FACIAL ASYMMETRY

DR SANKAR VINOD V
PROF & HEAD
MAR BASELIOS DENTAL COLLEGE
KOTHAMANGALAM
Common in humans

Aesthetic and
functional problems
Need to find the
underlying cause
• Facial asymmetry is defined as the presence of a clinically significant
variation between the two halves of the face that the patient [or
parents, in the instance of most congenital asymmetries] is concerned
about and that can be quantified by the clinician
‘prism’ concept representing maxillomandibular
complex
Severt and Proffit
Frequencies of facial laterality of
5% - upper
36% - middle
74% - lower

Chew et al
Asymmetry in 35.8% (of 212 patients) majority in class III patients
Aetiology
Classification
• Review Article Facial asymmetry revisited: Part I- diagnosis and treatment planning :D Srivastava et al. Journal of Oral Biology and Craniofacial Research-
2017,http://dx. doi. org/10.1016/j.jobcr.2017.04.010
Wolford LM, Movahed R, Perez DE. A classification system for conditions causing condylar hyperplasia. J Oral Maxillofac Surg.
2014 Mar;72(3):567-95. doi: 10.1016/j.joms.2013.09.002. Epub 2014 Jan 1. PMID: 24388179.
 Cross sectional imaging
technology

What's new Cone beam CT scanning

Use of CAD CAM

techniques
allow for screen surgical rehearsal

trial of different treatment plans

Use of mirror imaging

Manufacture of stereolithographic models

Splints and cutting guides

Patient specific implants

 History – Progressive or
static
Clinical assessment
• EVALUATION OF
FACIAL Photography
ASYMMETRY
Cephalography
3-D CT
 should be assessed in 3 planes

vertically
Hard tissue
horizontally(A-P)
anatomy
transversely

As well as for pitch and yaw

 Static and dynamic

Soft tissue
assessment
Cranial nerves

Low flow venous

malformations
 -Visual inspection
Palpation to differentiate soft tissue and
bony defects

Comparison of dental midline with facial

midline

Clinical Inspection of symmetry between

examination bilateral gonial angle and mandibular

body lower border

- Determination of amount of gingival

show per side, Evaluation of
malocclusion-Occlusal canting

Inclination of anterior teeth, open bites,

maximal interincisal opening, mandibular
deviation, and TMJ.
-
DIAGNOSTIC EVALUATION
(a) Symmetry of the orbit.
(b) Symmetry of the malar bones
(c) Symmetry of the nose
(d) Symmetry of the maxilla
1. Occulusal cant
2. Upper dental midlines.
3. Visibility of gums
(e) Symmetry of the mandible
1. Vertical dimension of ramus and body
2. Dental midline
3. Chin midline
4. Horizontal dimensions
5. AP dimensions
(f) Symmetry of the soft tissue
• Frontal view photographic
examination
• Study models
Radiographs

• Panoramic radiograph
• Posteroanterior cephalometric
radiograph
• Lateral cephalometric radiograph
 3D

• Stereophotogrammetry
• 3-D Stereolithographic (3-D-SLA) models
• 3-dimensionalprinting` (3-DP)
• Computed tomographic(CT) scans with 2-D & 3-D views
• Magnetic resonance imaging(MRI)
• Skeletal scintigraphy (Radionucleotide scans)
Grummon’s frontal
cephalometric
analysis
• The study indicates that SPECT is more sensitive to
identify condylar hyperactivity as compared to
planar bone scintigraphy in patients with clinical
presumptive diagnostic of condylar hyperplasia.
• Sensitivity, specificity and receiver operating characteristic (ROC) curves were
calculated for the different analytic methods.
• The ROC curve illustrates that UCH can be diagnosed significantly better by
determining the percentile bone activity in both condyles.
• The area under the curve (AUC) of the percentile comparison between the
affected and contralateral condyles was 0.93+/-0.04, that for the
condyle/clivus ratio was 0.75+/-0.07 and for the condyle/cervical spine (CS)
ratio 0.57+/-0.08.
• Sensitivity for the condyle/clivus ratio was 65% and specificity 61%.
Sensitivity for the condyle/CS ratio was 85% and specificity 31%.
• For the percentile difference of the condyles, sensitivity and specificity were
88%.
 MANAGEMENT

Accurate qualitative and quantitative diagnosis of patient’s particular facial

asymmetry

Facial asymmetry can be corrected by satisfying the following conditions:

I. Bringing the mandibular symphysis to the midsagittal plane.

2. Aligning the mandibular and maxillary occlusal planes to the horizontal plane
3. Aligning the bilateral facial height in order to attain optimum aesthetic result.
Timing of surgery

• early surgery
• delayed surgery

• Kazanjian suggested soft tissue repair in early childhood and hard tissue (bone) surgery after
adulthood
Presurgical orthodontics
• the dentition should not be orthodontically compensated for skeletal
disharmony.
• An existing cant of the occlusal plane should not be corrected.
• However, the dental arch should be leveled, and the orthodontist should ensure
that the apical base midline and incisor midlines follow the cant.
• When skeletal asymmetry exists, the dental midlines should not be made to
coincide but rather positioned in the midline of each jaw.
• When facial asymmetry will be corrected by single-jaw surgery, the dental
midline of the unoperated jaw should coincide with the facial midline
• In patients with hemifacial microsomia and TMJ ankylosis in whom a unilateral
open bite is created after the ramus height is increased, the height should be
maintained while allowing the vertical alveolar growth of the maxilla
 CAST PREDICTION

• Face bow
• Occlusal splint
• “Two-patient” concept in planning orthognathic surgery
• Cephalometric prediction tracing
• Model surgery
Single jaw surgery

• Le Fort I osteotomy
• Anterior maxillary or posterior maxillary osteotomy
• Inverted L osteotomy(SSRO)
• Extended lateral sliding genioplasty
 Bimaxillary (Double jaw) surgery

• Maxilla or mandible First?

Adjunctive soft-tissue manipulation procedures: Camouflaging

• buccal fat pad

• Grafts
• free dermal fat grafts
• alloplastic implants
• surgical grade, custom contoured silastic and surgical grade polyethylene
 POSTOPERATIVE PERIOD

• Mild elastic traction is used to maintain the occlusal splint in position

• Close the interocclusal space of the affected side. This-is achieved by extruding the posterior
teeth using mild elastics.

• Correct the cross bite created on the normal side while rotating the mandible.

• Correction of other occlusal problems, crowding and midline changes.

Distraction osteogenesis (DO)

• soft tissue redraping along the newly constructed and corrected facial skeleton
Surgery-first approach (SFA)

• reduced treatment time

• elimination of skeletal and soft tissue imbalances that might interfere with tooth movement
• ‘regional acceleratory phenomenon’
• No counteracting force from the investing soft tissues
 Lateral view: asymmetry in ramal height,
mandibular length and gonial angle

OPG: presence of gross anomalies,

supernumerary or missing teeth, shape and
height of ramus and condyles
Radiographic Assessment PA view: deviation
horizontal line be drawn through
bilateral FZ sutures to act as horizontal axis,
vertical line perpendicular to horizontal axis
through crista galli
Quantify and delineate the site ,extent and
balance between hard and soft tissues that
contribute to the facial asymmetry

This will allow for diff diagnosis and guide in

obtaining the most appropriate investigation

One diagnosis is confirmed treatment

planning can start
25 yrs./M
c/o deviation of
chin to left side
and pain on mouth
opening {left side}

Motivation : self
MEDICAL HISTORY
5-6 days after his birth, a swelling in the occipital region-
ruptured itself- got infected

2 yrs of age- open surgery for septic hip arthritis both hips

Age 6yrs. - gap arthroplasty + costochondral grafting for left

TMJ ankylosis

Mouth opening – improved after the surgery

Medical
History:
• HBSAg POSITIVE

General
examination:
• PICCLE-N
EXTRAORAL EXAMINATION
• UPPER THIRD
Normal
• Shape & symmetry : Nose
and chin deviated
• Supra orbital rims : raised
• Calvarium : Scar and
depression at the occipital
region.
• 2cm sebaceous cyst – left post
auricular region
• MIDDLE THIRD
normal
Septal deviation to left.
Lower third

• UPPER LIP
Length : 26mm (N:19-20)
Thickness: 13mm (N= 13- 17)

Incisor exposure at rest : 5mm(N=1-3mm)

Incisor exposure at smile :10 mm U + 4mm L

Interlabial distance:5mm
Lower third
• Lower lip
Length : 46mm (N =49 .83)
Vermillion exposure :13mm
Labiomental sulcus : 8mm deep
thickness:14mm
nasolabial angle: obtuse
• Occlusal cant : deviation to right

• TMJ : no clicking
palpable left joint movements

• Airway :Mallam petti class 4

INTRA ORAL EXAMINATION

• Teeth missing : 28,38,37,48

Crown : 21,31.
GD: 24,36,46,47 imp-23

• Mouth opening : 25mm

• Tongue : normal

• Occlusion : R & L Class 2

CT Scan
CT Scan
Symmetry evaluation
Problem list
• Facial asymmetry
• Costochondral grafted left TMJ
• Deviation of chin to left
• Occlusal cant tilted to right
• Mandibular Retrognathism
• Short ramus left side
• Deviated nose
• Grossly decayed teeth, crowns, impacted 23, supra erupted teeth
• Proclined lower incisors
• HBSAg positive
Rx Done
• Extended lateral sliding genioplasty
POSTOPERATIVE PHOTOGRAPHS
25/M
 c/o prognathic mandible

• Motivation : self
• M/H: NRH NKDA
Problem list
• Facial asymmetry
• Deviation of chin to left
• Occlusal cant tilted to left
• Prognathic mandible
• Protruded chin
• Skeletal class III
• Class III molar relationship
• Anterior crossbite
Rx Done
• Asymmetric BSSO set back
post op 1 month
27/M
 c/o facial asymmetry and pain on
mouth opening

• Motivation : self
• M/h : NRH,NKDA
Pre op
Problem list
• Facial asymmetry
• Enlarged condyle with arthritic changes
• Deviation of chin to Right
• Occlusal cant to the right
• Prognathic mandible
• Protruded chin
• Class III molar relationship
• Anterior open bite
• Proclined lower incisors
Rx done
First surgery

Left condylectomy with interpositional arthroplasty with left

temporal myofacial flap and inferior border ostectomy on the Lt
side

Second surgery- 1 yr. later

Extended lateral sliding genioplasty

Immediate post op
Intra op
2nd surgery pre op ( after 1 year)
18/F
 c/o facial asymmetry

• Motivation : self
• M/h : NRH,NKDA
Pre op
Problem list
• Facial asymmetry- hyperplastic left condyle
• Deviation of chin to Right
• Occlusal cant tilted to right
• Prognathic mandible
• Protruded maxilla
• Skeletal class III
• CLASS III molar relation
Rx Done
• Left condylectomy
• Lefort I osteotomy
• BSSO
• Lateral sliding genioplasty to Lt side
Immediate post op
Immediate post op
Post op 6 months
 PLANNING AND MANAGEMENT

Mild deviations: orthodontic treatment, Prosthodontic

restoration
Severe asymmetries require a combination of orthodontic and
orthognathic management

Surgical treatment
-a proper diagnosis with accurate evaluation of all facial
dimensions
-aspect of growth and development
-“single-splint” surgical technique is preferred by a number
of surgeons.
-degree of soft tissue movement as a response to skeletal
structure mobilization may be difficult to predict accurately
Orthognathic surgery can be combined with
> bone contouring
mandibular angle reduction
mandibular inferior border ostectomy
genioplasty
bony augmentation
> soft tissue contouring
buccal fat pad
masseter muscle reduction
> Minor touch-up procedures
fat graft injection
subcutaneous liposuction
Distraction osteogenesis:

Precise and predictable results

require
Accurate placement of an osteotomy or
corticotomy
Distraction device placement
Vector planning
Selection of a distractor
Consideration of effects of masticatory
muscles and soft tissues
 • Whenever coming up with a surgical treatment
plan, great emphasis should be given not only to
the diagnosis of asymmetry, but also to patient’s
CONCLUSION final facial balance, as well as stability of the
results achieved.