CRANIOMAXILLOFACIAL DEFORMITIES/SLEEP DISORDERS/COSMETIC SURGERY

Are There Mandibular Morphological

Differences in the Various Facial
Asymmetry Etiologies? A Tomographic
Three-Dimensional Reconstruction
Study
opez, DDS,* Juliana Ruiz Botero, DDS,y Juan Manuel Mu~
Diego Fernando L
noz, MD,z
ardenas-Perilla, MD,x and Mauricio Moreno, DDSjj
Rodrigo C

Purpose: Facial asymmetries (FAs) have been classified according to the mandibular morphological dif-
ferences to obtain better diagnostic and treatment decisions. The purpose of the present study was to
establish diagnostic differentiation among FAs using computed tomography (CT) and 3-dimensional
(3D) reconstruction.
Materials and Methods: We performed a cross-sectional study of patients with a diagnosis of FA, who
had been evaluated by CT and 3D reconstruction in the same clinical center from 2015 to 2018. The
following mandibular anatomic characteristics were compared between the 2 sides (deviated side vs
contralateral side) and type of FA: condylar length, mandibular ramus length and width, mandibular
body length, and symphysis deviation.
Results: The 53 patients included 23 men and 30 women (age range, 16 to 25 years). Six categories of FA
were identified: hemimandibular elongation (n = 25), hemimandibular hyperplasia (n = 2), hybrid hyper-
plasia (n = 3), asymmetric mandibular prognathism (n = 14), asymmetry of the glenoid fossa (n = 2), and
functional laterognathism (n = 7). The condylar length and mandibular ramus width were greater in the
displaced side than in the contralateral side, with differences of 2.0  2.8 mm (P < .001) and
0.5  1.7 mm (P = .009), respectively. The mandibular body length was greater on the contralateral
side (mean difference, 2.1  3.5 mm; P < .001). The symphysis deviation was 5.0  3.4 mm, and those
with a hybrid form presented with a greater deviation, with values greater than 10 mm, followed by those
with hemimandibular elongation.
Conclusions: The evaluation of the CT images and 3D reconstructions in patients with FA provided
detailed information of the mandibular structure that is useful to compare the differences between sides
and to classify the entities associated with FA.
Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial
Surgeons
J Oral Maxillofac Surg -:1-15, 2019

*Orthodontist and Assistant Professor, Orthodontics Department, Address correspondence and reprint requests to Dr L

opez: Ortho-
Universidad del Valle, Cali, Colombia. dontics Department, Universidad del Valle, Carrera 100 No. 5-169,
yOrthodontist, Universidad del Valle, Cali, Colombia. Oasis Unicentro, Consultorio 407C, Cali, Colombia; e-mail: dr.
zNuclear Medicine Specialist and Head, Nuclear Medicine diegolopez10@gmail.com
Department, Centro M
edico Imbanaco, Cali, Colombia. Received December 18 2018
xNuclear Medicine Specialist, Centro M
edico Imbanaco, Cali, Accepted May 29 2019
Colombia. Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral
kOral Maxillofacial Surgeon and Auxiliary Professor, Department and Maxillofacial Surgeons
of Orthodontics, Universidad del Valle; and Private Practice, Centro 0278-2391/19/30551-8
M
edico Imbanaco, Cali, Colombia. https://doi.org/10.1016/j.joms.2019.05.020
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.

1
2 MANDIBULAR MORPHOLOGICAL DIFFERENCES IN FACIAL ASYMMETRY
Facial asymmetry (FA) is a common finding in clinical
practice, with a reported range of prevalence of 21 to
85%, depending on the etiology.1 FA is associated with
functional and esthetic alterations, expressed by differ-
ences in size, shape, or disposition of the craniofacial
structures between the 2 sides of the sagittal mid-
dle plane.2,3
It has been suggested that the space correlation
between anatomic structures might be the factor
determining craniofacial conformation.4 Therefore,
the type of articulation connecting the temporal, oc-
cipital, and parietal bones is a reflex of the forces
generated during masticatory function, distributed
across the cranium. According to this concept, the
mandible and temporal bones will affect their position
and movement reciprocally, performing as a unit.4-6
Changes in the position of the articular components
occurring during growth could influence the
development of malocclusions and FAs as
morphological and functional expression of the
alteration. Similarly, the articular anatomy could be
determined by the mandibular condyle function and
by the type of occlusion and dental position, which
could act as modulators of the articular
morphology’s continuous remodeling.7-9
The etiology of FAs includes genetic and environ-
mental factors, which can be expressed during the
fetal, childhood, and adolescence periods, including
unilateral condylar hyperactivity,3 anatomic dishar-
monies during the growth of the craniofacial struc-
tures, functional occlusion disharmonies in the
occlusion and/or masticatory muscles, dominance of
a brain hemisphere,10 plagiocephaly (asymmetrical
deformity of the skull due to premature closure of
the lambdoid and coronal sutures on 1 side), and uni-
lateral craniosynostosis, among others. The duration
of evolution previous to detection will contribute to
the level of asymmetrical expression.3 Mild and diffi-
cult to perceive cases will not require any surgical
treatment because the skeletal and facial disharmony
will be masked by dental or soft tissue compensation
or a modification of the head’s posture.1
The most common types of FA will affect the middle
and lower thirds of the face, compromising dental oc-
clusion. The middle-third asymmetries will involve the
glenoid fossa, a fundamental component of the tempo-
romandibular joint. The lower third asymmetries will
compromise the mandible’s position with or without
lateral deviation of the menton. Depending on the eti-
ology and/or time of evolution, the FAs can be mild,
moderate, or severe.11-13 The pathological situations
causing FA from changes in the mandibular position
are presented in Tables 1 to 714-55 and Figures 1 to 7.
Because of the similarity in clinical signs and diag-
nostic protocols for pathologic entities causing FAs,
our hypothesis was that different types of FAs could
be classified and differentially diagnosed by significant
differences in mandibular size, as detected using
computed tomography (CT). Therefore, the purpose
of the present study was to describe the morpholog-
ical differences in mandibular bone tissues among
the different types of FAs related to changes in mandib-
ular position, using CT and 3D reconstruction. The
specific variables compared between the sides and
types of FA included the condylar length, mandibular
ramus length and width, body length, and symphy-
sis deviation.
Materials and Methods
PATIENTS AND PROTOCOL
The institutional ethics committee approved the
study, which was performed according to the princi-
ples of the Declaration of Helsinki (2013). The study
design was descriptive, comparative, and cross-
sectional. The study population included all patients
referred to the Centro M
edico Imbanaco Nuclear Med-
icine Department from 2015 to 2018 to be tested using
single-photon emission computed tomography /CT
(SPECT/CT) for FA. The inclusion criteria were as fol-
lows: patient-informed consent for confidential use
of data, a clinical diagnosis of FA, and a complete set
of CT images and SPECT data available. Patients with
antecedents of temporomandibular joint (TMJ) sur-
gery, orthognathic surgery, craniofacial trauma, or
any dentofacial syndrome were excluded.
The CT images were obtained using positron emis-
sion tomography/CT (Biograph mCT20; Siemens, Er-
langen, Germany), from vertex to sternum grip,
using the following parameters: slide width, 1.5 mm;
pitch, 1.0, and CARE dose (dose adjusted according
to the patient’s weight). A cubic matrix of 512  512
with isotropic voxel (size, 0.58  0.58  0.87 mm)
was used to avoid image distortion in different planes.
The CT images were reconstructed using a B26F ho-
mogeneous, low-dose filter for anatomic location. All
the patients were positioned with a head positioner
to avoid artifacts of movement and to allow for corre-
lation with the SPECT images. The set of DICOM (dig-
ital imaging and communications in medicine) images
was processed using an Osirix, version 7.5.1 (Pixmeo,
Bernex, Switzerland), workstation to obtain linear
measurements in the sagittal and coronal planes. The
data obtained for CT analysis are summarized
in Table 8.
The predictor variables considered for the present
study were the anatomic characteristics of the
mandible described in Table 8. The long side of the
mandibular deviation (right or left) was for all pur-
poses defined as the displaced side and the contralat-
eral side was defined as the short side or side to
which the jaw was deflected. The outcome variable


LOPEZ ET AL 3

Table 1. HEMIMANDIBULAR ELONGATION (FIG 1)

Variable Description

Etiology and diagnosis

Etiology related to trauma, hormonal and metabolic alterations14-17
Diagnosed during preadolescence and adolescence14,18
Greater prevalence in women14,15,19
Diagnosed by association of clinical extraoral and intraoral findings with radiographic and/or CT
findings20
Anatomic characteristics
Higher volume and condylar length in affected condyle compared with contralateral condyle21
Changes in space position of mandibular fossa on affected side
Normal length of mandibular ramus14,16
Canting of maxillary plane, occlusal and commissural, toward contralateral side14,16,21,22
Mandibular lateral deviation to contralateral side (horizontal vector)14,16,21,22
Molar Class III on affected side23,24
Cross-bite or edge to edge bite on contralateral side22-24
Negative tipping of posterior inferior teeth on contralateral side23,24
Midline deviation toward contralateral side21-24
Skeletal Class could be I, II, or III21,22
Imaging characteristics
Panoramic radiograph or CT will show changes in length and condylar volume14,16,25
Anteroposterior radiograph will show evidence of mandibular lateral deviation and maxillary
canting14,16
No differences in mandibular ramus length or gonial angle height
Gammagraphy results
Gammagraphy (SPECT) findings will be positive on affected side (difference $10% in the active
phase or <10% in inactive phase)26,27
Abbreviations: CT, computed tomography; SPECT, single photon emission computed tomography.
L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.

was the diagnostic group according to the FA clas- Results

sification.
STATISTICAL ANALYSIS
Stata, version 13 (StataCorp, College Station, TX),
software was used. Each measurement was summa-
rized by its average  standard deviation. The absolute
difference between sides was calculated and
compared using the t test or Wilcoxon signed rank
test, as appropriate. The comparison among the types
of FA has been presented graphically.
Each case was independently revised and classified
by 2 clinicians with experience in the diagnosis and
treatment of FA. The interobserver agreement was
83%, with a k value of 0.753 (standard error, 0.08;
P < .000). Cases of disagreement were discussed
with a third specialist to obtain consensus.
All the data were obtained and processed by the
same investigator, an expert in the use of this software.
To evaluate the confidentiality of the measurements, a
double reading of 20 patients was performed, obtain-
ing a Lin coefficient of correlation >0.90 for the 5 vari-
ables (Table 9).
In accordance with the selection criteria, the study
included 53 consecutive patients (23 men and 30
women [56.6%]), with a median age of 18 years (inter-
quartile range, 16 to 25). Of the 53 patients, 34 (64.2%)
had presented with left-side mandibular deviation. Us-
ing the diagnostic classification within the group of
condylar hyperplasia, 25 patients (47.1%) had pre-
sented with hemimandibular elongation (HE) at an
average age of 22.4 years, 2 (3.8%) had presented
with hemimandibular hyperplasia (HH) at an average
age of 16.5 years, and 3 (5.7%) had presented with
the hybrid form (HF) at an average age of 23.3 years.
Of the 53 patients, 14 (26.4%) were classified as having
asymmetric mandibular prognathism (AMP; average
age, 18.6 years), 7 (13.2%) had presented with func-
tional laterognathism (FL; average age, 22.6 years),
and 2 patients (3.8%) had presented with asymmetry
of the glenoid fossa (AGF; average age, 13.5 years).
Finally, 73.5% of the sample was distributed between
HE and AMP. The demographic characteristics accord-
ing to the diagnostic classification are listed in
Table 10. In the present sample, the patients with
4 MANDIBULAR MORPHOLOGICAL DIFFERENCES IN FACIAL ASYMMETRY

Table 2. HEMIMANDIBULAR HYPERPLASIA (FIG 2)

Variable Description

Etiology and diagnosis

Etiology related to osteochondroma14
Diagnosed during adolescence or young adulthood14,18
Greater prevalence in women19
Diagnosed by association of clinical extraoral and intraoral findings with radiographic and/or CT
findings20
Anatomic characteristics
Vertical asymmetry on 1 side of face14,16,21,22,28
Changes in anatomy of condylar head on affected side14,16
Increased length of mandibular ramus on affected side14,16,21,22
Increased vertical dimension on affected side (dentoalveolar overeruption or open bite)15,16,21
Significant canting of maxillary plane, occlusal and commissural, toward contralateral
side14,16,21,22
Mandibular lateral deviation not present or mild14,16,18
Midline dental deviation not present or mild14,16,18
No dental Class III on affected side; no contralateral cross-bite14,16,18
Skeletal Class could be I, II, or III21,22
Imaging characteristics
Double mandibular bodies observed in profile radiograph15
Difference in height of gonial angles evident on panoramic and anteroposterior radiographs and
CT25
Anteroposterior radiograph will show evidence of maxillary and occlusal canting28,29
Gammagraphy results
Gammagraphy (SPECT) will be positive on affected side (difference $10% in active phase or
<10% in inactive phase)26,27

Abbreviations: CT, computed tomography; SPECT, single photon emission computed tomography.
L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.

AGF and HH were younger than the patients with
other FAs.
For all the patients included in the present study, the
condylar length and mandibular ramus width were
greater on the displaced side than on the contralateral
side, with differences of 2.0  2.8 mm and
0.5  1.7 mm, respectively (Table 4). The differences
were statistically significant. The difference between
sides was also significant for the mandibular body
length and was greater on the contralateral side. The
symphysis deviation was 5.0  3.4 mm (Table 11).
According to the behavior of the morphological var-
iables within each of the types of FA, the average
condylar length was greater on the displaced side for
5 of the 6 evaluated pathologic entities, especially in
the HE cases. The mandibular ramus length was
greater on the displaced side in the HH and HF cases,
in contrast to the AGF, HE, FL, and AMP cases.
Regarding the mandibular ramus width, a tendency
was seen for greater values on the displaced side in
the cases of AGF, HE, HF, and AMP. However, in the
HH and FL cases, the contralateral side had a greater
width, although the differences were not statistically
significant (Table 12).
In most cases of HE, HH, FL, AMP, and HF, the
mandibular body length was greater on the contralat-
eral side than on the displaced side (Table 12). The
HF cases presented with greater deviation of the sym-
physis, with more values >10 mm, followed by cases of
HE (Table 12).
Discussion
The purpose of the present study was to provide cli-
nicians with information obtained from CT and 3D
reconstruction of the mandibular bone tissues that
will assist in the differential diagnosis of FAs necessary
to determine the best therapeutic approach. Our
research hypothesis was that the different types of
FA will present with significant differences in the
anatomic characteristics of the mandible. This was
confirmed for some types and variables; however, a
multivariate statistical analysis was not possible owing
to the small numbers for some types of FAs in the pop-
ulation studied.
A key finding in the present study was that the
mandibular body length was, in most FA cases, greater
on the contralateral side, in contrast to the expected


LOPEZ ET AL 5

Table 3. HYBRID FORM (FIG 3)

Variable Description

Etiology and diagnosis

In general, will develop in preadolescence and has rapid and aggressive evolution16,29,30
Anatomic characteristics
Vertical and horizontal facial asymmetry with menton lateral deviation18
Greater volume and condylar length on affected side14,16,21,22
Changes in space position of mandibular fossa on affected side
Increased length of mandibular ramus on affected side14,16
Vertical dimension increased on affected side (dentoalveolar overeruption or open bite16,29
Canting of maxillary plane, occlusal and commissural, toward contralateral side16,19,22
Molar Class III on affected side22-24
Contralateral cross-bite22-24
Negative tipping of posterior inferior teeth on contralateral side22-24
Midline deviation toward contralateral side22-24
Skeletal Class could be I, II, or III21,22
Imaging characteristics
Double mandibular bodies observed on profile radiograph16
Difference in height of gonial angles will be evident on panoramic and anteroposterior
radiographs and CT25
Panoramic radiograph or CT will show changes in length and condylar volume14,16,25
Anteroposterior radiograph will show evidence of maxillary and occlusal canting28-30
Gammagraphy results
Gammagraphy (SPECT) will be positive on affected side (difference $10% in active phase or
<10% in inactive phase)26,27

Abbreviations: CT, computed tomography; SPECT, single photon emission computed tomography.
L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.

Table 4. ASYMMETRIC MANDIBULAR PROGNATHISM (FIG 4)

Variable Description

Etiology and diagnosis

Will initiate in the first years of development (temporal, early mixed, or late mixed dentition)31
Etiology related to genetic and functional factors31,32
Anatomic characteristics
Molar Class III, which can be bilateral according to the time of evolution
No asymmetry in volume or condylar length between sides33,34
Mild or no maxillary plane canting35
Mandibular lateral deviation35
Midline deviation following mandibular deviation35
Lingual compensation of incisors and inferior posterior teeth
Facial profile altered (concave)35
Always skeletal Class III35
Imaging characteristics
Facial lower third deviation observed on anteroposterior radiograph36
Profile will show radiographic evidence of skeletal Class III36
Gammagraphy results
Gammagraphy not indicated37,38
Gammagraphy will show positive findings on side of mandibular deviation with difference
<10%37,38
Abbreviation: CT, computed tomography.
L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.
6 MANDIBULAR MORPHOLOGICAL DIFFERENCES IN FACIAL ASYMMETRY

Table 5. FUNCTIONAL LATEROGNATHISM (FIG 5)

Variable Description

Etiology and diagnosis

In general, will develop in the first stages of development and consolidates as skeletal
asymmetry; anatomic and functional etiology39
Anatomic characteristics
Lack of unilateral or bilateral congruence in occlusal cuspid-fossa relationship40
Patients reach midline up to first contact or interference contacts; then, lateral deviation occurs
to the minimum vertical dimension41
Overeruption of posterior teeth due to posterior discrepancy (squeezing out)40,41
Lack of eruption individual or in group of lower posterior teeth41
Posterior teeth altered tipping (augmented curve of Wilson)
Lack of transversal maxillomandibular coordination (pathologic transversal bone development)
Pseudo-Class III42
Imaging characteristics
No significant changes in condylar length, mandibular body or ramus, or maxillary inclination
observed on radiographs or CT scans
Gammagraphy results
Gammagraphy not indicated37,38
Gammagraphy will show positive findings on side of mandibular deviation with difference
<10%37,38

Abbreviation: CT, computed tomography.

L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.

increment on the displaced side. The HE and AMP The age data have indicated that most cases of FA are
were the most frequent types of FAs in this population, detected in young adults, although the range was initi-
although no cases of unilateral condylar resorption ated in preadolescence, in agreement with the reports
(UCR) were observed. by Wolford et al14 in 2014 and Nelke et al56 in 2018.

Table 6. ASYMMETRY OF GLENOID FOSSA (FIG 6)

Variable Description

Etiology and diagnosis

Initiates in first years of development9,43
Etiology related to defects in delamination, migration, and differentiation of neural crest cells of
cranial origin9
Diagnosed using CT43
Anatomic characteristics
Facial and occlusal alterations on affected side43
No asymmetry in volume or condylar length43
No asymmetry in mandibular ramus length43
Alterations in upper facial third (orbital height, malar bone, zygomatic arch, auditory meatus),
middle third (articular fossa), and lower third (changes in position of mandible)43
Imaging characteristics
CT scan will show upper projection of glenoid cavity on 1 side compared with contralateral
side43
3D reconstruction will show different orbital height, malar bone, zygomatic arch, and external
auditory meatus on side with upper projection of fossa43
Gammagraphy results
Gammagraphy not indicated37,38
Gammagraphy findings will be positive on side of mandibular deviation with difference
<10%37,38

Abbreviations: 3D, 3-dimensional; CT, computed tomography.

L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.


LOPEZ ET AL 7

Table 7. UNILATERAL CONDYLAR RESORPTION (FIG 7)

Variable Description

Etiology and diagnosis

Greater prevalence in women44
Diagnosed in patients aged 10-40 years44-47
Etiology related to articular inflammation by either local factors causing articular compression or
systemic factors44-48
Diagnosed using CT, MNR, and clinical and radiographic follow-up findings49-51
Anatomic characteristics
Progressive mandibular back movement44,45,47,52-54
Ipsilateral occlusal and facial alterations44,45,47,52-54
Ipsilateral dental Class II44,45,47,52-54
Midline deviation toward resorption side44,45,47,52-54
Asymmetry in volume and length of affected shortened condyle54
Alterations in facial lower third44,45,47,52-54
Skeletal Class II44,45,47,52-54
Imaging characteristics
CT scan will show reduction in height and volume of condyle with lack of cortical continuity
and presence of geodes or subchondral cysts50,54
NMR will show alterations in articular tissues and functional alterations50,51
Gammagraphy results
Gammagraphy not indicated37,38,54
Gammagraphy will show highly positive findings for healthy side; SPECT will not detect
osteoclastic activity in resorbing condyle55

Abbreviations: CT, computed tomography; NMR, nuclear magnetic resonance; SPECT, single photon emission computed tomog-
raphy.
L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.

The greater presence in women and greater deviation

toward the left side are findings coincident with those
from Raijmakers et al19 in 2012 and L
opez and Corral27
in 2016. However, these studies only considered cases
of condylar hyperplasia.
Nitzan et al21 postulated that the condyle and TMJ
are responsible for most postnatal asymmetries. In
contrast, Olate et al57 showed in 2013 that 30% of
the FAs exhibited condylar hyperactivity. Analyzing
the types of hyperplasia, Elbaz et al28 and Nelke
et al56 reported that HH is the most common form of
hyperplasia, which differed from the present finding
that HE was the most common, as described by Obwe-
geser and Malek.16
In 30 cases, the pathologic entity corresponded to
the hyperplastic process, which requires a nuclear
medicine test (SPECT) for diagnosis to detect the meta-
bolic activity in both condyles to establish the active or
passive state of the pathologic entity.27,58 However, in
23 cases, the asymmetry was related to other
processes that had caused the mandibular lateral
deviation. Therefore, it is clinically relevant to know
the etiologic, pathogenic, morphologic, and imaging
FIGURE 1. Schematic characterization of hemimandibular elon-
characteristics of each type to establish the best gation showing the horizontal vector predominating in the asymme-
diagnosis and make the right therapeutic decisions. try.
According to the diagnostic classification, 23 cases L

opez et al. Mandibular Morphological Differences in Facial Asym-
did not require SPECT; therefore, irradiation and metry. J Oral Maxillofac Surg 2019.
8 MANDIBULAR MORPHOLOGICAL DIFFERENCES IN FACIAL ASYMMETRY

FIGURE 3. Schematic characterization of hybrid hyperplasia

showing vertical and horizontal facial asymmetry.
L

opez et al. Mandibular Morphological Differences in Facial Asym-
metry. J Oral Maxillofac Surg 2019.
FIGURE 2. Schematic characterization of hemimandibular hyper-
plasia showing the vertical vector predominating in the asymmetry.
L

opez et al. Mandibular Morphological Differences in Facial Asym-
metry. J Oral Maxillofac Surg 2019.

costs could be avoided. In addition, it is well known

that SPECT is a test with low specificity, because the
increment in bone metabolism can result from
infectious, inflammatory, neoplastic, traumatic, or
hyperplastic processes.55,58 Positive SPECT findings
can result from increased vascularization,
mineralization, or changes in the autonomic nervous
system.59 Therefore, the specificity will be improved
when a prediagnosis of condylar hyperplasia is ob-
tained by proper correlation of the extraoral and in-
traoral clinical and CT findings.20 As shown in the
present study, the specific morphologic differences
among the pathologic entities can help determine
the differential diagnosis.
The inclusion of SPECT findings in the present study
was because Hodder et al,38 Kajan et al,60 and Fahey
et al61 have provided evidence of differences in the
percentage of uptake of technetium-99m in the con-
dyles of normal patients or in absence of pathologic
entities other than hyperplasia. This can be explained
by differences in the growth and rate of turnover of
FIGURE 4. Schematic characterization of asymmetric mandibular
articular tissue related to mechanic, functional, and prognathism showing mandibular overgrowth with lateral devia-
anatomic factors, such as in the cases of AMP, AGF, tion.
FL, and other entities. In such cases, condylar hyperac- L

opez et al. Mandibular Morphological Differences in Facial Asym-
tivity will be present in the side supporting more metry. J Oral Maxillofac Surg 2019.


LOPEZ ET AL
FIGURE 5. Schematic characterization of asymmetry of the gle-
noid fossa showing facial asymmetry with changes in the mandib-
ular position due to alterations in the height and position of the
articular fossa.
L

opez et al. Mandibular Morphological Differences in Facial Asym-
metry. J Oral Maxillofac Surg 2019.
FIGURE 6. Schematic characterization of functional laterognath-
ism showing facial asymmetry due to changes in the mandible posi-
tion without alterations in its anatomy.
L

opez et al. Mandibular Morphological Differences in Facial Asym-
metry. J Oral Maxillofac Surg 2019.
9
FIGURE 7. Schematic characterization of unilateral condylar
resorption showing facial asymmetry due to condylar shortening
on the affected side.
L

opez et al. Mandibular Morphological Differences in Facial Asym-
metry. J Oral Maxillofac Surg 2019.
articular charge, which will be the contralateral side of
mandibular deviation. However, the difference in the
percentage of uptake of the radioactive tracer was
<10%. In cases of hyperplasia, the difference will be
>10% in the affected condyle, which will not be the
condyle supporting more articular charge but the
one with increased metabolic activity. Therefore, it is
clinically relevant, as indicated by L
opez et al,62 to
interpret the SPECT results in terms of the numerical
findings. Regarding the morphologic differences, it is
common in patients with HE to detect an increment
in condylar length with a horizontal vector in the
asymmetry that causes the mandibular lateral devia-
tion and increases the distance of the symphysis
away from the midsagittal plane, with consistent
occlusal alterations.21,22
HE and AMP were the most frequent FA types pre-
sented, in agreement with the report by Wang
et al.63 They considered that menton deviations
exceeding 5 mm would be the most unacceptable
and those most frequently requiring surgical
correction.
In the cases of HH, an increment will frequently be
found in mandibular ramus length that causes vertical
asymmetry, with more growth on one side of the face
and ipsilateral occlusal changes. These changes, ac-
cording to Wolford et al14 and Higginson et al,25 will
be difficult to correct surgically owing to the volu-
metric changes in the angle and mandibular ridge of
the affected side in both the hard and the soft tissues.
10 MANDIBULAR MORPHOLOGICAL DIFFERENCES IN FACIAL ASYMMETRY

Table 8. DESCRIPTION OF MEASUREMENTS OBTAINED FOR COMPUTED TOMOGRAPHY ANALYSIS

Measurement Description

Condylar length
Mandibular ramus length
Ramus width
Mandibular body length
Deviation of midpoint of
symphysis
Laterognathia (side of
mandibular deviation)
Abbreviation: 3D, 3-dimensional.
L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.
In the sagittal view, a tangent to the posterior ridge of the mandibular ramus and a perpendicular
tangent to it from the deepest part of the mandibular notch are traced; the length is measured
from the most superior contour of the condyle to a medium point located in the
perpendicular plane that goes from the mandibular notch to the tangent to the posterior ridge
of the mandibular ramus (Fig 8)
In the sagittal view of 3D reconstruction, a line perpendicular to the Frankfort plane and
extended from the deepest point of the notch to the inferior ridge of mandibular body is
traced (Fig 9)
In the sagittal view of 3D reconstruction, a line parallel to the Frankfort plane and extending
from the deepest point of the anterior contour of the mandibular ramus to the posterior ridge
is traced (Fig 9)
In the sagittal view of 3D reconstruction, a line that goes from the bone–tissue gonion to the
bone–tissue pogonion is traced (Fig 9)
In the frontal view of 3D reconstruction, the distance from the point of the menton to a line
going from the lower third, projected from the middle part of the apophysis crista galli
perpendicular to the bizygomatic line, is measured in millimeters (Fig 10)
A visually qualitative variable indicates the direction of the mandibular deviation (right/left) and
can be observed on 3D reconstruction of the soft tissues (Fig 11)

In the hybrid form of hyperplasia (HF), a combina- described in Table 7 were taken from descriptions in
tion of factors will induce more severe sequelae in the reported data.
the 3 planes of space, including elongation of the The present study has provided evidence of signifi-
ramus on the affected side, mandibular deviation and cant changes in the mandibular ramus width, which
symphysis deviation on the contralateral side, and was increased in the displaced side in most types.
maxillary plane canting, contributing to the severity This finding could help explain why, in many cases
of the case.18,22 of FA treated by orthodontics and surgery, persistent
In AMP cases, no significant changes were found in asymmetry will remain, although the bone bases after
any of the 5 variables measured. Therefore, the most surgery will be well positioned and the teeth after or-
pathognomonic signs of AMP will be the skeletal clas- thodontic treatment will have excellent occlusion.
sification, facial profile, and the presence of mandib- The volumetric difference related to the ramus width
ular prognathism.33,34 could be the reason for these results, because any
In the FL cases observed in the present study, char-
acteristic changes were found in the mandibular posi-
tion owing to occlusal alterations or transversal
maxillomandibular discrepancy. Therefore, the diag-
nosis should be determined by the characteristics
listed in Table 5.
In the AGF cases, mandibular lateral deviation was
found on the affected side, which was the side with
greater projection and remodeling of the mandibular
fossa. The occlusal characteristics and symphysis
displacement will be similar to those with HE. Howev-
er, in AGF cases, the deviation will be toward the
affected side, but in HE, the deviation will be contralat-
eral. In contrast to other entities, AGF will show alter-
ations in the 3 facial thirds.43 The only images
adequate for the AGF diagnosis will be the coronal FIGURE 8. Condylar length shown on computed tomography
and transaxial CT views.43 scan, sagittal view.
In the present group of patients, no cases of UCR L

opez et al. Mandibular Morphological Differences in Facial Asym-
were found. The morphologic characteristics metry. J Oral Maxillofac Surg 2019.


LOPEZ ET AL
FIGURE 9. Three-dimensional reconstruction of bone tissues,
lateral view. A, Frankfort plane as reference, B, mandibular ramus
length, C, ramus width, and D, Mandibular body length.
L

opez et al. Mandibular Morphological Differences in Facial Asym-
metry. J Oral Maxillofac Surg 2019.
FIGURE 10. Three-dimensional reconstruction of bone tissues,
frontal view showing magnitude of the deviation of the midpoint of
the symphysis.
L

opez et al. Mandibular Morphological Differences in Facial Asym-
metry. J Oral Maxillofac Surg 2019.
11
FIGURE 11. Three-dimensional reconstruction of soft tissues
showing the side of mandibular deviation.
L

opez et al. Mandibular Morphological Differences in Facial Asym-
metry. J Oral Maxillofac Surg 2019.
volumetric differences in the bone or soft tissues will
not be corrected by surgery.64
According to the results of the present study, the
mandibular body length will be greater on the contra-
lateral side, in contrast to the expected increment on
the displaced side, because it will be the side exposing
the long side of the asymmetry. Some muscular and
biomechanical phenomena could help explain this.
Dong et al65 reported that electromyography activity
in the masseter and suprahyoid muscles will be
reduced on the affected side compared with the
contralateral side. Goto et al66,67 concluded that an
imbalance will be present between the contact area
and the occlusal force between sides in patients with
FA, with the stronger force on the unaffected side.
Also, Maki et al68 reported that the short side of the
asymmetry presented with cortical bone that was
more mineralized, which correlated with a greater vol-
ume of the masseter muscle on that side. In view of all
Table 9. INTRAOBSERVER AGREEMENT IN MORPHO-
LOGICAL MEASUREMENTS
Average P
Measurement Difference  SD Rho Value
Condylar length 0.210  0.381 0.985 .000
Mandibular ramus length 0.013  0.064 1.000 .000
Mandibular ramus width 0.222  0.734 0.933 .000
Mandibular body length 2.505  2.964 0.707 .000
Symphysis deviation 0.002  0.050 1.000 .000
Abbreviation: SD, standard deviation.
L

opez et al. Mandibular Morphological Differences in Facial Asym-
metry. J Oral Maxillofac Surg 2019.
12 MANDIBULAR MORPHOLOGICAL DIFFERENCES IN FACIAL ASYMMETRY

Table 10. DEMOGRAPHIC CHARACTERISTICS STRATIFIED BY DIAGNOSTIC CLASSIFICATION

Variable AGF (n = 2) HE (n = 25) HH (n = 2) HF (n = 3) FL (n = 7) AMP (n = 14) Total (n = 53)

Age (yr)
Median 13.0 19.0 16.0 19.0 18.0 18.0 18.0
Range 11-16 12-37 14-19 18-33 12-44 11-32 11-44
Gender
Female 2 15 1 2 4 6 30
Male 0 10 1 1 3 8 23
Mandibular
deviation side
Right 1 9 2 0 1 6 19
Left 1 16 0 3 6 8 34

Abbreviations: AGF, asymmetry of glenoid fossa; AMP, asymmetric mandibular prognathism; FL, functional laterognathism; HE,
hemimandibular elongation; HF, hybrid form; HH, hemimandibular hyperplasia.
L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.

these findings, if situations alter the mechanisms of
balance between the compressive and tensional forces
in tissues of the craniofacial structure, such as in the
case of mandibular lateral deviations, the force vectors
could trigger a series of remodeling events in the
mandibular body structure.
Although other forms are available by which to mea-
sure and evaluate the morphology of the mandibular
body, in the present study, we measured the sagittal
plane of the 3D model as the linear distance from
the gonion to pogonion on both the displaced and
the contralateral sides. This method has been accepted
in the reported data as reliable, and it will not be
affected by the superposition of structures or magnifi-
cation of images, which could happen in measure-
ments taken using 2-dimensional images.
The most relevant feature of the present study was
that we used 3D reconstruction data, including vari-
ables not frequently reported. One limitation of the
present study was that linear measurements were
taken to compare the sides in the mandibular struc-
ture, without consideration of the structures’ shapes
(ie, differences in the gonion angle, low edge of the
mandible, or menton). Another likely limitation,
considering that the most frequent FAs will compro-
mise the middle and lower thirds, is that the changes
in inclination, projection, and maxillary height were
not measured. In addition, the number of cases with
a low prevalence, such as HH, AGF, and UCR, was
not enough to provide conclusive evidence. These lim-
itations require the use of multicenter studies to gather
information on FA types with a low prevalence.
In conclusion, morphological differences in the
mandibular anatomical structure of patients with FA
were examined, which could help characterize the
different types of FA that cause this alteration. The
evaluation of the CT images and 3D reconstructions
in patients with FA has provided detailed information
that will be useful to compare the differences between
mandibular sides and classify the related entities, as in
the present study.
The differential diagnosis of FA types requires con-
siderations of their etiology, pathogenic patterns, age
of initiation, ability to cause developmental changes,

Table 11. COMPARISON OF MORPHOLOGIC VARIABLES IN DISPLACED AND CONTRALATERAL SIDE (N = 53)

Measurement Contralateral Side Displaced Side Absolute Difference Percentage P Value

Condylar length (mm) 20.1  3.0 22.1  3.7 2.0  2.8 7.9  12.9 .000*
Mandibular ramus length (mm) 42.2  4.5 42.1  4.3 0.1  3.1 0.5  7.4 .801
Mandibular ramus width (mm) 26.5  2.8 27.0  2.6 0.5  1.7 1.8  6.5 .009*
Mandibular body length (mm) 77.0  6.0 74.9  5.6 2.1  3.5 2.9  4.8 .000*
Symphysis deviation (mm) 5.0  3.4 NA NA NA

Note: Data presented as average  standard deviation.

Abbreviation: NA, not applicable.
* Statistically significant (P < .05).
L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.


LOPEZ ET AL 13

Table 12. COMPARISON BETWEEN SIDES STRATIFIED BY FACIAL ASYMMETRY AND MORPHOLOGICAL VARIABLE

Measurement Classification Contralateral Side (mm) Displaced Side (mm) Absolute Difference (mm)

Condylar length
AGF (n = 2) 20.5  1.4 21.1  1.6 0.6  0.2
HE (n = 25) 19.8  3.2 23.2  3.8 3.4  2.5
HH (n = 2) 23.6  1.5 22.9  0.5 0.7  1.0
HF (n = 3) 18.7  2.2 19.4  5.3 0.7  6.7
FL (n = 7) 20.8  3.1 21.8  3.1 1.0  1.8
AMP (n = 14) 20.2  2.7 21.0  3.9 0.8  1.9
Mandibular ramus length
AGF (n = 2) 40.3  4.7 39.5  6.4 0.8  1.5
HE (n = 25) 41.2  4.1 40.9  4.1 0.3  2.6
HH (n = 2) 41.3  0.04 43.0  1.6 1.7  1.6
HF (n = 3) 39.2  7.3 43.6  2.7 4.4  7.1
FL (n = 7) 43.9  4.2 42.6  5.6 1.3  2.6
AMP (n = 14) 44.2  4.4 43.8  3.9 0.4  2.8
Mandibular ramus width
AGF (n = 2) 26.1  1.6 27.0  2.1 1.0  0.5
HE (n = 25) 26.5  3.3 27.2  3.2 0.7  1.5
HH (n = 2) 27.8  1.5 26.9  2.0 0.9  0.5
HF (n = 3) 24.6  4.0 25.9  1.3 1.3  5.1
FL (n = 7) 26.5  2.5 26.1  1.9 0.4  1.5
AMP (n = 14) 26.6  2.0 27.2  2.2 0.6  1.3
Mandibular body length
AGF (n = 2) 66.7  0.2 68.5  3.7 1.8  3.5
HE (n = 25) 78.2  6.6 74.7  6.6 3.5  2.5
HH (n = 2) 79.1  5.2 77.5  4.3 1.6  0.8
HF (n = 3) 77.0  3.7 75.1  2.1 2.0  5.3
FL (n = 7) 75.7  3.9 75.5  3.9 0.2  3.4
AMP (n = 14) 76.6  5.4 75.3  5.1 1.3  4.3
Symphysis deviation
AGF (n = 2) 4.3  5.2 NA
HE (n = 25) 6.0  3.0 NA
HH (n = 2) 2.4  1.5 NA
HF (n = 3) 11.8  3.0 NA
FL (n = 7) 2.5  1.3 NA
AMP (n = 14) 3.6  2.7 NA

Note: Data presented as average  standard deviation.

Abbreviations: AGF, asymmetry of glenoid fossa; AMP: asymmetric mandibular prognathism; HE, hemimandibular elongation;
HF, hybrid form; HH, hemimandibular hyperplasia; FL, functional laterognathism.
L

opez et al. Mandibular Morphological Differences in Facial Asymmetry. J Oral Maxillofac Surg 2019.

extraoral and intraoral clinical characteristics, 2-
dimensional and 3D image characteristics, histologic
features, and nuclear medicine test results.
Acknowledgments
The authors appreciate the Research Institute of Centro M
edico
Imbanaco for its support during the development of this project.
References
1. Baek C, Paeng JY, Lee JS, Hong J: Morphologic evaluation and
classification of facial asymmetry using 3-dimensional computed
tomography. J Oral Maxillofac Surg 70:1161, 2012
2. Kim YH, Sato K, Mitani H, et al: Asymmetry of the sphenoid bone
and its suitability as a reference for analyzing craniofacial asym-
metry. Am J Orthod Dentofacial Orthop 124:656, 2003
3. Kim SJ, Lee KJ, Lee SH, Baik HS: Morphologic relationship be-
tween the cranial base and the mandible in patients with facial
asymmetry and mandibular prognathism. Am J Orthod Dentofa-
cial Orthop 144:330, 2013
4. Kantomaa T: The shape of the glenoid fossa affects the growth of
the mandible. Eur J Orthod 10:249, 1988
5. Woodside DG, Metaxas A, Altuna G: The influence of functional
appliance therapy on glenoid fossa remodeling. Am J Orthod
Dentofacial Orthop 92:181, 1987
6. Sato S: A Treatment Approach to Malocclusion Under the
Consideration of Craniofacial Dynamics. Skokie, IL, Grace Print-
ing Press Inc, 2001
7. Sato S: The dynamic functional anatomy of craniofacial complex
and its relation to the articulation of the dentitions, in Slavicek R
14 MANDIBULAR MORPHOLOGICAL DIFFERENCES IN FACIAL ASYMMETRY
(ed): The Masticatory Organ. Vienna, Austria, Gamma
Medizinisch-Wissenchaffliche Fortbildungs-AG, 2002
8. Sejrsen B, Jakobsen J, Skovgaard LT, Kjaer I: Growth in the
external cranial base evaluated on human dry skulls, using nerve
canal openings as references. Acta Odontol Scand 55:356, 1997
9. Minoux M, Rijli FM: Molecular mechanisms of cranial neural
crest cell migration and patterning in craniofacial development.
Development 137:2605, 2010
10. Bj€ork A, Bj€
ork L: Artificial deformation and cranio-facial asymme-
try in ancient Peruvians. J Dent Res 43:353, 1964
11. Cohem MM: Perspectives on craniofacial asymmetry. III. Com-
mon and/or well-known causes of asymmetry. Int J Oral Maxillo-
fac Surg 24:127, 1995
12. Kim JY, Jung HD, Jung YS, et al: A simple classification of facial
asymmetry by TML system. J Craniomaxillofac Surg 42:313,
2014
13. Hwang HS, Youn IS, Lee KH, LIM HJ: Classification of facial asym-
metry by cluster analysis. Am J Orthod Dentofacial Orthop 132:
279.e1, 2007
14. Wolford LM, Movahed R, Perez DE: A classification system for
conditions causing condylar hyperplasia. J Oral Maxillofac
Surg 72:567, 2014
15. L
opez DF, Corral CM: Condylar hyperplasia: Characteristics,
manifestations, diagnosis and treatment. A topic review. Rev
Fac Odontol Univ Antioq 26:425, 2015
16. Obwegeser HL, Makek MS: Hemimandibular hyperplasia-
hemimandibular elongation. J Maxillofac Surg 14:183, 1986
17. Chen Y, Ke J, Long X, et al: Insulin-like growth factor-1 boosts the
developing process of condylar hyperplasia by stimulating chon-
drocyte proliferation. Osteoarthritis Cart 20:279, 2012
18. Rodrigues DB, Castro V: Condylar hyperplasia of the temporo-
mandibular joint: Types, treatment, and surgical implications.
Oral Maxillofac Surg Clin North Am 27:155, 2015
19. Raijmakers P, Karssemakers L, Tuinzing D: Female predomi-
nance and effect of gender on unilateral condylar hyperplasia:
A review and meta-analysis. J Oral Maxillofac Surg 70:e72, 2012
20. Vernucci RA, Mazzoli V, Galluccio G, et al: Unilateral hemiman-
dibular hyperactivity: Clinical features of a population of 128 pa-
tients. J Craniomaxillofac Surg 46:1105, 2018
21. Nitzan DW, Katsnelson A, Bermanis I, et al: The clinical charac-
teristics of condylar hyperplasia: Experience with 61 patients. J
Oral Maxillofac Surg 66:312, 2008
22. Veeranki S, Park JH, Pruzansky D, et al: A current review of asym-
metry. J Clin Orthod 52:325, 2018
23. L
opez-Buitrago DF, Herrera-Guardiola S: Orthodontic treatment
with the MEAW technique following high condylectomy for
the treatment of condylar hyperplasia: Case series. Rev Fac
Odontol Univ Antioq 29:187, 2018
24. Lopez DF, Herrera-Guardiola S: Orthodontic treatment after high
condylectomy in patients with unilateral condylar hyperplasia. J
Clin Orthod 50:727, 2016
25. Higginson JA, Bartram AC, Banks RJ, Keith DJW: Condylar hyper-
plasia: Current thinking. Br J Oral Maxillofac Surg 56:655, 2018
26. Saridin CP, Raijmakers PG, Tuinzing DB, Becking AG: Bone scin-
tigraphy as a diagnostic method in unilateral hyperactivity of the
mandibular condyles: A review and meta-analysis of the litera-
ture. Int J Oral Maxillofac Surg 40:11, 2011
27. L
opez DF, Corral CM: Comparison of planar bone scintigraphy
and single photon emission computed tomography for diagnosis
of active condylar hyperplasia. J Craniomaxillofac Surg 44:70,
2016
28. Elbaz J, Wiss A, Raoul G, et al: Condylar hyperplasia: Correlation
between clinical, radiological, scintigraphic, and histologic fea-
tures. J Craniofac Surg 25:1085, 2014
29. Nolte JW, Schreurs R, Karssemakers LHE, et al: Demographic fea-
tures in unilateral condylar hyperplasia: An overview of 309
asymmetric cases and presentation of an algorithm. J Cranio-
maxillofac Surg 46:1484, 2018
30. Angiero F, Farronato G, Benedicenti S, et al: Mandibular condylar
hyperplasia: Clinical, histopathological and treatment consider-
ations. Cranio 27:24, 2009
31. Pirttiniemi PM: Associations of mandibular and facial asymme-
tries—A review. Am J Orthod Dentofacial Orthop 106:191, 1994
32. Persing J, James H, Swanson J, Kattwinkel J: American Academy
of Pediatrics Committee on Practice and Ambulatory Medicine,
Section on Plastic Surgery and Section on Neurological Surgery:
Prevention and management of positional skull deformities in in-
fants. Pediatrics 112:199, 2003
33. Goulart DR, Mu~ noz P, Olate S, et al: No differences in morpholog-
ical characteristics between hyperplastic condyle and class III
condyle. Int J Oral Maxillofac Surg 44:1281, 2015
34. Goulart DR, Mu~ noz P, Cantı́n L
opez MG, et al: Comparative eval-
uation of condylar volume between patients with unilateral
condylar hyperplasia and class III dentofacial deformity. J Oral
Maxillofac Surg 75:180, 2016
35. Baek SH, Cho IS, Chang YI, Kim MJ: Skeletodental factors
affecting chin point deviation in female patients with class III
malocclusion and facial asymmetry: A three-dimensional anal-
ysis using computed tomography. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 104:628, 2007
36. Grayson B, Cutting C, Bookstein FL, et al: The three- dimensional
cephalogram: Theory, technique, and clinical application. Am J
Orthod Dentofacial Orthop 94:327, 1988
37. Cisneros GJ, Kaban LB: Computerized skeletal scintigraphy for
assessment of mandibular asymmetry. J Oral Maxillofac Surg
42:513, 1984
38. Hodder SC, Rees JI, Oliver TB, et al: SPECT bone scintigraphy in
the diagnosis and management of mandibular condylar hyper-
plasia. Br J Oral Maxillofac Surg 38:87, 2000
39. Lux CJ, Conradt C, Burden D, Komposch G: Dental arch widths
and mandibular-maxillary base widths in class II malocclusions
between early mixed and permanent dentitions. Angle Orthod
73:674, 2003
40. Sato S, Suzuki Y: Relationship between the development of skel-
etal mesio-occlusion and posterior tooth-to-denture base
discrepancy. J Jap Orthod Soc 47:796, 1988
41. Ishizaki K, Suzuki K, Mito T, et al: Morphologic, functional, and
occlusal characterization of mandibular lateral displacement
malocclusion. Am J Orthod Dentofacial Orthop 137:454.e1,
2010
42. L

opez DF, Corral CM: Therapeutic management of a pseudo
class III malocclusion. Rev Mex Ortod 3:248, 2015
43. L

opez DF, Ruiz J: Asymmetry of glenoid fossa as differential diag-
nosis for hemimandibular elongation. Rev Mex Ortod 5:217,
2017
44. Handelman CS, Greene CS: Progressive/idiopathic condylar
resorption: An orthodontic perspective. Semin Orthod 19:55,
2013
45. Arnett GW, Milam SB, Gottesman L: Progressive mandibular ret-
rusion—Idiopathic condylar resorption. Part I. Am J Orthod
Dentofac Orthop 110:8, 1996
46. Kuettner KE: Biochemistry of articular cartilage in health and
disease. Clin Biochem 25:155, 1992
47. Arnett GW, Milam SB, Gottesman L: Progressive mandibular ret-
russion—Idiopathic condylar resorption. Part II. Am J Orthod
Dentofac Orthop 110:117, 1996
48. Zambrano-Zaragoza JF, Agraz-Cibrian JM, Gonz
alez-Reyes C,
et al: Ankylosing spondylitis: From cells to genes. Int J Inflam
2013:501653, 2013
49. Hoppenreijs T, Maal T, Xi T: Evaluation of condylar resorption
before and after orthognathic surgery. Semin Orthod 19:106,
2013
50. Hatcher DC: Progressive condylar resorption: Pathologic pro-
cesses and imaging considerations. Semin Orthod 19:97, 2013
51. Laskin DM, Greene CS, Hylander WL: Temporomandibular Dis-
orders: An Evidence-Based Approach to Diagnosis and Treat-
ment. Chicago, IL, Quintessence, 2006, p 105
52. Wolford L: Idiopathic condylar resorption of the temporoman-
dibular joint in teenage girls. Bayl Univ Med Cent Proc 14:246,
2001
53. Young A: Idiopathic condylar resorption: The current under-
standing in diagnosis and treatment. J Indian Prosthodont Soc
17:128, 2017
54. L

opez DF, Ruiz J, Castro MA: Ankylosing spondylitis as etiologic
factor in condylar resorption: Comprehensive review and case
report. EC Dent Sci 17:1840, 2018


LOPEZ ET AL
55. Wu F, Jiang Y, Ma L, et al: Detection of bone metastases in
patients with cancer: 99mTc-MDP bone scan and 18F-FDG
PET/CT. Biomed Res 28:1299, 2017
56. Nelke KH, Pawlak W, Morawska-Kochman M, quczak K: Ten
years of observations and demographics of hemimandibular hy-
perplasia and elongation. J Craniomaxillofac Surg 46:979, 2018
57. Olate S, Almeida A, Alister JP, et al: Facial asymmetry and
condylar hyperplasia: Considerations for diagnosis in 27 consec-
utive patients. Int J Clin Exp Med 6:937, 2013
58. Saridin CP, Raijmakers P, Becking AG: Quantitative analysis of
planar bone scintigraphy in patients with unilateral condylar hy-
perplasia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
104:259, 2007
59. Love C, Din AS, Tomas MB, et al: Radionuclide bone imaging: An
illustrative review. Radiographics 23:341, 2003
60. Kajan ZD, Motevasseli S, Nasab NK, et al: Assessment of growth
activity in the mandibular condyles by single-photon emission
computed tomography (SPECT). Aust Orthod 22:127, 2006
61. Fahey FH, Abramson ZR, Padwa BL, et al: Use of (99m) Tc-MDP
SPECT for assessment of mandibular growth: Development of
normal values. Eur J Nucl Med Mol Imaging 37:1002, 2010
62. L
opez DF, Ruiz Botero J, Corral CM, et al: Comparison of
99m
Tc-MDP SPECT qualitative vs quantitative results in patients
15
with suspected condylar hyperplasia. Rev Esp Med Nucl Imagen
Mol 36:207, 2017
63. Wang TT, Wessels L, Hussain G, Merten S: Discriminative thresh-
olds in facial asymmetry: A review of the literature. Aesthet Surg
J 37:375, 2017
64. Lisboa CO, Martins MM, Ruellas ACO, et al: Soft tissue
assessment before and after mandibular advancement or
setback surgery using three-dimensional images: Systematic
review and meta-analysis. Int J Oral Maxillofac Surg 47:
1389, 2018
65. Dong Y, Wang XM, Wang MQ, Widmalm SE: Asymmetric muscle
function in patients with developmental mandibular asymmetry.
J Oral Rehabil 35:27, 2008
66. Goto TK, Nishida S, Yahagi M, et al: Size and orientation of masti-
catory muscles in patients with mandibular laterognathism. J
Dent Res 85:552, 2006
67. Goto TK, Yamada T, Yoshiura K: Occlusal pressure, occlusal con-
tact area, force and the correlation with the morphology of the
jaw-closing muscles in patients with skeletal mandibular asym-
metry. J Oral Rehabil 35:594, 2008
68. Maki K, Miller AJ, Okano T, et al: Cortical bone mineral density in
asymmetrical mandibles: A three-dimensional quantitative
computed tomography study. Eur J Orthod 23:217, 2001