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T
he word symmetry is derived from
Causes Examples
the Greek word symmetria which
means ‘of like measure’. Symmetry
Developmental Hemimandibular elongation
is defined as correspondence in size,
Hemimandibular hyperplasia
shape and relative position of parts on
Hemifacial microsomia
opposite sides of a dividing line or median
Achondroplasia
plane. Asymmetry is described as a lack
Hemifacial hypertrophy
or absence of symmetry. When applying
Torticollis
this to the human face, it illustrates an
Hemifacial atrophy (Parry-Romberg syndrome)
imbalance or disproportionality between
the right and left sides. A degree of
Pathological Tumours and cysts
asymmetry is normal and acceptable in
Infection
the average face. It may be caused by a
Condylar resorption
range of factors that affect the underlying
skeletal structure or soft tissue drape.
Traumatic Condylar fractures
However, the importance of early diagnosis
and the detection of progressive causative
Functional Mandibular displacement
conditions is essential for the management
of facial asymmetry. This article will Table 1. Causes of mandibular asymmetries.
focus on asymmetries of the mandible
and on some of the aspects of maxillary
asymmetry.
The causes of mandibular Developmental; Traumatic;
asymmetry can be divided into (Table 1): Pathological; Functional.
Matthew SY Chia, BDS, MFDS RCS(Eng), MSc, MOrth, FTTA in Orthodontics, Eastman Dental Hospital and Mayday Hospital, London,
Farhad B Naini, BDS, FDS RCS, MSc, MOrth RCS, FDSOrth RCS, Consultant Orthodontist, St George’s and Kingston Hospitals and Daljit S
Gill, BDS(Hons), BSc(Hons), MSc, FDS RCS, MOrth, FDSOrth RCS, Consultant Orthodontist/Hon Senior Lecturer, UCL Eastman Dental Institute,
London, Honorary Consultant Orthodontist, Great Ormond Street Hospital, London, UK.
May 2008 Orthodontic Update 45
a a b
Figure 2. (a) Patient presenting with left-sided hemimandibular hyperplasia. (b) Note the right-sided
chin point deviation which is clearly visible from below. (c) An OPG radiograph of the same patient
demonstrating increased vertical mandibular growth on the left side, increased alveolar height, a left-
sided lateral open bite, and displacement of the inferior dental canal on the left.
a b
Figure 3. (a) Patient presenting with a hybrid form of hemimandibular hyperplasia (left side) and
hemimandibular elongation (right side). (b) A panoramic radiograph illustrating both the hyperplasia
and elongation of the mandible.
a b
Figure 4. (a) Patient presenting with right-sided hemifacial microsomia. Lack of mandibular growth
on the right side has resulted in chin displacement to the affected side. (b) A panoramic radiograph
illustrating the lack of mandibular growth on the right side.
represent a fluctuation in normal growth.7,8 reflect this. Displacements can occur in also provides an overview of the dental and
the same or opposite direction to the bony structures of the mandible, providing
Intra-oral clinical mandibular asymmetry and may work to information regarding pathology, the
Dental midlines mask or accentuate the asymmetry. number of teeth and any other hard tissue
The maxillary and mandibular anomalies. However, owing to the focal
dental midlines should ideally be
Occlusion trough used in panoramic tomography,
coincident with the midline of the face. If there can be distortions in different areas of
Occlusion in the vertical plane
there is a discrepancy in the mandibular the image.
Maxillary and mandibular cants
dental midline, it is important to recognize Posterior-anterior cephalometric
can be observed by asking patients to bite
whether it is of skeletal or dental origin. If radiographs allow the comparison of left
on a tongue spatula and comparing this
the mandibular dental midline is coincident and right hard tissue structures. Distortion
horizontal reference with the inter-pupillary
with the chin point, then the discrepancy is and unequal enlargement are minimized.
plane, in the absence of vertical orbital
likely to be skeletal in origin and therefore Midlines of the skeletal structures and the
dystopia.
correction may require an orthognathic dentition can be examined as they are
approach. If the dental midline is not Occlusion in the transverse plane both seen on this projection. However,
coincident with the chin point, a dental There is often no mandibular these radiographs can be misleading as
cause should be considered. displacement associated with true a result of variation in the orientation of
Examination of the upper and skeletal crossbites. However, if there is a the transmeatal axis. It is recommended
lower dental midlines should be carefully displacement, then the dental midlines can that these views be taken by clinicians in
undertaken in two different mandibular change in the same or opposite direction a specialist care environment. Examination
positions: to the mandibular asymmetry. Dental of this radiograph allows the localization
In centric relation (retruded contact crossbites can originate from occlusal of the asymmetry by using a midsagittal
position, RCP); interferences, which cause the mandible reference plane (where there tends to
In centric occlusion (intercuspal position, to shift laterally or anteriorly so that the be the most symmetry). There are three
ICP). posterior teeth can better interdigitate. methods used to examine this image,
The position of the chin point A change in dental midlines between including the anatomic approach, the
and mandibular displacements should also centric relation and centric occlusion will bisection approach and triangulation
be noted during these movements. True become apparent if a lateral mandibular approach.
mandibular asymmetries will demonstrate displacement exists. There may also be a Other radiographic
similar midline discrepancies in centric shift in the chin point when this occurs. views, including the transcranial
relation and centric occlusion. However, Serial and reproducible and transpharyngeal views of the
lateral functional displacements of the clinical records of the patient, including temporomandibular joints, can also be
mandible are usually the result of occlusal imaging and study models, are required to taken to investigate pathology, arthritic
interferences following initial tooth determine if an asymmetry is progressive, disease and trauma to this area.
contacts, and the change in midlines will before the treatment can be considered.
Photographs
Imaging Extra-oral photographs must
Radiographs be taken in frontal view, with profile and
a The panoramic radiograph three-quarter profile views from both left
allows a comparison of the shape of the and right sides in patients with asymmetry.
mandibular rami and condyles bilaterally. It Superior and inferior views of the mandible
Figure 7. (a) A three-dimensional CT scan can be used to assess the underlying skeletal deformity. (b) An
example of a Technetium isotope scan used to assess the growth activity of skeletal sites. In the example
shown there is no increased uptake in the condylar regions.
50 Orthodontic Update May 2008
Management of mandibular
may also form a useful record. A front and to locate the position of any bony asymmetries
view of the patient in occlusion biting deformity. The management of mandibular
on a tongue spatula will give a record of asymmetries is summarized in Table 5.
transverse occlusal canting. The intra-oral Radioisotope imaging
views will provide important information Radioisotope imaging (Figure Functional asymmetry
about the occlusion. These should be 7b) uses radioactive compounds that Restoration of functional occlusion
taken in centric relation and centric have an affinity for target tissues. Once Orthodontic treatment can be
occlusion in cases exhibiting mandibular they are concentrated in a target tissue, used to eliminate crossbites that lead to
displacement. the radiation emissions are detected functional displacements of the mandible.
and imaged using a gamma camera. This Options involve removable or fixed
Laser scanning
allows an investigation of function and appliances. Upper removable appliances
Optical surface scanning has structure of the target tissue. Technetium can eliminate a posterior crossbite with
been used to monitor three-dimensional is the most commonly used isotope and is the use of a midline expansion screw.
facial growth.9 This is a non-invasive used to image bones and salivary glands. Fixed appliance approaches include the
technique and the associated software It can be used to investigate tumour use of the quadhelix, rapid maxillary
allows the digitization and comparison pathology, especially in the salivary glands expansion and auxiliary expansion arches
of images over time. Over 60,000 points and, more importantly, detect the function used in conjunction with routine bonded
are recorded in 10 seconds producing and growth in the condylar head. This appliances.12
an accuracy of 0.5 mm.10 Hence, it is form of imaging is rarely used nowadays
because of the excess radiation exposure Occlusal adjustment and occlusal splints
possible to examine facial asymmetry
and the high number of false positive Very minor occlusal adjustments
quantitatively. Laser scanning has also
results. can be made to remove premature contacts
been used in plastic surgery to study
facial asymmetry.11 that cause mild deviations of the mandible.
Stereophotogrammetry
Computed tomography (CT)
Stereophotogrammetry is a Skeletal asymmetry
CT scanners use X-rays method of acquiring three dimensional
to produce sectional images but the images using multiple photographs of the
radiographic film is substituted with same object taken at different angles. In
sensitive gas or crystal detectors. These orthodontics, this can be used to quantify
convert the X-ray beams passed from facial morphology and detect changes in
the patient into digital data. It provides growth and development of the face. It
excellent imaging of the hard and soft can be used to monitor facial asymmetry
tissues with more manipulation of the as it is both non-invasive and reproducible.
tomographic sections. However, they are
both expensive and tend to require high Articulated study models
radiation dosage. They can be used for The functional occlusion of a
the investigation of pathology, including patient can be assessed more accurately
tumours and temporomandibular joint with the use of study models that have Figure 8. A hybrid functional appliance allowing
imaging. Sectional images and 3D been articulated with a facebow transfer. differential eruption of the maxillary teeth on the
reconstructions (Figure 7a) can also be It is important to take a jaw registration left side to compensate for an occlusal cant.
used to study developmental deformities in centric relation so that any premature
May 2008 Orthodontic Update 51
Distraction osteogenesis is
described as the induction of a callus
of bone by osteotomy or corticotomy
followed by distraction of proximal and
distal ends to increase bone length. It has
been used to treat mandibular asymmetries
where the mandibular ramus and body
are to be lengthened.14 This is indicated in
severe cases of mandibular asymmetry, for
example due to hemifacial microsomia or
condylar fractures at an early age.
providing us with Figures 6 and 9. Orthod Dentofacial Orthop 1991; 100: Reconstr Surg 1999; 104: 928−937.
19−34. 12. Gill D, Naini F, McNally M, Jones A. The
6. Peck S, Peck L, Kataja M. Skeletal management of transverse maxillary
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Cochrane Synopses
Interspace/interdental brushes 10.1002/14651858. CD003452.pub2. Cochrane Database of Systematic
for oral hygiene in orthodontic Reviews 2007, Issue 3. Art. No.:
patients with fixed appliances ‘Prominent upper front teeth are an CD005098. DOI: 10.1002/14651858.
Goh HH. Interspace/interdental brushes important and potentially harmful CD005098.pub2.
for oral hygiene in orthodontic patients type of orthodontic problem. This
with fixed appliances. Cochrane Database condition develops when the child’s ‘Anchorage is the resistance to
of Systematic Reviews 2007, Issue 3. Art. permanent teeth erupt and children unwanted tooth movement during
No.: CD005410. DOI: 10.1002/14651858. are often referred to an orthodontist orthodontic treatment. Control of
CD005410.pub2. for treatment with dental braces to anchorage is important in treatment
reduce the prominence of the teeth. planning and often dictates treatment
‘Patients with fixed orthodontic braces If a child is referred at a young age, objectives. It has been suggested
need to make extra efforts to keep their the orthodontist is faced with the that more effective anchorage
teeth clean. It has been recommended dilemma of whether to treat the reinforcement may be offered by
by dentists and hygienists that special patient early or to wait until the child surgically placed temporary anchorage
interdental or interspace brushes are is older and provide treatment in early devices.
required to maintain clean teeth. These adolescence. There is little evidence to
special brushes and the braces mean The evidence suggests that support the use of surgical anchorage
that toothbrushes need replacing more providing orthodontic treatment, for systems over conventional means of
frequently and therefore mean an children with prominent upper front orthodontic anchorage reinforcement.
increase in cost. teeth, in two stages does not have any However there is evidence from one
There is no evidence to show advantages over providing treatment recent trial that showed mid-palatal
that this recommendation is supported in one stage, when the children are in implants are an acceptable alternative
by clinical investigations.’ early adolescence.’ to conventional techniques for
reinforcing anchorage.
Orthodontic treatment for Reinforcement of anchorage The review authors were
prominent upper front teeth in during orthodontic brace able to find only limited evidence
children treatment with implants or on the use of surgical means of
Harrison JE, O’Brien KD, Worthington HV. other surgical methods preventing anchorage loss compared
Orthodontic treatment for prominent Skeggs RM, Benson PE, Dyer F. with conventional techniques and
upper front teeth in children. Cochrane Reinforcement of anchorage during the data showed equivalence, but not
Database of Systematic Reviews 2007, orthodontic brace treatment with superiority of either type.’
Issue 3. Art. No.: CD003452. DOI: implants or other surgical methods.