Download - Management of Facial asymmetry
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MANAGEMENT OF FACIAL ASYMMETRY
PRESENTED BY:
Dr. SHAZEENA QAISER
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INTRODUCTION
• Facial esthetics evaluation is the most important part of the orthodontictreatment-planning procedure.
• The attainment of the best facial esthetic appearance for a given patient is aprimary goal of orthodontic treatment.
• The evaluation of a patient’s frontal symmetry is the most critical aspect ofdiagnosis because this is the most appreciated view for any individual. Eventhe most esthetic faces are associated with mild forms of facial asymmetry.
• The individuals who report for an orthodontic treatment are oftenassociated with facial asymmetry that may be greater than the acceptablenorms.
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DEFINITIONS ‘DORLAND’• Symmetry:
The similar arrangement in form & relationship of parts around a common axis or on each side of a plane of a body.
• Asymmetry
Variations in the size & relationships of the two sides of a body
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Woo (1931)-
• Bones of cranium show asymmetry- rt. side being larger
• Bones of facial complex – contralateral asymmetry.
Vig & Hewitt (AO 1975)-
• Dentoalveolar region exhibit greatest symmetry.
• Allows symmetric functions even with asymmetric jaws.
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CLASSIFICATION OF FACIAL ASYMMETRIES
1. Skeletal asymmetries
2. Soft tissue asymmetries
3. Functional asymmetries
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ETIOLOGY
AJO PIRTTINIEMI 1994
A. PRENATAL CAUSES
• 1. Facial clefting syndromes - unilateral CLCP - craniofacial clefts
I. GENETIC
• 1. Hemi facial microsomia
• 2. Neurofibromatosis
• 3. Birth trauma
• 4. Intra uterine pressure during preg.
II . CONGENITAL
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B. Postnatal causes
• 1. Trauma & infection
• 2. Muscle dysfunction
• 3. Functional deviations
• 4. TMJ derangements
• 5. Hemi mandibular hypertrophy
• 6.Pathologies
ENVIRONMENTAL
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A. Malformations with abnormal developmental
processes in embryonic stage ( 1%)
1.Hemifacial microsomia
2.Congenital hemifacial hypertrophy
3.Cleft lip & palate
COHEN 1982
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B. Deformations caused by non disruptive
mechanical forces during fetal period:(2%)
1.Congenital muscular torticollis
2.Postural scoliosis
3.Plagiocephaly
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C. Disruptions caused by breakdown of normal
developmental processes with onset later in life
1.Unilateral condylar hyperplasia
2.Hemifacial atrophy
3.Infections & inflammations
4.Fracture & trauma
5.Lateral malocclusion
6.Muscular dysfunction
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DIAGNOSIS
1.History
2. Clinical examination
3.Radiographic examination
4.Photographic analysis
5.Digital videography
6.Articulated study models
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HISTORY:
• -Can reveal aetiology
• -Severity of deformity
CLINICAL EXAMINATION
• Reveals asymmetry in the
vertical, antero-posterior , lateral dimension.
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EXTRAORAL EVALUATION
• Frontal
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-Mid pupillary distance aligned with commissures
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1. Inter ocular dimensions-
interpupillary-65mm
inter canthal- 35mm
2.Midfacial bony support-
lower third of iris of the eye to be covered
with lower eyelid
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VERTICAL
Vertical reference plane- nasion to subnasale
•upper horizontal plane – bipupillary line
• lower horizontal line - through the stomion
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Arnett and Bergman AJO1993
• The pupils are assessed for level with the horizon.
If in level - used as horizontal reference line
• (1) upper canine level
• (2) lower canine level
• (3) chin and jaw level.
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The pupils are not level to the horizon:
A constructed frontal horizontal reference line is visualized as follows:
• 1. Frontal natural head posture.
• 2. Horizontal line parallel to the horizon through the pupil area
• 3. Assess other structures relative to this line
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SUBMENTO VERTEX VIEW
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INTRA ORAL EXAMINATION
1. Evaluation of the dental midlines
2. Vertical occlusal evaluation
-Transverse cant of maxilla
3. Transverse and antero-posterior occlusal evaluations
• Unilateral cross bites
• B-L inclination of teeth
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FUNCTIONAL EXAMINATION
1. Maximal opening
2. TMJ evaluation
• postural rest position
• -CR-CO discrepancy
• -laterocclusion/ laterognathia
3. Motor & sensory evaluation
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RADIOGRAPHIC EXAMINATION
Importance of head position
1. The lateral cephalogram
2. The panoramic radiograph
3. Postero-anterior projection
4. Submento vertex view
5. 3-D cephalograms
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LATERAL CEPHALOGRAM
Only little useful information
In CR ,CO and initial contact permits visualization of mand.position
OPG:Gross pathologies -Size &shape of condyle, ramus &body of mandible
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PA CEPHALOGRAM
• Important adjunct for qualitative & quantitative evaluation of dentofacial region
• Extent of deformity( orbital/ upper facial symmetry),
• Skeletal /dental involvement.
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Various P.A Analysis:
• Rickett’s Analysis
• Svanholt and Solow Analysis
• Grummon’s Analysis
• Grayson’s Analysis
• Hewitt analysis
• Chierici method
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• COMPUTED TOMOGRAPHY
3-D evaluation of osseous & soft tissues Complex diagnosis
•3-DIMENSIONAL CT
-Reproduces detailed skeletal pathology
- Assess post treatment changes
•MRI SCAN
-Also provide 3-D representation of deformity
-For better visualization of soft tissue
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PHOTOGRAPHIC ANALYSIS
• Head position, patient position, flash
• Extra oral Photographs –
Frontal - lips relaxed , smile
Oblique ( rt & lt) ,
Profile ( rt & lt),
Submental
• Intra oral photographs
• Impossible to assess dynamic asymmetries
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Photographic montage/ composite photographs
• -reveal altered facial form and disclose difference in configuration of both sides of the face
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TREATMENT MODALITIES
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SKELETAL ASYMMETRIES:
• In growing Individuals, orthopedic appliances in conjunction with orthodontics are used to help improve or correct the developing imbalance.
• Severe discrepancies may require a combination of surgery and orthodontics.
• Abnormalities of the coronoid and condylar processes as well as in the position and shape of the articular disks should be considered when limited opening, acute mal- occlusions, or mandibular deviations are found.
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FUNCTIONAL ASYMMETRIES
• Mild deviations caused by functional shifts -minor occlusaladjustments
• More severe deviations -orthodontic treatment to align the teeth
• Occlusal splints may be necessary to properly evaluate the presence and extent of the functional shift by eliminating the habitual posturing and de- programming the musculature.
• Because functional shift can also be the result of a skeletal asymmetry, rapid maxillary expansion, orthognathic surgery, and orthodontic treatment may be indicated in the management of these cases.
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SOFT TISSUE ASYMMETRIES
• Deformities caused by soft tissue imbalance can be treated by either augmentation or reduction surgery.
• Augmentations include the use of bone grafts and silicone implants to re-contour the desired areas of the face.
• With the mild dental, skeletal, and soft tissue deviations the advisability of treatment should be carefully considered.
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Asymmetry Treatment
Growing Children
Hybrid Functional
Appliances
Distraction
Osteogenesis
Adults
Surgical
OSTEOTOMYOrthodontic camouflage
Functional asymmetry
OcclusalCallibration
Splints
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TREATMENT POSSIBILITIES
1. MAXILLARY ARCH EXPANSION
2. ORTHODONTIC ARCH COORDINATION
3. SPLINTS
4.OCCLUSAL THERAPY
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MAXILLARY EXPANSION
• 1. Slow expansion
• 2. Orthopedic rapid palatal expansion
• 3. SARPE
• 4. Segmental osteotomy
To achieve desired expansion with stability,it should be accomplished by sutural adjustments & not by alveolar bending dental tipping
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SLOW EXPANSION:
• Can bring about skeletal expansion in primary dentition
• Lingual arch /quad helix- 50% sk. exp.
• Jack screw
• FR functional regulator - indirect effect
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RAPID PALATAL EXPANSION
• Very successful in children prior to sutural closure.
• 0.5mm day- 10 mm exp. in 20 days- 75- 80% of sutural
expansion
Haas type
Hyrax type
Minn expander
• 3:2 ratio of widening in canines & molars
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SARPE:
• Brown(1938)-described SARPE with midpalatal split
• Shetty(1994)-main areas of resistance to expansion are midpalatal suture followed by pterygomaxillarybuttress
• Subtotal Lefort I osteotomy –except posterior and superior articulations
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• Should be done after mand Decompensation
• During surgery – activated by 1- 1.5mm – 5 days of rest –0.5mm day
• Spacing between central incisors
• Expansion completed within 4 weeks of surgery
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Segmental Lefort I osteotomy
• Indicated in open bite cases, where SARPE is contraindicated
• Total down fracture of maxilla followed by anterior segmenting.
•Maximum expansion occurs in molar area
• Advantage: minimal relapse
•Disadv: exp. more than 6mm
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Repositioning splints AJO 1991. Schmid et.al.
• Used mainly in TMJ dysfunctions
• Indicated only when it is impossible to identify functional interferences due to neuromuscular adaptation
• Superior repositioning splints are preferred
• Regular wear for 2-3 mths enables compensatory changes in TMJ.
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Orthopaedic Hybrid Functional Appliances
• Hybrid /blend of several components designed to address specific problems
These components produce basal and dentoalveolar changes by acting on the following:
• 1. Eruption (biteplanes)
• 2. Linguofacial muscle balance (shields or screens)
• 3. Mandibular repositioning
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• Functional appliances used either alone or in conjunction with surgery for the following purposes:
• (1) to improve symmetry of the mandible and maxillary deficiency,
• (2) to restore the dental occlusion,
• (3) to expand soft tissues
• (4) to lengthen the mandibular ramus
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Herbst appliance:
• Works as an artificial joint between the maxilla and the mandible. The appliance is fixed to the teeth -orthodontic bands.
• The appliance is constructed to displace the mandible anteriorly and to the unaffected side for correction of the mandibular retrusion and asymmetry.
• The construction bite - incisors in an edge-to-edge position , midline overcorrected by 3.5 mm.
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Twin block AJO 1988 Clark
•When activated unilaterally - correct postur mand. displacement (mid line displacement an asymmetric buccal segment relationships).
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DISTRACTION OSTEOGENESIS
•The regeneration of bone between vascularised bone surfaces that are separated by gradual distraction.
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Surgical Osteotomy
•Maxillary hypoplasia:
Le-forte 1 osteotomy With max.advancement.•Maxillary hyperplasia:
maxillary segmental setback.•Maxillary vertical excess:
leforte-1 osteotomy with maxillary impaction.
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mandibular hyperplasia: 1)sagital split osteotomy.2)sub-sigmoid osteotomy.
•Mandibular hypoplasia:1)sagital split osteotomy with mandibular
advancement.
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Orthodontic camouflage-When skeletal deformity is very mild and any further change is
not expected, camouflage should be considered.1. Transverse cant correction
• 2 occlusal planes : upper &lower Connects incisal edge of C.I to M-B cusp tip of I molars –important for normal intercuspation .
• Natural plane of occlusion: axial inclinations of premolars to be perpendicular & that of molars mesially inclined
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•Normal –transverse occlusal plane – esthetic&- parallel to the transcommisural line & a line tangent to lower lip
• Asymmetry cases – transcommisural lines’ll not be parallel to other facial planes – treatment occlusal plane should not be parallel to facial planes
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2. Midline coordination
• Translate midline (asymmetric extractions)
• Tipping of the teeth to midline
• Altering the occlusal cant
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Occlusal therapy
• Selective grinding /Occlusal adjustment
-Reshaping the occlusal surfaces of the teeth to achieve a desired occlusal contact pattern
-Removal of the tooth structure limited to enamel.
• Restorations of teeth –
crowns & FPDs
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Rule of thirds
Each inner incline of posterior teeth is divided into 3 equal parts:
• If opposing centric cusp tip contacts the third closest to the central fossa – selective grinding
• If opposing centric cusp tip touches the middle third – crowns FPDs
• If opposing centric cusp tip contacts the cusp tip –orthodontic arch coordination
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DENTAL COMPENSATIONS
• Midline shifts- dental compensation to make the dental midline shift
• Axial inclination of molars
– to compensate for the developing cross bite in the contralateral side
• Canting of maxillary occlusal plane
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Surgical
•Conditions with severe skeletal asymmetries are not able to be corrected by orthodontic camouflage and growth modification so surgical procedures are used to correct the deformities or asymmetries.
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1. Distraction osteogenesis
2.Maxillary surgeries - Lefort I
3. Mandibular surgeries
- BSSO
- Inferior body osteotomy
- genioplasty
4. TMJ surgeries
5. Autogenous/alloplastic augmentation
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1)Rhinoplasty.
2)Genioplasty.
3)Cheiloraphy.
COSMETIC SURGERIES
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CONCLUSION
•A team approach in the management ofasymmetries always produces a high degree ofsuccess which influences the social & personalwell being of these patients.
•Joining hands together enlightens the futureof such patients.
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