January 2019 Orthodontics 29

Enhanced CPD DO C

Clara Gibson Joseph Noar

Assessment of
Facial Asymmetry in
Orthognathic Patients
Abstract: Discrepancies between dental and facial midlines are not uncommon and these may have a dental or a skeletal cause. When
planning orthognathic surgery, a decision must be made whether to accept or correct these. This paper presents a simple technique that
uses graph paper to evaluate any midline discrepancies as an aid to pre-treatment discussion and explanation with the patient.
CPD/Clinical Relevance: Accurate diagnosis of the clinical problem and complete patient understanding of the situation are imperative,
both for informed consent and for a favourable treatment outcome. Tracing of a posterior-anterior cephalogram on graph paper can aid
treatment planning and patient comprehension.
Ortho Update 2019; 12: 29–31

Facial symmetry is long established
to be a principal component of
an aesthetically pleasing face.1 A
symmetric face is perceived as ‘more
beautiful’ by layperson observation.2
Perfect bilateral symmetry, however,
is rare and the face often has a
mild degree of asymmetry, not
perceptible on normal everyday
observation.3
Prevalence of facial
asymmetry in orthodontic patients
has been reported as 12%−37%
in the US.4,5 This increased to 50%
when assessed radiographically.6 A
CBCT study by Gribel et al in 2014
demonstrated a similar prevalence
rate of 44% of mandibular
asymmetries in 250 Class I patients.7
Asymmetry may lie at the
hard or soft tissue level and involve
skeletal, dental, muscular or functional
components.8 Both developmental
and environmental influences may
be implicated when assessing the
aetiology. Chia et al outline four main
causes:
1. Pathological;
2. Traumatic;
3. Functional; and
4. Developmental.9
Often the true aetiology may
not be clear and thus ‘asymmetry of
development’ just becomes apparent
throughout growth.
A thorough assessment of
facial symmetry is important from the
patient’s first consultation. Transverse
and vertical dimensions may be
assessed from an extra-oral frontal view.
The facial midline is constructed using
trichion and glabella. Coincidence of
the maxillary dental midline may
then be assessed, both to the
facial midline and the mandibular
centreline. Nasal deviation may
distort midline assessment and
there may be an acquired postural
compensation, for example, a head
tilt that camouflages the extent of
the asymmetry.10
Supplementary
imaging techniques, such as
photographs, tomography and
bone scintigraphy, can help
precisely and accurately determine
the relative contribution of
the structures contributing
to the asymmetry. Plain film
radiographic investigation may
include lateral cephalograms or
panoramic views. Overlapping of
left and right sides affords limited

Clara Gibson, BDentSc, MJDF RCS(Eng), MClin Dent, MOrth RCS(Eng), Orthodontic Registrar, Department of Orthodontics and Joseph
Noar, MSc, BDS, FDS RCS DOrth, MOrth RCS, MOrth RCS(Ed), FHEA, Consultant Orthodontist, Department of Orthodontics, Eastman Dental
Hospital, 256 Gray’s Inn Road, London WC1X 8LD, UK.

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30 Orthodontics
Figure 1. Facial view on smiling.
Figure 2. Posterior-anterior cephalogram.
value to lateral cephalograms.
Panoramic views are useful to assess
mandibular asymmetry but can also
be affected by head positioning or
a head rotation. Posterior-anterior
radiographs are more suitable
for assessment of asymmetries
as bilateral structures can be
compared.11 Cone beam computed
tomography (CBCT) is undoubtedly
the imaging technique of choice for
the most accurate investigation.12
Figure 3. Graph tracing of posterior-anterior
cephalogram.
The higher associated radiation
doses, however, may be of concern
to the patient, who may have
undergone numerous previous plain
film radiographs up to the point of
orthognathic surgical planning.
Orthodontic management
of facial asymmetries is limited to
the aim of achieving coincidence of
the maxillary dental centreline with
the mid-facial axis. However, when
an orthognathic surgery approach
is used, symmetry, or lack thereof,
is important to determine from the
outset. The treatment plan may
aim to accept or correct a dental or
skeletal asymmetry.
A means of graphically
representing the radiographic
tracing from a posterior-anterior
cephalogram to detect and measure
a facial asymmetry will now be
described.
Case report
A 19-year-old male
patient presented with a Class III
incisor relationship on a moderate
Class III skeletal base with increased
vertical proportions. His malocclusion
was associated with a 4 mm reverse
overjet, 2 mm anterior open bite, and
bilateral buccal crossbites without
displacement.
He previously had
undergone a course of upper
fixed appliance treatment aged
13, involving extraction of ectopic
maxillary canines.
The orthognathic
surgery plan was for a 4 mm
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January 2019
maxillary advancement with a 2 mm
posterior differential impaction and
mandibular set back to Class I.
On initial extra-oral
examination, the upper centreline
appeared to be 5 mm to the right of
the mid facial axis (Figure 1). Further
examination using trichion and
glabella as a reference for the facial
midline, indicated that the maxillary
dental centreline was, in fact, correct
to the mid facial axis. The nose and
philtrum were deviated to the left,
contributing to the appearance
of an apparent discrepancy
between maxillary dental and facial
centrelines. The mandibular dental
centreline was coincident with the
maxillary centreline.
Due to the significant
nasal deviation, it was difficult to
establish the correct facial midline
fully. There was a variance of
opinions between clinicians involved
in the patient’s care with regard
to the correct midline position.
In addition, the patient himself
was uncertain and needed further
reassurance that the maxillary dental
midline was correct to facial midline
when there appeared to be such a
visual discrepancy. Due to the size
of the apparent midline discrepancy,
further imaging was felt necessary
to verify the coincidence of the
centrelines. The patient was advised
that this appearance of a centreline
discrepancy may become more
obvious to him following surgical
maxillary advancement and thus may
necessitate correction of the nasal
deviation.
A posterior-anterior
cephalogram was therefore taken
(Figure 2). The radiograph was traced
using a 0.7 mm tip pencil and this
tracing was transferred onto 1 mm
engineering graph paper (Figure 3).
This allowed for ease of visualization
and measurement of bilateral
structures. The tracing indicated that
the maxillary and mandibular dental
centrelines were correct to each
other and coincident with the facial
midline. The analysis indicated that
there was a panfacial asymmetry in
the transverse plane, with the right
half of the face being relatively wider
than the left.
Discussion
This case shows the
importance of accurate diagnosis
and treatment planning. It is essential
January 2019
to establish the correct position
for the maxillary dental centreline
using accurate reference points. A
nasal and/or philtrum deviation can
complicate the identification of the
true facial midline and can result in a
compromised final outcome.
CBCT is the imaging
technique of choice for the
most accurate investigation. The
Sedentexct guidelines suggest their
use for assessment of complex cases
of skeletal abnormality.12 There
is, however, a significantly higher
radiation dose associated with CBCT,
and the additional information
obtained may not always justify the
additional radiation exposure.
A posterior-anterior (PA)
cephalogram offers an additional
radiographic view that supplements
the findings of other plain film views.
It allows for the evaluation of vertical
and/or transverse facial asymmetries,
the width and transverse positions
of the maxilla and mandible, and
the relative vertical dimensions
of bilateral osseous and dental
structures.11 The midline structures
are used to quantify the asymmetry
as deviation to the left or right
sides.13
Posterior-anterior
cephalographs lack the standardized
and reproducible technique of
lateral cephalography.14 The head
position is not easily reproducible
and superimposition of structures
can complicate accurate landmark
identification. However, it has been
shown that transverse measurements
or widths are least affected by
positional errors.15 The Ricketts
PA cephalographic analysis is the
most widely used quantifiable
method of analysis. This provides
age-dependent normative values.16
Measurement of a patient relative
to normative values, however, often
has limited use. In this case, it was
more important to localize the site
of asymmetry and plan its influence
on the surgical outcome than to see
how far the patient deviated from a
normal range.
Thus by plotting the
radiographic tracing on graph
paper, it provided a clear visual aid
to the identification of potential
asymmetries. It assisted in discussion
with the patient, enabling him to
visualize the correct position of the
centrelines and better appreciate
the overall facial asymmetry and the
likely effects of surgery. This approach
maximizes the chances for optimal
understanding and for obtaining truly
informed consent from the patient.
Conclusion
Facial asymmetry is a
common finding in orthodontic
and orthognathic patients. An
accurate assessment and diagnosis
is imperative if an optimal treatment
outcome is to be achieved. The use
of a posterior-anterior cephalogram
and graph paper tracing may prove
to be a useful technique to examine
the coincidence of dental and skeletal
centrelines further and assess the
overall asymmetry.
References
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Orthodontics 31
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CPD Answers for
October 2018
1. B
2. D
3. D
4. B
5. B
6. A
7. B