e n t or extraction may be required.
As previously discussed, if the discrepancy is skeletal in
origin and no crossbite exists, the m o v e m e n t is still
a r o u n d the arch if no orthognathic surgery is p l a n n e d
(Fig 19). Sometimes orthodontists will try to correct
an asymmetric posterior occlusion by the use of Class
II elastics on o n e side, Class III elastics on the othm,
a n d / o r anterior crisscross elastics. T h e effects of Class
II and Class Ill elastics are shown in Figure 20. T h e
m o v e m e n t is an en masse m o v e m e n t in which the
entire arch is rotated a r o u n d its center o f resistance.
Not only is this m o v e m e n t difficult to achieve, but it
can lead to crossbite and lack of arch harmony.

163

Occlusal Plane Considerations

T h e patient who is treated surgically should have the
occlusal plane, as evaluated f r o m the frontal view,
parallel to facial structures, such as the eyes. In the
nonsurgical patient with a skeletal asymmetry, there
may be a cant to the plane of occlusion relative to the
face. This cant is not easily altered f r o m a line
c o n n e c t i n g posterior teeth because of m e c h a n i c a l
difficulties in i n t r u d i n g entire posterior segments.
F u r t h e r m o r e , the lips may also be angled so that a
m o r e aesthetic relationship of the canted occlusion
and the lips is observed. Figure 21 shows compensatory differences between molar axial inclinations. T h e
u p p e r left molar is leaning toward the buccal and the
right m o l a r is leaning toward the lingual. Relative to
the entire occlusal plane based on the face (such as a
line c o n n e c t i n g the pupils of the eyes), there is a
marked difference. In some patients, a vertical asymmetry may be present in which the right side of the
m a n d i b l e has grown vertically m o r e than the left,
p r o d u c i n g a cant in the occlusal plane. Notice that this
plane, which would be a t r e a t m e n t plane of occlusion
for a nonsurgical patient, minimizes the axial inclination difference. Study casts that are t r i m m e d to the
canted occlusal plane may n o t show as m u c h variation
in axial inclination between the right and the left sides
as would be observed f r o m the PA h e a d film, in which
a truer horizontal plane is used for orientation (Fig
21).

Figure 22.

An anterior crisscross elastic produces the

undesirable side effect of canting the occlusal plane
(A). Patient showing unaesthetic canting p r o d u c e d by
anterior crisscross elastics. Mechanics to move the
incisors a r o u n d the arch should have b e e n used (B).

164

Charles J. Burstone

It may be desirable to treat to a canted occlusal

plane if a skeletal asymmetry is present and very
undesirable in a skeletally symmetric patient. O n e of
the undesirable effects of the use of an anterior
cFisscross elastic is that it can cant the plane of
occlusion. T h e patient in Figure 22 had an anterior
crisscross elastic attached f r o m the u p p e r right to the
lower left. Note that the occlusal plane has canted
down to the patient's right side.

Summary
T h e r e are many t r e a t m e n t options for patients who
show asymmetries in occlusion. These include orthog-

nathic surgery, orthopedics and orthodontics employing extraction or n o n e x t r a c t i o n therapy. Part of the
decision in t r e a t m e n t selection and the detailed treatm e n t plan that d e t e r m i n e s tooth position in threedimensional space is based on differentiating skeletal
from dental problems.
This article has c o n c e n t r a t e d on the utility of using
tooth position, mainly axial inclinations, as a diagnostic tool. Such i n f o r m a t i o n can be gleaned from the
study casts and can serve as a guide to help in
developing a c o m p r e h e n s i v e and valid t r e a t m e n t plan
for the patient. This is n o t to suggest that an overall
evaluation be ignored, because the clinical examination and the use of p r o p e r cephalometric techniques
are equally important.