Republic of Iraq

Ministry of Higher Education

and Scientific Research
University of Baghdad
College of Dentistry

Facial Asymmetry

A Project Submitted to
The College of Dentistry, University of Baghdad, Department of
Orthodontics in Partial Fulfillment for the Bachelor of Dental
Surgery

By
Hiba Ammar Yehya

Supervised by
Dr. Sara M. Al-Mashhadany
BDS, MSc. Orthodontics
 Certification of the Supervisor

I certify that this project entitled "Facial asymmetry" was prepared by the

fifth-year student Hiba Ammar Yehya under my supervision at the College of

Dentistry/University of Baghdad in partial fulfilment of the graduation

requirements for the Bachelor Degree in Dentistry.

Supervisor’s name: Dr. Sara M. Al-Mashhadany

I
 Dedication

This graduation project is dedicated with gratitude to God who has been
with me through my lifetime. To my parents who always motivate and support
me to achieve success, you mean the world to me.

II
 Acknowledgment

First of all I would like to present my thanks to "Allah" for inspiring me with
energy and strength to accomplish this work, and I pray upon his great prophet
Mohammad (peace be upon him).
I would like to thank Prof. Dr. Raghad A. Al-Hashimi, dean of college of
dentistry, university of Baghdad, for offering me the opportunity to perform my
study.
Grateful thanks are expressed to Assist. Prof. Dr. Yassir A. Yassir, chairman
of orthodontic department, for his scientific support and encouragement.
My special thanks and apperciation to my supervisor Dr. Sara M. Al-
Mashhadany, for her cooperation and scientific care.
Finally, I would like to thank my lovely family for support and encouragement.

III
 List of Contents
Subjects Page
No.
Introduction 1
Aim of the study 2
Chapter One: Review of Literature 3
1.1 Facial Asymmetry 3
1.2 Etiology of facial asymmetry 4
1.2.1 Congenital 4
1- Cleft lip and palate 4
2- Hemifacial microsomia 4
1.2.2 Developmental 5
1- Hemimandibular elongation 5
2- Hemimandibular hyperplasia 5
3- Torticollis 5
4- Hemifacial atrophy (Parry-Romberg syndrome) 5
5- Condylar hyperplasia 6
6- Intrauterine pressure 6
1.2.3 Pathological 6
1- Temporomandibular joint ankylosis 6
2- Cysts and tumors 6
3- Infection 7
4- Condylar resorption 7
1.2.4 Traumatic 7
1- Condylar fracture 7
2- Facial trauma 7
3- Mandibular displacement 8
IV
1.3 Classification of facial asymmetry 8
1.3.1 Dental asymmetry 8
1.3.2 Skeletal asymmetry 8
1.3.3 Muscular asymmetry 9
1.3.4 Functional asymmetry 9
1.4 Dignosis of facial asymmetry 9
1.4.1 Medical and dental history 9
1.4.2 Extra-oral examination 10
1- Evaluation of facial midline 10
2- Evaluation of vertical relation 11
3- Evaluation of transverse relation 11
4- Functional evaluation 12
1.4.3 Intra-oral evaluation 12
1.4.4 Dignostic records 12
1- Photographs 12
2- Study models 13
3- Radiographs 13
A- Orthopantomographs 13
B- Postero-anterior cephalometry 14
C- Computed tomography 15
4- Stereophotogrammetry 15
5- Stereolithographic model 16
1.5 Management of facial asymmetry 16
1.5.1 Orthodontic treatment 17
1- Growth modification 17
2- Orthodontic camouflage 17
1.5.2 Surgical treatment 17

V
1- Pre and post surgical orthodontics 17
2- Single jaw surgery 18
3- Two jaw surgry 19
4- Distraction osteogenesis 19
5- Genioplasty 20
1.6 Case report 20
Chapter Two: Discussion 23
Chapter Three: Conclusion and Suggestion 25
References 26

VI
 List of Figures
Figures Page
No.
Fig 1.1 Extraoral photograph in frontal view 3

Fig 1.2 Patient with hemifacial microsomia 4

Fig 1.3 Frontal view photograph of two patients at rest and at 10

smiling
Fig 1.4 Occlusal cant 11

Fig 1.5 Submental and superior view 12

Fig 1.6 Facial photographs 13

Fig 1.7 Orthopantomopraphs 14

Fig 1.8 Grummons and Ricketts analysis 14

Fig 1.9 CT scan of patient with Hemifacial microsomia 15

disorder
Fig 1.10 Stereophotograph 16

Fig 1.11 Facial asymmetry demonstrated on stereolithographic 16

model
Fig 1.12 Hybrid appliance 17

Fig 1.13 CT scan of the patient showing the osteoma 20

Fig 1.14 Condylectomy for removal of osteoma 21

Fig 1.15 3D preoperative and postoperative virtual surgical 21

planning

VII
Fig 1.16 pre-operative and post-operative follow up 22
photograph of the patient
Fig 1.17 Photographs showing the pre-operative and post- 22
oprative follow up occlusion of the patient after 6 months

VIII
 Introduction
The word symmetry is derived from the Greek word 'symmetria' which
means ‘common measure’. Symmetry is defined as correspondence in size,
shape and relative position of parts on opposite sides of a dividing line or
median plane. Asymmetry is described as a lack or absence of symmetry. When
applying this to the human face, it illustrates an imbalance or disproportionality
between the right and left sides (Chia et al., 2008).
Normal faces are not completely symmetric, they consists of a multitude
of minor asymmetric components (Edler et al., 2001). Perfectly symmetric
faces, constructed in computer software, are unnatural and are not as beautiful as
the natural asymmetric ones (Haraguchi et al., 2008).
It is known that a certain degree of asymmetry is beautiful, but the border
line between normal asymmetry and asymmetry that requires treatment is
subjective (Lee et al., 2010). Slight facial asymmetry can be found in normal
individuals, even in those with aesthetically attractive faces. This minor facial
asymmetry is common, usually indiscernible and does not require any treatment
(Bishara et al., 1994).
The appearance of facial asymmetry as abnormal depends on individual
perception. Mild to moderate facial asymmetry can be managed by camouflage
orthodontic treatment. Severe skeletal asymmetry most often requires a surgical
management protocol (Ko et al., 2009). Not all adult facial asymmetry patients
are candidates for surgical correction; therefore, patient assessment and selection
remain major issues in diagnosis and treatment planning (Jung and kim, 2015).

1
 Aim of the study

The aim of our study is to illustrate the methods that are beneficial for
examining facial asymmetry and collect diagnostic data and management of
patients with facial asymmetry according to the degree of asymmetries.

2
 Chapter one
Review of literature
1.1 Facial Asymmetry
Facial symmetry refers to a complete match in size, location, shape and
arrangement of each facial component about the sagittal plane. That is,
asymmetry refers to the bilateral difference between such components. A perfect
bilateral symmetry almost never exists in the human body (Ko et al., 2009).
Facial asymmetry refers to the deviation from the regular mirror image (Fig 1.1)
or difference in the proportion of two sides of the face (Maheshwari et al.,
2015).
Symmetrical appearances frequently show variations, owing to embryonic
tissue development and environmental factors. Embryonic development of the
face is initiated at the third week of intrauterine life, largely by the organization
of the frontonasal, maxillary, and mandibular prominences. Relative or
subclinical asymmetry is often encountered due to the failure in coordinated
development and maturation of the craniofacial structures originating from these
prominences (Thiesen et al., 2015).

Fig 1.1: Extraoral photograph in frontal view. Patient with relative symmetry (A) in which the median
sagittal plane was determined and used to create mirror images on the right and left sides (B and C,
respectively). Note that the original and mirror images differ from one another (Thiesen et al., 2015).

Acquired facial asymmetries are not only manifest during the

developmental and growing stages of life, but also in adulthood. They are
3
predisposed by certain traumatic events, infections, or pathologies(Cheong and
Lo, 2011).
1.2 Etiology of facial asymmetries
Chia et al. in 2008 divided the etiology of facial asymmetry into
1.2.1 Congenital
1- Cleft lip and palate
Cleft lip and palate, the pathology more often occurs unilaterally on the
left side and this phenomenon probably has a genetic basis (Haraguchie et al.,
2002). Cleft lip and palate patients generally present anterior and posterior
crossbites and mid-face deficiency with a tendency towards a Class III
malocclusion (Shetye and Evans, 2006).
2- Hemifacial microsomia
Hemifacial microsomia is a congenital craniofacial malformation caused
by hypoplasia of anatomical structures deriving from the first and second
branchial arches. As a result, hemifacial microsomia involves facial skeleton,
soft tissues, ear, and cranial nerves as shown in Fig 1.2 (Ongkosuwito et al,.
2013). The occlusion may be affected with crowding and a unilateral crossbite
on the affected side. Tooth development can also be disturbed on the affected
side and the prevalence of hypodontia is five times more common in these
patients than the normal population (Monahan et al., 2001).

Fig 1.2 Patient with hemifacial microsomia (Keogh et al., 2007).

4
1.2.2 Developmental
1- Hemimandibular elongation
Hemimandibular elongation is a developmental deformity of unknown
etiology affecting the mandible unilaterally. It commonly presents with a
progressively increasing transverse displacement of the chin point in young
adulthood. The occlusion follows the displaced skeletal pattern so that the
mandibular dental centreline does not coincide with the midfacial line. There
will also be a crossbite observed on the unaffected side and possibly a scissor
bite on the affected side (Obwegeser and Makek, 1986).
2- Hemimandibular hyperplasia
Hemimandibular hyperplasia is a three-dimensional developmental
enlargement of one side of the mandible including the condyle, condylar neck,
ramus and body. It typically only affects one side of the mandible. There is an
increase in the height of the affected side, giving the face a rotated appearance
and The condition usually commences in puberty and hence the maxillary
dentition on the affected side will over erupt to compensate for the excessive
vertical mandibular growth, which results in a characteristic transverse cant of
the maxillary occlusal plane (Obwegeser and Makek, 1986).
3- Torticollis
Torticollis is a condition of unknown cause, consist of a unilateral tilt of
the neck to one side caused by developmental condition and it is usually
unilateral and results in the development of a cervicofacial asymmetry with the
interpupillary plane slanted downward and the chin deviated to the side of the
affected sternocleidomastoid muscle (Pirttiniem et al., 1989).
4- Hemifacial atrophy (Parry-Romberg syndrome)
Parry-Romberg syndrome is a disorder that is characterized by
progressive atrophy of underlying soft tissues and bones on one side of the face.
It is more common on the left side and in females. The facial changes include
the tissues around the nose and nasolabial fold and later progresses to the angle
5
of the mouth, eyes, ears and neck. It follows the distribution of the trigeminal
nerve. It may also cause muscle and facial bone atrophy. This can lead to the
development of a mandibular asymmetry (Pinheiro et al., 2006).
5- Condylar hyperplasia
Condylar hyperplasia of mandible is over development of condyle
unilaterally or bilaterally leading to facial asymmetry, mandibular deviation,
malocclusion and articular dysfunction. Prominent features include an enlarged
mandibular condyle, elongated condylar neck, outward bowing and downward
growth of body and ramus of mandible on affected side, causing fullness of face
on that side (Mehrotra et al., 2011).
6- Intra uterine pressure
Intra uterine pressure on the fetus head, as well as pressure in the birth
canal during parturition can cause molding of the skull bones and facial bones,
causing observable craniofacial asymmetry. However this problem is usually
transient and the skull and facial bones return to their normal shape within a few
weeks to few months (Noordhoff and Chen, 2006).
1.2.3 Pathological
1- Temporomandibular joint ankylosis
Temporomandibular joint ankylosis is a pathological condition, in which
the mandible fuses to the fossa. It may result from a number of factors such as
arthritis, infection, trauma, congenital deformities, or idiopathic factors
(Movahed and Mercury, 2015). In a growing child, this condition can lead to
unilateral mandibular under development on the affected side (Zhi et al., 2009).
2- Cysts and tumors
Tumours of the orofacial region may affect the soft tissues, salivary
glands, nerves and bones . The ameloblastoma is a common odontogenic tumour
that may occur in the childhood. It is a locally aggressive benign tumour that
develops from the remnants of the odontogenic epithelium and may present in
the mandible asymmetrically. Dentigerous cysts, keratocysts and fibrous
6
dysplasia have asymmetric presentations in the mandibular region (Frunza et
al., 2014).
3- Infection
Various infections can present a mandibular asymmetry include dento-
alveolar abcess and acute parotitis. These are characterized by their rapidity of
onset, pain, pyrexia, malaise and associated regional lymph node involvement
(Dhanvanth et al., 2018).
4- Condylar resorption
There are a number of conditions that may cause resorption of the
mandibular condyles include juvenile rheumatoid arthritis, post-steroid therapy
and orthognathic surgery. Rheumatoid arthritis as a child can affect the
temporomandibular joint unilaterally or bilaterally, causing changes in
mandibular function and structure. Destruction of the joint and disc can be seen
as the condition affects bone and cartilage. If unilateral condylar resorption
occurs, then this may result in a mandibular asymmetry (Hwang et al., 2004).
1.2.4 Traumatic
1- Condylar fracture
Trauma to the condylar region during childhood may result in growth
arrest and impaired function. If growth arrest does occur, this may produce a
chin asymmetry towards the side of the affected condyle. The loss of function is
usually caused by an ankylosis in the temporomandibular region. This is
initiated by the intra-articular bleeding and resulting haematoma formation that
follows traumatic episodes in children (Proffit et al., 1980).
2- Facial trauma
Traumatic events that occur at a young age usually interrupt the process
of growth in the facial regions. This leads to detrimental influences on the
development of the cranio-facial skeleton, resulting in asymmetric changes of
the face and causing long-term aesthetic, physical, and psychological distress
(Morris et al., 2012).
7
3- Mandibular displacement
A buccal crossbite occurs when the buccal cusp of a mandibular molar
occludes buccal to the buccal cusp of the corresponding maxillary tooth. Slight
transverse narrowing of the maxilla or associated dentition may result in
mandibular to maxillary cusp to-cusp occlusal interferences, resulting in a lateral
displacement of the mandible as the patient tries to achieve maximam
intercusption on closure. Some authors have suggested that mandibular growth
is restricted on the side of the crossbite and may result in shortening of the
ramal height on that side and contribute to the development of a mandibular
asymmetry. However, there is not yet any firm evidence to support this theory
(Schmid et al., 1991).
1.3 Classification of facial asymmetry
Facial asymmetries are classified based on the craniofacial structures
involved into:
1.3.1 Dental asymmetry
Early loss of deciduous teeth, a congenital missing tooth or teeth, and
habits such as thumb sucking . Tooth asymmetry generally does not involve the
entire arch. On the other hand, teeth in the same morphologic class tend to have
the same direction asymmetry. For example, if the maxillary first premolar is
larger on the right side, the maxillary second premolar will also tend to be larger
on the right side but the molars need not be larger on that side. In addition,
asymmetry tends to be greater for the more distal tooth in each morphologic
class (i.e., the lateral incisors, second premolars, and third molars) (Garn et al.,
1966).
1.3.2 Skeletal asymmetry
Skeletal asymmetry may involve one bone such as the maxilla or
mandible, or it may affect a number of skeletal structures on one side of the
face, as in hemifacial microsomia. When one side of osseous development is

8
affected, the contralateral side will most inevitably be influenced resulting in
compensational or distorted growth (Bart and Kopf, 1978).
1.3.3 Muscular asymmetry
Muscular asymmetry can occur in conditions such as hemifacial
microsomia and cerebral palsy. Abnormal muscle function, as in masseter
hypertrophy, can itself cause an asymmetrical appearance of the face. Fibrosis of
the sternocleidomastoid muscle as seen in torticollis may create evident
craniofacial deformation if left untreated for a period of time (Yu et al., 2004).
1.3.4 Functional asymmetry
Functional asymmetry may result from the mandible being deflected
laterally if occlusal interferences prevent proper intercuspation in the centric
position. These functional deviations may be caused by a constricted maxillary
arch or a local factor such as a malpositioned tooth. In some cases,
temporomandibular joint derangement, such as an anteriorly displaced disc,
may result in a midline shift during mouth opening caused by interference in
mandibular translation on the affected side (Reyneke et al., 1997).
1.4 Diagnosis of facial asymmetry
Not all adult facial asymmetry patients are candidates for surgical
correction; therefore, patient assessment and selection remain major issues
indiagnosis and treatment planning (Jung and Kim, 2015).
1.4.1 Medical and dental history
Following the patient’s chief complaint and evaluation of their medical
and dental history helps clinicians identify the precise cause of the asymmetry.
Childhood traumas or infections related to the craniofacial area and records of
dental history, such as abnormal eruption or premature loss of the dentition,
should also be taken into account (Maheshwari et al., 2015).

9
1.4.2 Extra-oral examination
1- Evaluation of facial midline
The first step in examining facial symmetry is determining the reference
midlines of the face. The reference upper midline is often established by the line
connecting through soft tissue Glabella (G’—the center point of the eyebrows)
and Subnasale (Sn—the central point of the nasal septum and the upper lip)
points. Following this reference line, clinicians can assess the upper facial
symmetry, and any remarkable deviations from this line should be noted and
examined carefully. Regarding the lower midline, some authors consider a
reference line through Sn and Pogonion (Pg’—the most projecting median point
on the anterior surface of the chin). If the reference lower midline is aligned
with the upper midline, the chin is centered, otherwise, the mandible is
considered shifted and further investigation should be made to determine
whether the mandibular deviation is functional or not. Note Fig 1.3 (Haraguchi
et al.,2008).

Fig 1.3: Frontal view photographs of two patients at rest and at smiling. An imaginary mid-pupillary line
and a facial median line are dividing the face into four parts for asymmetric evaluation. Both patients are
diagnosed with facial asymmetry with regard to these two reference lines (Iyer et al., 2021).

10
2- Evaluation of vertical relation
The occlusal plane canting is performed in extra-oral examination.
Patients are requested to hold a tongue blade between their canines to compare
the vertical and transverse relation of the occlusal plane to the interpupillary
plane (Fig 1.4). In asymmetric cases, the occlusal plane has an inclination of
more than 4° from the reference plane (Srivastava et al., 2018). The exact cause
of occlusal canting can be either due to an uneven dental eruption, a functional
shift of the mandible, or the rotation of the entire maxilla and mandible arches,
and should be accurately identified (Cheong and Lo, 2011).

Fig 1.4: Occlusal cant in relation to the pupillary plane and asymmetry marked from medial canthi to the
oral commissure (Andrade et al., 2021).

3-Evaluation of transverse relation

Andrade et al. in 2021 suggests that submental [worm’s-eye] and
superior [bird’s-eye] views are very useful in assessing deviation of the
assessment of midline structures such as nasal bridge, nasal tip, philtrum, and
the chin point as shown in Fig 1.5.

11
 (A) (B)
Fig 1.5: (A) shows submental(worm’s-eye) view and (B) shows superior (bird’s-eye)view. Note the
discrepancy in the midline of both pictures. (Andrade et al., 2021).

4- Functional evaluation
The patient is made to perform the various functional movements such as
opening of the mouth, protrusive movements and the lateral movements of the
mandible and any imbalance between the two sides is recorded.
Temporomandibular joint evaluation is done to check any symptoms of clicking,
popping or tenderness to rule out any temporomandibular joint dysfunction
(Joondeph, 2000).
1.4.3 Intra-oral evaluation
Various occlusal traits, such as impacted or ankylosed teeth, congenital
deformities, dental discrepancy, deep bite, open bite, unilateral/bilateral
crossbite, the curve of Spee, the curve of Wilson, and periodontal tissue
conditions, are recorded in this step. The upper and lower dental midline are
evaluated at rest, in centric relation, centric occlusion, at smiling, and other
functional positions of the jaw (Maheshwari et al., 2015).
1.4.4 Dignostic records
1- Photographs
The routine frontal-relaxed and smiling, profile view and oblique view
photographs of the patient are taken (Fig 1.6). The photographs are assessed for
any gross asymmetry between the two sides of the face (Edler et al., 2004).

12
 Fig 1.6: Facial photographs (Maheshwari et al., 2015).

2- Study models
The articulated study models give a comprehensive three-dimensional
view of dental relations. The study models can be used to assess the presence of
constricted arches and crossbites, which might be the cause of functional
asymmetry in the patient. Three-dimensional models can be assessed for various
parameters using software to indicate the position of dental asymmetry.
Characteristic dental anomalies have been reported in the facial asymmetry
group, including asymmetry of the curve of Spee, molar inclination, dental arch
form, lateral overjet, and slanting of the occlusal plane (Kusayama et al., 2003).
3- Radiographs
Andrade et al. in 2021suggests the use of Radiographic diagnostic aids
such as :
A- Orthopantomographs
Orthopantomograph is a tool to evaluate mandibular asymmetry and
dental status. The anatomy of the condyle-ramus unit, body, and inferior border
of the mandible is readily discernible (Fig 1.7). Increase or decrease in
dimensions or changes in mandibular morphology can be studied. In cases of
unilateral asymmetry, the affected side can be compared to the normal side. It is
also an excellent tool for the screening of maxillofacial pathology that may
cause facial asymmetry, e.g., tumors and fibro-osseous lesions.
13
Fig 1.7: Orthopantomograph demonstrates the difference in height of the mandibular body and
displacement of the inferior alveolar nerve canal toward the inferior border (Andrade et al., 2021).

B- Postero-anterior cephalometry:
The postero-anterior cephalogram allows a comparative study of the
symmetry between the structures of the right and left sides. Projections can be
obtained in both open mouth position and centric occlusion with head oriented
in natural head position to identify the full extent of static and dynamic
[functional] asymmetry. The horizontal reference plane is represented by a line
passing through the bilateral zygomatico-frontal sutures. The vertical reference
plane is a line perpendicular to the horizontal plane passing through crista galli.
Also, any shift in the dental midlines can be assessed by comparing them to the
skeletal midline. The Grummons and Ricketts analyses are commonly used PA
cephalometric analyses for the evaluation of facial asymmetry as shown in Fig
1.8.

Fig 1.8: Grummons and Ricketts analysis using PA Cephalogram (Andrade et al., 2021).

14
C- Computed tomography/Cone Beam CT with 3D Reconstruction
The main advantage of the 3D CT scan is that it helps in visualization
and treatment planning of complex facial asymmetry in cases like hemifacial
microsomia (Fig 1.9), temporomandibular ankylosis, and unilateral condylar
hyperplasia . Unlike cephalometric and panoramic radiographs, there is no
superimposition of structures, the absolute position of anatomical landmarks
can be defined, and viewing is possible from any angle. It is also an excellent
tool for patient education. The disadvantage of the CT scan is the exposure to a
high radiation dose; with the introduction of the CBCT, the amount of
radiation exposure has been greatly reduced.

Fig 1.9: CT scan of patient with Hemifacial microsomia disorder (Andrade et al., 2021).

4- Stereophotogrammetry
Stereophotogrammetry using two or more cameras, configured as a
stereopair to generate a 3-dimensional image of the face by triangulation. This
provides a useful three-dimensional assessment of facial soft tissue asymmetry
before and after orthognathic surgery as seen in Fig 1.10 (Hajeer et al., 2004).

15
Fig 1.10: Stereophotograph shown in Figure A was used to overlap the mirror image of the left side of face
on the right sides. A mirror image of the right side of the face overlapping the left side of the face and the
differences are shown in (B) (Cheong and Lo, 2011).

5- Stereolithographic Models
3-D models have been successfully utilized for correction of complicated
facial asymmetry cases when compared to similar treatments without its use.
The models facilitate direct visualization of complex 3D facial asymmetry,
decrease operating time due to better treatment planning, and can also be used as
an educational tool for patients (Fig 1.11) (Wong et al., 2005).

Fig 1.11: Facial asymmetry demonstrated on stereolithographic model involving both the midface and
mandible with hyperplasia involving the right side (Andrade et al., 2021).

1.5 Management of facial asymmetry

Decisions about intervention for dentofacial deformities depend on patient
awareness of the aesthetic problem, the extent of the occlusal deformity, and
concomitant sagittal or vertical jaw imbalance (ko et al., 2009).

16
 Facial asymmetry may involve dental, skeletal and soft tissue components
and a combination of orthodontic treatment and orthognathic surgery may be
indicated.
1.5.1 Orthodontic treatment
1- Growth modification
In cases where a mandibular asymmetry or deficiency is identified at a
young age, growth modification may be attempted by using hybrid functional
appliances which act by components causing eruption of teeth (bite planes),
altering the linguo-facial muscle balance and mandibular repositioning through
construction bites. Such appliances allow selective dento-alveolar eruption and
encourage normal mandibular growth to compensate for asymmetrical
deficiencies as seen in Fig 1.12 (Peter and Katherine, 1986).

Fig 1.12: Hybrid appliance (Peter and Katherine, 1986).

2- Orthodontic camouflage
If the mandibular skeletal asymmetry is acceptable, and any abnormal
growth has ceased, but a dental midline shift still exists, then this may be
camouflaged orthodontically. A number of techniques can be used in
conjunction with fixed appliances to correct dental midline discrepancies
including asymmetric extraction patterns, asymmetric lace backs, push-pull
mechanics and asymmetric elastics (Chia et al., 2008).
1.5.2 Surgical treatment
1- Pre and post surgical orthodontics
Andrade et al. in 2021 suggests the Pre-surgical orthodontic treatment in
patients with facial asymmetry must include the following:
17
A- The presence of a dental and facial midline shift is best corrected at the time
of orthognathic surgery provides the best results.
B- Any occlusal cant correction should not be attempted orthodontically. Cant is
evidently skeletal in nature and should be corrected surgically.
C- Levelling and alignment of the dental arches should be done.
D- Post-operative position of the upper incisor and the upper lip-maxillary
incisor relationship is the most important factor determining surgical result. This
should be checked intra-operatively before fixation of the maxilla.
E-Position of the symphysis similarly is another important determinant of a
satisfactory post surgical correction in cases of asymmetry; thus the anatomical
position and surgical limits of symphysis correction should be determined pre-
surgically.
F- The facial midline reference should be taken from the unaffected jaw.
G- In cases of hemifacial microsomia and temporomandibular joint ankylosis, a
unilateral open bite is created after increasing the ramus height. This is done to
correct the skeletal cant by allowing the vertical alveolar growth of maxilla.
H- Based on the severity of crowding, the amount of retraction and uprighting
needed; upper second premplar extraction [minimal decompensation] or upper
first premolar extraction [greater decompensation] is indicated.
2- Single jaw surgery
Single jaw surgery is usually done in cases of uncomplicated
asymmetries affecting mandible only, such as in deviant prognathism. Bilateral
ramal osteotomies. Sagittal split ramus osteotomy and intraoral vertical ramus
osteotomy are routinely used orthognathic mandibular procedures for correction
of asymmetric dentofacial deformities. Sagittal split ramus osteotomy is usually
employed for cases having mild to moderate magnitude of asymmetry (up to 7–
8 mm). Intraoral vertical ramus osteotomy is usually preferred for correction of
larger asymmetries (magnitude more than 8 mm) with associated temporo-
mandibular joint disorder's symptoms. it offers the advantages of short
18
rehabilitation time (being quick and safe operation in cases of asymmetric
mandibular prognathism), easy and rapid correction of early occlusal instability
and lower risk of permanent inferior alveolar nerve injury, when compared to
sagittal split ramus osteotomy (Fonseca et al., 2000).

3- Two jaw surgery

The various orthognathic surgical procedures, which are routinely used
are bone grafting, Le fort I maxillary osteotomy and intra-oral vertical ramus
osteotomy. Most of the skeletal asymmetries require two-jaw surgeries for
complete correction. Surgical planning of two-jaw orthognathic surgery requires
three-dimensional consideration in the sagittal, coronal and horizontal planes.
Ideally, the dental midline and skeletal midline are aligned to the facial midline.
The intercommissural plane should be parallel to the inter exocanthal plane.
Orthognathic surgeries are often supplemented with additional surgical
procedures involving bone contouring such as mandibular angle reduction,
mandibular inferior border ostectomy, bony augmentation and soft tissue
contouring such as buccal fat pad reduction, masseter muscle reduction, fat graft
injection and subcutaneous liposuction (Tai et al., 2012).

4- Distraction osteogenesis
Multiplanar distraction osteogenesis can be used to correct mandibular
hypoplasia. The treatment planning using distraction osteogenesis involves
osteotomy, distraction device placement, vector planning and selection of a
distractor. Only a single osteotomy and two pin sites are required for mandibular
distraction. Distraction for lengthening mandibular ramus also increases soft
tissue by increasing the volume of medial pterygoid muscle (McCarthy et al.,
1992).

19
5- Genioplasty
The lower border osteotomy (genioplasty) of the mandible can reposition
the chin point transversely or vertically in order to address the asymmetry. It is
one of the most stable movements compared with managing mandibular
asymmetries by other orthognathic movements. It is reported that a minimum of
6 mm between the inferior border of the mental nerve canal and the proximal
osteotomy during sliding genioplasty can greatly reduce the chance of inferior
alveolar nerve damage, although it does not completely eliminate the risk. Thus,
keeping at least 6 mm of space should be a goal during surgery to protect the
patient (Ousterhout, 1996).
1.6 Case report
A 25 years old Iraqi male patient came to the oral and maxillofacial
surgery department at Al-Shaheed Ghazi Al-Hariri Hospital, suffering from
facial asymmetry. The patient was dignosed with CT scan (Fig 1.13) that shows
presence of osteoma on the left condylar head causing shifting of occlusion and
chin deviation to the right side.

Fig 1.13: CT scan of the patient showing the osteoma

The first step in the surgical treatment steps was condylectomy with removal of
large osteoma through preauricular approach as shown in Fig 1.14

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 Fig 1.14: Condylectomy for removal of osteoma

The second step of surgery was unilateral sagittal split osteotomy of right side
with rotation of the mandible to the left side to correct occlusion and chin
deviation. Surgery done by using 3D virtual planning as shown in Fig 1.15.

The surgical steps was operated by Dr. Sabah Abdulaziz Issa.

Fig 1.15: 3D preoperative and postoperative virtual surgical planning

21
 Fig 1.16 pre-operative and postoperative follow up photograph of the patient

Fig 1.17: Photographs showing the pre-operative and post-oprative follow up occlusion of the patient after
6 months

22
 Chapter Two
Discussion
Facial asymmetry is common in humans. Significant facial asymmetry
causes both functional as well as esthetic problems. When patients complain of
facial asymmetry, the underlying cause should be investigated. The etiology
includes a combination of genetic and environmental factors, such as
syndromes, hypoplasia or hyperplasia of the condyle, fracture and trauma,
infection, inflammatory arthritis or unilateral functional cross bite (Pirttiniemi,
1994).
Facial asymmetry affects lower half of the face more than upper face.
Clinically apparent facial asymmetries were most often recorded at the level of
the chin in 74% of patients and midface asymmetries were documented in
roughly a third 36% (Severt and Proffit, 1997). A possible explanation would
be the longer mandibular growth periods, in addition to the maxilla being rigidly
attached to the stable region of synchondroses at the cranial base (Haraguchi et
al., 2002).
Assessment of facial asymmetry consists of a patient history, physical
examination, and medical imaging. Medical imaging is helpful for objective
diagnosis and measurement of the asymmetry, as well as for treatment planning.
Components of soft tissue, dental and skeletal differences contributing to facial
asymmetry are evaluated. Frequently dental malocclusion, canting of the
occlusal level and midline shift are found. Posterior-anterior cephalometric
radiographs using Grummons and Ricketts analyses allow the comparison of
left and right hard tissue structures. The lateral view on cephalometry provides
limited useful information for asymmetries in the ramal height, mandibular
length and gonial angle. The right and left structures are superimposed on each
other and resulting in significant differences in magnification. (Cheong et al.,
2011).
23
 Currently, there are several available methods for capturing and
quantifying craniofacial surface morphology. These include direct
anthropometry and digital photography as well as newer three-dimensional
surface imaging systems which assist in reducing the magnification errors
produced from geometric distortions that commonly affect conventional 2D-
acquisition methods (Hajeer et al., 2004).

24
 Chapter Three
Conclusion and Suggestion
Conclusion
 Over the years, technology and advanced imaging techniques have aided in the
accurate detection of facial disproportion. These diagnostic tools allow the
clinicians to better understand the etiological and triggering factors leading to
facial asymmetries.
 An orthodontic consultation is required if there are dental or occlusal problem.
 Skeletal problems may require surgical treatment planning which include staged
procedures. The first stage comprises orthognathic surgery, facial bone
contouring surgery, genioplasty, and contouring of soft tissues such as the
masseter muscle and buccal fat pads .

Suggestion
Further studies can be done to provide more information of facial
asymmetry by 3-dimensional assessment using stereophotogrammetry and
stereolithographic models.

25
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