Diagnosis of facial asymmetry

4. DIAGNOSIS OF FACIAL ASYMMETRY

In diagnosing facial and dental asymmetries, a thorough clinical examination and

radiographic survey are necessary to determine the extent of the soft tissue, skeletal,
dental and functional involvement.2
4.1. Clinical Evaluation
Commencing with determining the chief complaint and evaluating the medical
history remains the foremost essential diagnostic aid revealing asymmetry in the
sagittal, coronal and vertical dimensions.6
4.1.1 Medical History
First of all, Patient is asked for prenatal, natal history and about forceps delivery.
And then Rule out any underlying medical condition or syndrome which can present
as a facial asymmetry. For example, Treacher Collins syndrome, torticollis, scoliosis,
plagiocephaly etc.2
4.1.2 Dental Evaluation

1. Evaluation of dental midlines (fig.4.1):

Clinical examination should include an evaluation of dental midline in the
following positions:

fig.4.1
• Mouth Open
• In Centric Relation
• At Initial Contact
• In Centric Occlusion
• Difference between true asymmetry & functional asymmetry needs to
be assessed.
True asymmetry of dental or skeletal origins, if uncomplicated by other factors,
will exhibit similar midline discrepancy in centric relation, and in centric occlusion.
On the other hand, asymmetries due to occlusal interferences may result in
mandibular functional shift following initial tooth contact. The shift can be either in
the same or opposite direction of the dental and skeletal discrepancy and may either
accentuate or mask the symmetry.2
Patient should also be evaluated to detect functional asymmetries related to
temporomandibular joint derangements.2

Facial Asymmetry 20
 Diagnosis of facial asymmetry

2. Vertical Occlusal Evaluation (Fig. 4.2):

The presence of a canted occlusal plane could be the result of a unilateral
increase in the vertical length of the condyle and ramus. Similarly, the maxilla or
temporal bone supporting the glenoid fossa could be at different levels on each side of
the head. Such asymmetries are often detected by clinically evaluating the patient.
The cant in the occlusal plane can be readily observed by asking the patient to bite on
the tongue blade to determine how it relates to the inter-pupillary plane.2

Fig. 2
Vertical skeletal asymmetries associated with progressively developing unilateral
open bites, may be the result of condylar hyperplasia or neoplasia.2

3. Transverse and antero-posterior occlusal evaluation:

Asymmetry in the Bucco-lingual relationship, e.g. a unilateral posterior
crossbite, should be carefully diagnosed to determine if it is skeletal, dental, or
functional. If there is a mandibular deviation from centric relation to centric
occlusion, the lower dental midline and chin point should be compared to other
midsagittal dental, skeletal and soft tissue landmarks in the open, initial contact and
closed mandibular positions.
In some cases, such a clinical examination is not sufficient to detect a functional
shift that has been acquired for a prolonged period of time. When this is suspected, an
“occlusal splint” might need to be constructed for the patient to wear. The appliance
will allow the musculature to freely guide the mandible to its proper relationship
without the distracting influence of occlusal interferences (Fig. 3).2

Fig. 3 (A) (B) (C)

Facial Asymmetry 21
 Diagnosis of facial asymmetry

Fig. 3(A): in centric occlusion, of the patient in the early mixed dentition with
unilateral right posterior crossbite. (dental midline coincide)
(B): in centric relation, shift in the lower midline. Posterior occlusion was cusp to
cusp buccolingually.2
Dental arch asymmetries could be the result of localized factors such as early
loss of a deciduous tooth or they could be associated with rotation of the entire dental
arch and its supporting skeletal base. Lundstrom found that use of the maxillary
raphe, as a reference line for the median plane, is not a reliable way to determine
maxillary asymmetries in either the antero-posterior or lateral dimensions. Therefore,
each dental arch should be evaluated separately both clinically and using oriented
dental casts, to accurately determine the bilateral symmetry of the molar and canine
positions.2
Examination of overall shape of the maxillary and mandibular arches from an
occlusal view may disclose not only the side asymmetries but also differences in the
bucco-lingual angulation of the teeth. It is important to realize that expansion of the
dental units to correct a crossbite in the presence of a skeletal constriction may
adversely influence the stability of the correction.
Arch asymmetry could also be due to rotation of the entire maxilla and mandible.
The diagnosis of a rotary displacement of the maxilla may require further evaluation
by mounting the dental casts on an anatomic articulator using facebow transfer.2
Symmetrograph (Fig. 4):
Asymmetrical arch shape in transverse and anteroposterior direction, assessed
using a template, oriented to mid-palatal raphe and tuberosity plane.

Fig. 4 (A) (B)

Extraoral direct clinical assessment involves visual inspection of facial
morphology, palpation of facial structures and contours to distinguish between soft
and bony defects; inspection of symmetry between the bilateral gonial angle and
contours of mandibular body, mandibular deviation, cant of the inferior border of the
chin and TMJ evaluation. At smiling, comparison of dental midline with the true
facial midline and determination of the amount of gingival show per side should be
done. Additionally, smile symmetry is also assessed by the parallelism of
commissural and pupillary lines to each other (Fig.5). Canting of occlusal plane needs
to be assessed at rest, and during smiling positions. Intraorally, malocclusion, tipping

Facial Asymmetry 22
 Diagnosis of facial asymmetry

of anterior and posterior teeth, open bite, cross bite, midline deviations, functional
mandibular shifts and maximum interincisal opening should be assessed.6

Fig. 5
Patients with facial asymmetry usually exhibit compensatory head posturing due
to which the head is tilted slightly to the right or left to minimize/mask the effect of
asymmetry. Therefore prior to making an objective, quantitative examination,
clinician should deliberately orientthe patient’s head to correct any compensatory
head posture. Patient is also advised to eliminate other compensatory mechanisms
such as mannerisms and hairstyle that might mask the asymmetric deformity, thus
misleading the treatment plan.6
When evaluating the craniofacial structures for asymmetry, the purpose of the
clinical examination is threefold:
• Qualitative analysis: Identifying the specific locations of the facial asymmetry
(skeletal and/or soft tissue).
• Quantitative analysis: Objectively quantifying the degree of facial asymmetry.
• Craniofacial growth assessment: To determine, as far as possible, the locations,
magnitude and direction of any further growth of the craniofacial complex.
As with all systematic clinical facial evaluation, an overall qualitative (visual,
anthroposcopic) assessment is followed by a comprehensive quantitative
(anthropometric and cephalometric) analysis. Having obtained the necessary data, a
further qualitative assessment is carried out, to determine whether the results of the
quantitative assessment corroborate the qualitative evaluation.4

4.2 Photographic Evaluation

(1) Frontal facial examination:
Bilateral symmetry: The face must be examined for bilateral symmetry with the
patient in natural head position (NHP), bearing in mind that a small degree of
asymmetry is present in most individuals and essentially normal. The clinician may
need to make minor manual adjustments to the patient’s head position, as patients will
often have developed a compensatory head posture to minimize the aesthetic impact

Facial Asymmetry 23
 Diagnosis of facial asymmetry

of their facial asymmetry, often tilting their heads to the right or the left, around the
sagittal axis (Fig. 6).4

Fig. 6This patient developed a compensatory head posture, rotating his head around
the sagittal axis.
Facial midline (midsagittal plane) With the patient in NHP, a true horizontal line
may be drawn through the mid - glabellar region (soft tissue glabella), midway
between the eyebrows, perpendicular to a true vertical, e.g. a plumb line from the
ceiling. From this true horizontal line, a perpendicular facial midline (midsagittal
plane) may be constructed from glabella (Fig. 7).4

Fig. 7Facial midline, parallel to a true vertical line (TrV).

In less severe dentofacial deformities, the mid - philtrum of the upper lip
(midpoint of Cupid’s bow) will commonly be in the midline of the face, except in
exceptional circumstances, e.g. cleft lip or severe nasal asymmetry distorting the
upper lip. A line joining this point to soft tissue glabella forms the facial midline. In
the symmetrical face, this line will extend to the midpoint of the chin (soft tissue
pogonion). The midpoint of the nasal bridge and the nasal tip (pronasale) should be on
this line if the nose is symmetrical (Fig. 8).4

Fig. 8Facial midline, connecting glabella and the mid - philtrum of the upper lip
(midpoint of Cupid’s bow).

Facial Asymmetry 24
 Diagnosis of facial asymmetry

With the lips slightly separated, the maxillary and mandibular dental midlines
may be assessed in relation to the facial midline, in particular to the mid - philtrum of
the upper lip (midpoint of Cupid’s bow). Having obtained the patient’s permission,
these points may be marked on the patient’s face with a skin pencil, in order to permit
more accurate assessment (Fig. 9).4

Fig. 9The midpoints of different structures may be marked on the patient’s face with a
skin pencil
Vertical reference lines/ planes (Fig. 10): Having established the facial midline,
further vertical lines may be drawn parallel to facial midline through any pair of
bilateral landmarks suspected of being asymmetrical. It is then possible to assess:

• The orientation of these lines in relation to the facial midline and the bilateral
structures that they pass through.
• The horizontal distance of each of the bilateral landmarks to the facial
midline.4

Fig. 10
Horizontal (transverse) reference lines/ planes (Fig.11): Horizontal reference lines
may be constructed by connecting bilateral landmarks. It is then possible to assess:

• If the lines are perpendicular to the facial midline.

• The relative orientation of the various lines, which should ideally be parallel to
one another, with the absence of transverse cants.

Facial Asymmetry 25
 Diagnosis of facial asymmetry

• The vertical level of bilateral structures to a baseline horizontal reference line,

e.g. left and right cheilion (the angle of the mouth) to a horizontal line through
subnasale (Fig.12). Such linear measurements may be used anthropometrically
or on facial photographs and three-dimensional (3D) facial soft tissue scans if
landmark identification is reliable.4

Fig. 11 Fig. 12
Fig. 12 The vertical level of bilateral structures to a baseline horizontal reference line may be
used to evaluate bilateral facial symmetrical relationships.

The presence of a cant in the transverse occlusal plane may be observed in

relation to the interpupillary line (or a true horizontal plane) with the patient biting on
a wooden spatula (or holding it against the maxillary teeth if there is a lateral open
bite), both in the incisor/canine region and the premolar/ molar region (Fig. 13), or a
Fox’s occlusal guide plane (Fig. 14). In the absence of a transverse maxillary cant
and/or vertical orbital dystopia, the transverse occlusal plane should be parallel to the
interpupillary plane. Following the frontal facial clinical examination, the
asymmetrical face may be evaluated clinically and photographically from a number of
different views.4

Fig. 13 Fig. 14
Superior view (Fig. 15): The superior view is taken directly from above and behind,
with the patient’s head hyperextended. Th is view is useful for assessment of the
symmetry of the nasal bridge, and the horizontal projection of the forehead, orbits and
particularly the zygomas and paranasal areas.4

Facial Asymmetry 26
 Diagnosis of facial asymmetry

Fig. 15 superior view

Submental view (Fig. 16): The submental view is taken directly from below, with the
patient’s head hyperextended. Th is view is required to assess the symmetry of the
mandibular body and the base of the nose, and is also useful for assessing any
asymmetrical projection of the forehead, orbits, zygomas and paranasal areas.4

Fig. 16submental view

Lateral view: The left and right profile views may be used to compare the contours
of the left and right sides of the face. Th is view is particularly useful for assessment
of asymmetry in the contour of the inferior border of the mandible.4
Oblique lateral (three - quarter) view: These views are taken with the patient in
NHP and are useful for assessment of asymmetry of the nose, zygomas, paranasal
areas and the mandibular ramus and body outline, including the gonial angle.4
Transverse occlusal plane view: This view is ideally taken with the patient in NHP.
An orthodontic cheek retractor may be placed in order to retract the lips and cheeks
(Fig. 17); alternatively, an assistant may stand behind the patient and retract the
cheeks using photographic retractors (Fig. 18). A transverse cant of the maxillary
occlusal plane may be assessed in relation to a true horizontal plane or to the
interpupillary plane in the absence of vertical orbital dystopia.4

Facial Asymmetry 27
 Diagnosis of facial asymmetry

Fig. 17 Fig. 18
Composite analysis: Compare full face photograph with composites consisting
of two right or two left Sides (Fig. 19).19

Fig. 19
The positions nasal bridge, nasal tip, philtrum, chin point are assessed with dental
landmarks i.e. upper incisor midline, lower incisor midline (Fig. 20).19

Fig. 20
Rule of fifth describe the ideal transverse relationship of the face (Fig. 21).19

Fig. 21

Facial Asymmetry 28
 Diagnosis of facial asymmetry

A well-proportioned face is vertically divided in to equal thirds. Subnasale to upper

lip inferior - lower lip superior to soft tissue menton - 1/3rd and 2/3rd (Fig. 22).19

Fig. 22
Deficient or excess: Total width is compared with total face height (ratio)(Fig. 23).19

• Zy-zy/Tr-Gn x 100= 75%

• Zy-zy =0.75x facial height

Fig. 23
Three-dimensional image analysis
Three-dimensional image analysis is becoming a more popular and viable option
for assessing the soft and hard tissues. Methods include lasers, structured light
(included stereophotogrammetry as described above), video-imaging allowing
dynamic image analysis, radiation methods such as three dimensional cephalometry,
computed tomography scans (CT) and cone beam computed tomography (CBCT) and
other methods including magnetic resonance imaging (MRI) and ultrasound.
There are many potential advantages and disadvantages associated with the
above methods. However, perhaps the greatest disadvantage is the associated cost,
including purchasing the equipment and necessary software, therefore limiting the
number of clinicians able to offer such techniques. Another important aspect to
consider is the radiation exposure, which is substantially higher for CT and CBCT in
comparison to conventional radiography and should therefore not be used routinely,
but instead used only for exceptional cases.1

Facial Asymmetry 29
 Diagnosis of facial asymmetry

4.3 Anthropometry
Anthropometry is the scientific measurement of human beings. With advances in
digital technology anthropometry is no longer restricted to direct measurements with
instruments such as callipers, but is more increasingly being carried out using three-
dimensional scanner technology.
Farkas and Cheug (1981) used direct anthropometry to measure asymmetry in
healthy Caucasian children, with a sample size of over 300 they found that mild
asymmetry (defined as a difference between the left and right sides of less than 3 mm
in absolute measurements or 3% between comparative size) was common, the right
side of the face was more likely to be the larger side and asymmetry was most likely
to affect the upper third of the face. Measurements were recorded from the lateral
aspect of the face using a standard spreading calliper after the facial landmarks had
been identified and marked with ink on each subject. Studies being carried out now
are more likely to use indirect measurements. Wong et al (2008) investigated the
validity and reliability of facial anthropometric linear distances measured both
directly and indirectly using 3D digital photogrammetry. They found that the 3dMD
photogrammtey system (3-dimensional imaging system) that they used was valid and
reliable. Aynechi et al (2011) assessed the accuracy and precision of 3D systems
either with or without prior landmark identification against direct anthropometry and
found that the 3dMD system offered an accurate and precise method that was
comparable to direct anthropometry either with or without prior landmark
identification.4

4.4 Radiographic Evaluation:

In addition to the clinical evaluation, differentiation between various types of
asymmetries can be aided by the use of radiographs. A number of projections are
available to properly identify the location and cause of the asymmetry.2
4.4.1 Lateral Cephalogram (Fig. 24):
This projection, although commonly available to the clinician, provides little
useful information on asymmetries in the ramal height, mandibular length and gonial
angle. It is limited by the fact that the right and left structures are superimposed on
each other and are at different distances from the film and x-ray source resulting in
significant differences in magnifications.
Criticisms of lateral projections have also been made because of the
predetermined orientation using ear roads. In the other words, the assumption is made
that the external auditory meatus are symmetrical, while in reality they may vary in
more than one plane of space.

Facial Asymmetry 30
 Diagnosis of facial asymmetry

Therefore, the interpretation of the lateral cephalogram in diagnosing

asymmetries is of limited value.2

Fig.24Vertical asymmetry of the left and right inferior mandibular borders is evident
on a lateral cephalograph; superior structures are well superimposed.4

4.4.2 Panoramic Radiograph:

The panoramic radiograph may provide information regarding the relative height
of the mandibular condyle, ramus and body bilaterally (Fig. 25). Asymmetrical
morphology may be identified with comparative bilateral measurements.
Degenerative changes to the condylar heads, such as from condylar resorption, may
be evident.4

Fig. 25
4.4.3 PA Cephalogram:
The posteroanterior (PA) cephalometric radiograph is indicated when a clinically
significant facial asymmetry is evident. Analysis of this radiograph will permit the
evaluation of any underlying dentoskeletal asymmetry.4
It is a valuable tool in the study of the right and left structures since they are
located at relatively equal distances from the film and x-ray source. As a result, the
effects of unequal enlargement by diverging rays are minimized and the distortion is
reduced. Comparison between sides is therefore accurate since the midlines of the
face and dentition can be recorded and evaluated.2

Facial Asymmetry 31
 Diagnosis of facial asymmetry

Postero-anterior cephalograms can be obtained in centric occlusion as well as

with the mouth open. The latter position might help determine the extent of the
functional deviation, if any is present.2
Since the advent of cephalometric radiography, orthodontists have focused on
the lateral x-ray as their primary source of patient skeletal and dentoalveolar data.
However, the frontal (PA) and Basilar views can also contain valuable information for
diagnosis and treatment planning procedures. So, various dental and skeletal widths
and skeletal asymmetries that are not available from lateral cephalogram can be
quantified from PA cephalogram. For that many authors give analysis like Ricketts
cephalometric Analysis (1961), Grayson’s Analysis (1983), and Grummons Analysis
(1987). These all analysis will be discussed in the chapter 5.

4.4.4 Sub- mentovertex Radiograph

One of the inherent problems associated with the PA cephaologram is the
identification of an appropriate mid-sagittal reference plane. In attempt to overcome
this problem the submentovertex (SMV) radiograph was suggested as the radiograph
of choice for the assessment of facial asymmetry. The SMV cephalogram has the
advantage that the mid sagittal reference plane can be based on cranial structures
(Ritucci and Burstone, 1981) that are remote from the facial bones and some of these
structures have been found to have a high degree of symmetry (Pearson and Woo,
1935). Several methods for analysing the SMV radiograph are currently in use
(Fosberg et al, 1984; Lew and Tay, 1993) but reliability can be affected by the patient
positioning during x-ray exposure (Lew and Tay, 1993).1
4.5 Adjunctive Techniques
Additional soft tissue markers such as barium markers can used to enhance the
diagnostic value of PA and lateral cephalogram. The PA barium cephalometric
radiograph in conjunction with facial anthropometric measurements is beneficial in
planning correction of the cant of occlusal plane.3 Majority of cases require
supplementation of clinical examination with other diagnostic modalities such as
stereophotogrammetry, stereolithographic models and special imaging techniques for
accurate localization of level of deformity in asymmetric structures6.

4.5.1 Stereo photography:

Three- dimensional stereometry, utilising two or four cameras configured to
capture a pair of stereo images of the surface of patient’s face, is used to generate
a 3-D image of the face by triangulation performed through sophisticated stereo
algorithms. MorphoStudio (3dMD’s synchronized digital six-camera 3dMDface
system) photogrammetric imaging system provides a precise and accurate 3-D

Facial Asymmetry 32
 Diagnosis of facial asymmetry

assessment of soft tissue asymmetry (without the posing error found in

conventional photogrammetry) before and after orthognathic surgery.6

4.5.2 Special/Sophisticated imaging

4.5.2.1 Corrected tomograms – Axially corrected tomograms are helpful in

delineating the shape and size of the abnormal condyle in cases of condylar
hyperplasia or osteochondroma.6

4.5.2.2 Computed tomographic (CT) scans with 2-D and 3-D views provide
advantages of improved and accurate radiographic diagnosis and resolution,
particularly in anomalies such as craniosynostosis, hemifacial microsomia and
TMJ ankyloses. 3D CT scan reconstruction graphically illustrates the foramina
representing the location of great vessels and cranial nerves in the base of the
skull which are in close proximity near the operative area of TMJ ankylosis.2

This permits the surgeon to change technique or to make preoperative

contingency plans prospectively, thus increasing the safety and predictability
of the final surgical outcome.3 Additionally, 3-D CT images can provide
useful information for the fabrication of stereolithographic models to facilitate
evaluation and surgical planning. In recent times, Cone-beam computed
tomographic (CBCT) scanning of TMJ has gained popularity as it provides the
clear images of skeletal tissues with fairly low quantity of radiation dose (Fig.
26).6

Fig. 26
It also offers the advantages of acquisition of multiple cuts from a single scan
and allows multiple images of the joint to be viewed in the lateral and PA dimensions
during the same scan. Visualization of the articular disc can be improved by injecting
radio-opaque contrast material into the joint space before obtaining the scans.
Accurate integration of CBCT and 3-D photorealistic surface imaging of the face
facilitates rapid and precise creation of patient specific 3-D computer models that can
be used for diagnosis, treatment planning, treatment simulation and assessment.

Facial Asymmetry 33
 Diagnosis of facial asymmetry

Moreover, appropriate application of digital 3-D diagnostic and treatment

planning imaging softwares (Digi graph, Dentofacial Planner, etc) aid in estimation of
skeletal and soft tissue effects of orthognathic surgery, improving communication
among clinician, patient and staff, thus allowing treatment changes (based on Surgical
Treatment Objective) which can be recommended based on patient’s individual
preference within his or her anatomic, biologic and physiologic limits.6

4.5.2.3 Magnetic resonance imaging(MRI) – MRI, utilising nonionizing radiation is

a valuable aid in obtaining extremely accurate images of internal hard and soft
tissues of the TMJ, which assists in diagnosing osteoarthritis, condylar
resorption, avascular necrosis and regressive remodelling involving the TMJ
in dentofacial asymmetries. MRI data used in conjunction with facial scan
helps to create a 3-D photorealistic head model of the patient, thus assisting in
visualization and simulation of the treatment effects in a virtual space.6

4.5.2.4 Skeletal scintigraphy (Radionucleotide scans) (Fig. 27)– It is a dynamic

method of growth analysis depending on the differential uptake of
technetium–99 m methylene diphosphonate (Tc-99 m) radioisotope into
metabolically active bone.28 Radionucleide scans are potentially useful in
diagnosis and treatment planning of asymmetries of condylar hyperplasia and
deviate prognathism type.6

Fig. 27

4.5.2.5 Laser scanning - Optical surface scanning has been used to monitor three-
dimensional facial growth. This is a non-invasive technique and the associated
software allows the digitization and comparison of images over time. Over
60,000 points are recorded in 10 seconds producing an accuracy of 0.5 mm.10
Hence, it is possible to examine facial asymmetry quantitatively. Laser
scanning has also been used in plastic surgery to study facial asymmetry.20

Facial Asymmetry 34
 Diagnosis of facial asymmetry

4.6 Three-dimensional facial soft tissue scans 3D facial soft tissue scans may be
used to evaluate facial soft tissue morphology and to monitor asymmetrical
growth by superimposition of serial scans (Fig. 28).4

Fig. 28
The main advantage is no radiation exposure and the possibility of
combining 3D computed tomography (CT) views of the dentoskeletal structures
with a 3D soft tissue facial surface scan. Such technology is currently expensive
and the systems require further development.4
4.7 Dental study cast (Fig. 29)
Dental casts of the occlusion are always useful when occlusal abnormalities
are observed. Asymmetrical dental arch forms may be analysed by placing a
transparent ruled grid over each arch, with the grid axis in the midline oriented
over the midpalatal raphe, allowing direct observation of distortions in arch form.4

Fig. 29
Dental casts are also useful in assessing whether any progressive changes to
the dental occlusion are occurring over time, particularly in patients with
mandibular asymmetries. In patients with hemi-mandibular hyperplasia, where a
unilateral open bite or transverse cant of the maxillary occlusal plane is occurring,
it is beneficial to mount the dental study casts on an adjustable articulator using a
facebow transfer. A facebow is used to record the relationship of the patient’s
maxillary arch to the condylar hinge axis of the temporomandibular joints.4

Facial Asymmetry 35
 Diagnosis of facial asymmetry

4.8 Pathological special investigations - If pathology is suspected of causing the

asymmetry, the patient should be referred for specialist care. Incisional and
excisional biopsies will allow histological diagnosis. This will reveal the nature of
the hard or soft tissue pathology, for example, fibro-osseous lesions or tumour-
like lesions. Sialography is the radiographic examination of the major salivary
glands by introducing a radio-opaque contrast medium into the ductal system. It
will allow the detection of the size, nature and origin of a swelling or mass in the
area.20
A profound knowledge of facial asymmetry is essential to critically analyse
all the features involved, and accurately quantify the magnitude of disproportion.
This would help formulate more satisfying treatment plan in terms of optimizing
aesthetics and function while taking into consideration the perceptions and
expectations of the patient.

Facial Asymmetry 36