ORIGINAL ARTICLE

Assessing soft-tissue characteristics of facial

asymmetry with photographs
Mi-song Lee,
a
Dong Hwa Chung,
b
Jin-woo Lee,
c
and Kyung-suk Cha
d
Cheonan, Korea
Introduction: Precise diagnosis and treatment of facial asymmetry are important in orthodontics. The aims of
this study were to determine the soft-tissue characteristics of patients perceived to have severe asymmetry
requiring treatment and the soft-tissue factors affecting the subjective assessment of facial asymmetry.
Methods: In the rst part of this study, 5 observers examined 1000 photographs of patients receiving ortho-
dontic treatment and selected 100 for further assessment. These photographs showed 50 patients who were
considered to have little or moderate asymmetry and 50 who were considered to have severe asymmetry. A
pilot study was performed to select the reference photographs representing the most symmetric (score of 0)
and the most asymmetric (score of 100). A panel of 9 orthodontists then rated the facial asymmetry of the 100
patients on a 100-mm visual analog scale. The scale was divided into 3 equal regions. Region 1 included pa-
tients with the least facial asymmetry; according to the orthodontists, these patients did not require treatment.
Region 2 included patients with moderate facial asymmetry who did not require treatment. Region 3 included
patients with the most facial asymmetry who did require treatment. Results: One-way analysis of variance
showed that lip canting, chin deviation, body inclination difference, and gonial angle difference had signicant
differences between the groups. Chin deviation and gonial angle difference were signicant factors affecting
the assessment of facial asymmetry, according to stepwise linear regression analysis. Conclusions: These
results will help in the diagnosis and treatment planning for patients with asymmetry. (Am J Orthod
Dentofacial Orthop 2010;138:23-31)
A
bout 80% of adults who seek orthodontic treat-
ment want to improve facial aspects that are not
associated with structural or functional prob-
lems.
1
Patients who do not perceive their facial asym-
metry in the early stage of orthodontic treatment
might begin to recognize it as treatment progresses.
2,3
De Smit and Dermaut
4
and Foster
5
reported that faces
with ideal proportions and symmetry are not beautiful.
On the other hand, they reported that abnormal propor-
tions and asymmetric faces have unfavorable aspects.
The correction of facial asymmetry is becoming an
important goal of orthodontic treatment and orthog-
nathic surgery. It has been reported that all patients
have some craniofacial asymmetry, including those per-
ceived as normal.
6
Ferrario et al
7
found variable degrees
of soft-tissue facial asymmetry in healthy white dental
students with normal dentition. Therefore, it is widely
recognized that facial asymmetry is often present in
the normal craniofacial complex. In addition, it was
reported that an occlusal cant of 0

to 3

has been
observed in normal, healthy patients.
8,9
There is no invisible demarcation line, or even
a range, marking the distinction between normal and
abnormal asymmetry in terms of soft-tissue characteris-
tics. A demarcation line determining the necessity of
orthognathic surgery for facial asymmetry is also
unknown. The borderline between normal and abnormal
asymmetry might be determined by subjective evalua-
tion such as the patients, or the orthodontists, percep-
tion of facial asymmetry.
Although cephalometric measurements address skel-
etal symmetry,
10
subjective evaluations, such as the per-
ception of facial asymmetry, might be based on soft-
tissue features, including the outline of the face.
11-13
Robinson et al
14
reported that a beautiful face should be
harmonious with comparable size and position of
the skeletal structures and soft tissues. They stated that
a favorable face can be shown by the soft tissues.
A diagnosis of facial asymmetry is normally made
based on the measurements from a posteroanterior
cephalogram or 3-dimensional (3D) skeletal computed
tomography (CT) images by a clinician. However, the
From the Graduate School of Dentistry, Dankook University, Cheonan, Korea.
a
Postgraduate student.
b
Associate professor, Department of Orthodontics, School of Dentistry.
c
Professor and chairman, Department of Orthodontics, School of Dentistry.
d
Professor, Department of Orthodontics, School of Dentistry.
The authors report no commercial, proprietary, or nancial interest in the
products or companies described in this article.
Reprint requests to: Dong Hwa Chung, Dankook University, School of
Dentistry, Department of Orthodontics, San 7-1, Shin-Bu Dong, Cheonan,
ChungNam, South Korea; e-mail, abeh@dankook.ac.kr.
Submitted, March 2008; revised and accepted, August 2008.
0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.08.029
23
patients decision for treatment or satisfaction with the
result is subjective and can be assessed by a perceptive
assessment.
15
There is a gap between the patient and the
clinician in terms of the assessment of facial asymmetry.
Therefore, the rst assessable tool for patients with
facial asymmetry must be the soft tissues.
There has only been 1 study on the correlation
between the perception of facial asymmetry and the
cephalometric measurements, and no reports of the
relationship between the perception of facial asymmetry
and the soft-tissue measurements.
16
The aims of this study were to survey the facial fron-
tal photographs by subjectively evaluating facial asym-
metry with a visual analog scale (VAS) and to determine
the differences in soft-tissue measurements between the
groups. The next steps were to determine the soft-tissue
characteristics of patients perceived as having severe
asymmetry and the borderline of abnormal asymmetry.
Finally, the factors affecting the severity of the subjec-
tive assessment of facial asymmetry were determined.
This study should help clinicians make a differential
diagnosis of asymmetric patients and develop an
appropriate treatment plan.
MATERIAL AND METHODS
Five observers screened 1000 standardized facial
frontal photographs and selected 50 with little or no fa-
cial asymmetry and another 50 with moderate or severe
facial asymmetry. The inclusion criteria were as
follows: over 18 years of age, no congenital abnormal-
ities in the maxillofacial region, no prior surgery for an
injury involving the maxilla or the mandible, and stan-
dardized facial photographs taken before treatment
with sufcient quality for evaluation.
The nal sample consisted of photographs of 61
women and 39 men (ages, 18.0-30.1 years; mean, 25.1
years). The photographs had been taken with a digital
camera (350D, Canon, Seoul, Koea) with a distance of
1.5 m between the patient and the focus. The patients
were seated upright on a special chair, with the Frank-
fort plane parallel to the oor. The patients looked
directly at the camera lens. Both ears were exposed,
and the right and left distances between the exocanthus
and the hairline were the same. The patients were in
occlusal rest postion.
The color photographs were printed individually on
size A4 paper. The printed photographs were used to
measure several soft-tissue measurements.
Five orthodontists in the Department of Orthodontics,
Dankook University, Cheonan, Korea, selected the 5 most
symmetric facial photographs and the 5 most asymmetric
facial photographs. The photographs selected most
frequently were called the reference photographs to
represent the most symmetric and the most asymmetric
faces; they were assigned scores of 0 and 100.
Apanel of 9 orthodontists fromthe Department of Or-
thodontics, Dankook University, were asked to judge the
100 frontal photographs. The photographs were pre-
sented for 1 minute each, in randomorder. The orthodon-
tists rated the facial asymmetry on a 100-mm VAS,
marked most symmetric (0) on the left and most
asymmetric (100) on the right. A 100-mm ruler was di-
vided into 3 equal regions, and the meaning of the regions
was explained to the panel. Region 1 included patients
with little or no facial asymmetry and not requiring treat-
ment. Region 2 included patients with moderate facial
asymmetry but still not requiring treatment. Region 3 in-
cluded patients with the most facial asymmetry who re-
quired treatment. All assessments were subjective.
During the session, the 2 reference slides represent-
ing 0 and 100 on the VAS were projected continuously.
The panel was told of these set scores. The assessments
were repeated twice with 2 weeks between sessions.
When each judge had nished, the 100-mm VAS
values were measured to the nearest 0.1 mm by using
a caliper and recorded on a data sheet. The raw data
were entered in an Excel spreadsheet (Microsoft,
Redmond, Wash).
The 9 assessment scores of each patient were aver-
aged. The average scores from rst and second sessions
of each patient were compared by using the Student t
test. The difference between assessments was not signif-
icant. Therefore, the second-session scores were used.
The patients were classied into 3 groups according
to the average assessment scores in the previously xed
regions. Group I patients had scores of 0 to 33.3, group
II patients had scores of 33.4 to 66.7, and group III
patients had scores of 66.8 to 100. The printed frontal
photographs were measured to analyze the soft-tissue
characteristics of each group.
The soft-tissue landmarks used in this study are
described in Table I and Figure 1. Most points used in
this study were proposed by Farkas.
17
The midsagittal reference line was dened as the
line from glabella to subnasale. The horizontal refer-
ence line was the line perpendicular to the midsagittal
line passing through the midpoint of both pupils. Ten
lines, except for the midsagittal and horizontal reference
lines, were established. These lines were used for the
angular measurements. These were the bipupillary
line, otobasion inferius line, lip line, gonion line, prona-
sale line, chin line, ramus line (right and left), and man-
dibular body line (right and left) (Table II).
Nine angular and 2 linear measurements were made.
The angular measurements were eye canting, otobasion
24 Lee et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2010
canting, lip canting, gonion canting, nose deviation,
chin deviation, ramal inclination difference, body incli-
nation difference, and gonial angle difference. Table III
givess the denitions of these measurements. Eye cant-
ing, otobasion canting, lip canting, and gonion canting
were measured by using the horizontal reference line.
Nose deviation, chin deviation, ramal inclination, and
body inclination were measured by using the midsagit-
tal reference line. The ramal inclination difference,
body inclination difference, and gonial angle difference
were measured to calculate the difference between the
right and left angles. All angular measurements were
used as absolute quantities.
Statistical analysis
The linear measurements were calculated by using
the asymmetry index (Table III). Each distance for right
and left soft-tissue gonion (Go) was measured from the
midsagittal and horizontal reference planes, respec-
tively. The asymmetry indexes were calculated with
the following formula:
asymmetry index %5jR Lj=M3100;
where R is the value of the right distance, L is the value
of the left, and M is the average of the right and left
values.
The distance for Go from the midsagittal plane was
dened as the horizontal Go value. The distance from
the horizontal plane was dened as the vertical Go
value. Therefore, there were 2 types of asymmetry in-
dexes: for horizontal Go and vertical Go. The asymme-
try index for horizontal Go is the ratio of the right and
left horizontal Go lengths; the horizontal Go length
means the length from the midsagittal reference line
to Go (right and left). The asymmetry index for vertical
Go is the ratio of the right and left vertical Go length; the
vertical Go length means the length from the horizontal
reference line to Go (right and left).
The SPSS software program (version 10.0, SPSS,
Chicago, Ill) was used. One-way analysis of variance
(ANOVA) was used to analyze the differences among
the 3 groups. Bonferroni tests were performed for
post-hoc analysis of the differences. The sex differences
were examined with the Student t test.
Stepwise linear regression analysis was performed
to determine the independent variables that were
associated most closely with the assessment of facial
asymmetry (dependent variables). The linear regres-
sion equation was:
Y 5 a 1b
1
X
1
1 b
2
X
2
1 .1 b
k
X
k
where, a, b
1
, and b
2
.b
k
are constants, and X
1
, X
2
.,
and X
k
are independent variables that are combined lin-
early to explain the variation in the dependent variable
(Y).
Reliability was assessed by using duplicate mea-
sures on a subset of randomly selected photographs
scored 2 weeks apart. Systemic error, assessed by com-
paring the mean differences between replicates to the
standard error, was not statistically signicant. The ran-
dom technical error was calculated by using Dahlbergs
formula.
18
The method error was\2.0

for all measure-

ments except for ramus inclination difference, which
was 2.5

.
RESULTS
The patients were classied into 3 groups by using
the assessment scores of facial asymmetry. Group I in-
cluded patients with little or no facial asymmetry, not
requiring treatment. Group II included patients with
moderate facial asymmetry but not requiring treatment.
Group III included patients with severe asymmetry, re-
quiring treatment. One-way ANOVA showed that lip
canting, chin deviation, body inclination difference,
and gonial angle difference were signicantly different
between the groups. In group I, the mean scores of the
Table I. Denitions of landmarks used in this study
Landmark Denition
Pp (pupil) The apparently black circular opening in the center of the iris of the eye
G (glabella) The most forward projecting point of the forehead in the midline of the supraorbital ridges
Na (soft-tissue nasion) The middle point of the soft-tissue frontonasal suture
O (otobasion inferius) The inferior insertion of the ear
Sn (subnasale) The point at which the columella merges with the upper lip in the midsagittal plane
Pr (pronasale) The middle point of the outline of the nose tip
Ch (cheilion) The most lateral extent of the outline of the lips
Me (soft-tissue menton) The most inferior point of the soft-tissue outline on the chin
Go (soft-tissue gonion) The most everted point of the soft-tissue outline of the angle of the mandible
Pre (preaureculare) The most lateral point of the soft-tissue facial outline in front of tragus
Zero point The intersection of midsagittal line and horizontal line
American Journal of Orthodontics and Dentofacial Orthopedics Lee et al 25
Volume 138, Number 1
factors for lip canting, chin deviation, body inclination
difference, and gonial angle difference were 1.61

,
1.11

, 2.80

, and 2.31

, respectively. In group II, the

mean scores were 2.29

, 2.00

, 3.75

, and 3.05

, respec-
tively. In group III, the mean scores were 3.09

, 3.64

,
7.11

, and 6.14

, respectively (Table IV).

The sex differences were not signicant statistically
according to the Student t test. Chin deviation tendency
of each group was evaluated in Table V.
Pearson correlation coefcients were examined to
determine the factors affecting the assessment of facial
asymmetry (Table VI). The affecting factors were found
to be lip canting, chin deviation, ramus inclination dif-
ference, body inclination difference, and gonial angle
difference. The Pearson correlation coefcients for lip
canting, chin deviation, ramus inclination difference,
body inclination difference, and goninal angle were
0.33

, 0.59

, 0.21

, 0.48

, and 0.44

, respectively.
Stepwise linear regression analysis was used to
understand the affecting factors better (Table VII).
The analysis showed that chin deviation and gonial
angle difference signicantly affected the assessment
of facial asymmetry. Therefore, 2 regression equations
were made. The following regression equation was
used to include both factors:
Y 5 6:8X
1
1 1:7X
2
127:9
where Y means the assessment of facial asymmetry
(scores), X
1
means chin deviation (degrees), and X
2
means gonial angle difference (degrees). The coef-
cients of these factors were 6.8

and 1.7

for chin devi-

ation and gonial angle difference, respectively, and the
constant was 27.9.
If we include the most powerful independent factor,
we can make a simple equation about chin deviation and
the assement of facial asymmetry (Fig 2).
DISCUSSION
Facial asymmetry was investigated subjectively
in relation to the soft-tissue features by using facial
frontal photographic measurements.
12,13
Naoya
16
reported a subjective evaluation of facial asymmetry
using frontal photographs. In that study, 10 orthodon-
tists classied 100 facial frontal photographs; there
was a correlation between the subjective evaluation of
facial asymmetry and the cephalometric indexes. How-
ever, the author did not report the soft-tissue factors
responsible for the assessment. We examined the rela-
tionship between the assessment of facial asymmetry
and the soft-tissue characteristics using frontal facial
photographs. Nine orthodontists were asked to score
the frontal photographs using a VAS, and the factors
that affect facial asymmetry assessment were estab-
lished. The frontal photographs were classied into 3
groups according to the assessment scores.
Group I contained patients considered almost
symmetric who needed no treatment. Group II included
Fig 1. A drawing used for the subjective evaluation and
the landmarks on the facial soft tissues: 1, Pp (pupil); 2, O

(otobasion inferius); 3, Ch (cheilion); 4, Go (soft-tissue

gonion); 5, Me (soft-tissue menton); 6, G (glabella); 7,
Sn (subnasale); 8, Pr (pronasale); 9, Na (soft-tissue
nasion); 10, Pre (preaureculare).
Table II. Denitions of reference lines constructed in
this study
Reference line Denition
Midsagittal line G-Sn
Horizontal line Perpendicular to midsagittal
line passing through
the midsagittal line
Bipupillary line Right Pp-left Pp
Otobasion inferius line Right O-left O
Lip line Right Ch-left Ch
Gonion line Right Go-left Go
Pronasale line Na-Pr
Chin line Zero point-Me
Ramus line (right and left) Pre-Go (right and left)
Mandibular body line (right and left) Go (right and left)-Me
26 Lee et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2010
patients with moderate asymmetry who did not require
treatment. Group III comprised patients with severe
asymmetry who required treatment.
ANOVA (Table IV) showed that chin deviation,
body inclination difference, gonial angle difference,
and lip canting were signicantly distinct variables be-
tween the groups. The mean values in group III were
3.1

, 3.6

, 7.1

, and 6.1

for lip canting, chin deviation,

body inclination difference, and gonial angle difference,
respectively. These values from experts suggest criteria
for assessing asymmetric patients.
Skeletal analysis with x-rays has been used to diag-
nose facial asymmetry. Generally, orthodontists evalu-
ate facial asymmetry by analyzing the facial skeleton
quantitatively using frontal cephalometry. They estab-
lish a midsagittal reference plane and compare the
difference between the right and left values. Ricketts
et al
19
and Svanholt and Solow
20
evaluated facial asym-
metry by measuring the angles in frontal cephalometry.
Solow
21
and Nakasima and Ichinose
22
measured height
and dimensions. Vig and Hewitt
23
measured areas and
compared both sides. These authors basically used the
skeletal measurements of asymmetric faces.
However, Michaels and Tourne
24
and Yogosawa
25
reported that skeletal deformities can be hidden by
soft tissues such as muscles and skin. Peck et al
26
sug-
gested that many people with skeletal asymmetry have
a symmetric face, and that there are differences between
skeletal and soft-tissue asymmetries. In addition, Hara-
guchi et al
27
reported differences between the degrees of
actual skeletal asymmetry and soft-tissue asymmetry
perceived in Class III patients. They emphasized the
necessity of soft-tissue analysis. It has been suggested
that people considered to be symmetric and harmonious
in a clinical examination have some facial asymmetry,
as shown in radiographic examinations.
7,8,10,23,27,28
Ferrario et al
7,8
and Haraguchi et al
27
suggested that
soft-tissue asymmetry appeared to be less severe than
skeletal symmetry. Lee
29
evaluated facial asymmetry
using facial photographs and frontal cephalometric
Table III. Denitions of angular and linear measurements used in this study
Measurement Denition
Eye canting (

) :Horizontal reference line-bipupillary line

Otobasion canting (

) :Horizontal reference line-otobasion inferius

Lip canting (

) :Horizontal reference line-lip line

Gonion canting (

) :Horizontal reference line-gonion line

Nose deviation (

) :Midsagittal reference line-pronasale line

Chin deviation (

) :Midsagittal reference line-chin line

Ramus inclination difference (

) The difference of right and left :midsagittal reference line-ramus line

Body inclination difference (

) The difference of right and left :midsagittal reference line-mandibular body line
Gonial angle difference (

) The difference of right and left :Pre-Go-Me

Asymmetry index for horizontal Go (%) The ratio of right and left horizontal Go length
Asymmetry index for vertical Go (%) The ratio of right and left vertical Go length
Table IV. Comparisons of measurements among the groups
Group I Group II Group III
P value Mean SD Mean SD Mean SD
Eye canting 1.48 0.93 1.47 1.15 1.55 1.05 NS
Otobasion canting 1.36 0.90 1.61 2.03 1.36 1.19 NS
Lip canting 1.61 1.12 2.29 1.47 3.09 2.31 0.00*
Gonial canting 2.02 1.20 1.96 1.31 2.34 2.08 NS
Nose deviation 1.42 1.23 1.37 1.17 1.73 1.18 NS
Chin deviation 1.11 0.96 2.00 1.38 3.64 2.19 0.00*
Ramus inclination difference 2.55 2.33 3.73 2.93 4.18 3.66 NS
Body inclination difference 2.80 1.90 3.75 2.53 7.11 4.86 0.00*
Gonial angle difference 2.31 2.05 3.05 2.62 6.14 5.95 0.00*
Asymmetry index of H-Go 6.34 4.42 9.20 7.12 8.50 7.79 NS
Asymmetry index of V-Go 5.78 3.53 5.30 3.58 6.68 6.17 NS
According to 1-way ANOVA, H-Go and V-Go indicate horizontal and vertical Go.
*P\.01; NS, not signicant.
American Journal of Orthodontics and Dentofacial Orthopedics Lee et al 27
Volume 138, Number 1
radiographs, and reported less difference in the horizon-
tal and vertical lengths on the soft tissues than on the
hard tissues.
Therefore, we suggest that there is a difference be-
tween the asymmetry perceived in the soft tissues and
the actual skeletal asymmetry in patients with facial
asymmetry. Examining the subjective assessments for
facial asymmetry is an important clinical procedure
for orthodontic diagnosis.
The soft-tissue features can be quantied by mea-
suring frontal facial photographs or 3-dimensional
(3D) CT images. Patients with a chief complaint of fa-
cial asymmetry visit the clinic after seeing their images
in the mirror or photographs of themselves. Further-
more, photographs are easy to take, feasible, cheap,
and useful compared with 3D CT images. Therefore,
a frontal photograph would be an effective tool for diag-
nosing facial asymmetry and making a decision for
treatment.
Few studies have examined the reference plane for
photographs in facial asymmetry analysis. Most studies
on soft-tissue facial asymmetry suggested reference
planes related to the eyes (horizontal) and nose (verti-
cal). Ras et al
30,31
used a horizontal plane passing
through the exocanthi and pupils, and a vertical plane
perpendicular to and bisecting a line connecting the
exocanthi. OGrady and Antonyshyn
32
dened a vertical
midsagittal plane passing through nasion, pronasale,
and labrale superius, and an axial plane connecting
the exocanthi and the bridge of the nose.
Determining a midsagittal reference plane is essen-
tial for diagnosing asymmetry, because all differences
between the right and left sides are measured and com-
pared from the midsagittal plane. Paek et al
33
suggested
the midsagittal reference plane as a line connecting gla-
bella and anterior nasal spine because the differences
between the right and left measurements with this line
were the smallest in normal subjects. Therefore, in
this study, the midsagittal reference plane was dened
as a line connecting soft-tissue nasion and subnasale.
Soft-tissue nasion was chosen because glabella is dif-
cult to identify in frontal photographs, and subnasale is
the counter-landmark of the anterior nasal spine. The
horizontal reference plane was then determined perpen-
dicular to the midsagittal plane, bisecting the bipupil-
lary line. The reason that the vertical reference plane
was set in advance was that the effects of eye canting
could not be evaluated if the horizontal plane was deter-
mined rst by using the eyes. The landmarks dened in
this study described the facial soft tissues with almost
the same weight for all features (eyes, ears, nose, mouth,
gonion). People can mask facial asymmetry by their
posture.
AVAS was used to subjectively assess facial asym-
metry. VAS values provide rapid, convenient, valid,
reproducible, and representative ratings of dental and
facial appearance.
34
For quantication of the subjective
assessments, Faure et al
35
suggested 3 methods for
assessing facial esthetics: plane VAS, ratio scale, and
ranking scale. The plane VAS has no reference or no
ranking; it just scores the subjective evaluation. The ra-
tio scale uses the reference photograph with a score of
60 with the typical procedure for the VAS. The ranking
scale is used to arrange the photographs fromthe least to
the most esthetic.
Phillips et al
36
used the ranking scale. However, it
was less preferable because it allowed for too many
tied scores, which impaired the assumption of continu-
ous data. In addition, the plane VAS tends to lack objec-
tivity and reproducibility. Therefore, among the 3
methods, the ratio scale with a typical VAS procedure
was used, giving the reference photographs scores of
0 and 100 scores.
Johnston et al
37
standardized the raw scores to
z-scores to remove interexaminer variations in scale
while removing any differential effects between panels
and judges. However, Schlosser et al
38
reported no sig-
nicant difference between raw scores and z-scores.
Therefore, the raw scores were used as the data in this
study.
Farkas
39
suggested that the maximum normal asym-
metry would furnish a threshold value for identifying
asymmetric subjects. Obviously, this threshold is
Fig 2. Scattergram of facial asymmetry scores accord-
ing to chin deviation. This simple functional graph
includes only the rst independent variable as chin devi-
ation was drawn according to stepwise linear regression
analysis.
28 Lee et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2010
important, particularly in borderline patients whose fa-
cial asymmetry is not clinically discernible.
40
Ferrario
et al
28
suggested a borderline for normal facial asymme-
try. They examined 314 normal patients, identied land-
marks on their facial soft tissues directly, measured the
distance from central point to the landmark to obtain the
length and percentage differences between the right and
left sides, and dened the asymmetric borderline.
However, they used a 3D method3D computerized
electromagnetic digitizerthat is difcult to use as
a standard. Hence, their borderline is difcult to apply
generally. In this study, we attempted to detect the bor-
derline between normal and abnormal asymmetry as in
previous studies but in a feasible way. The mean values
in the 3 groups were suggested instead of the border-
lines. The values we obtained are signicant and should
be helpful in diagnosing asymmetry because they distin-
guish specic groups. Groups I and II were considered
to have normal asymmetry, and group III had abnormal
asymmetry because of the need for treatment. The need
for treatment reects the perception of facial asymmetry
and could be a clinical guideline for treating facial
asymmetry.
Head tilting might slightly correct a deviated chin.
Kim and Hwang
41
reported that asymmetric patients
tended to tilt their heads to compensate for a deviated
menton. The more asymmetric the patients, the more
they tilted their heads. Those authors suggested that,
in a patients clinical examination, some tilting of the
eyes can create doubt as to whether the patient has
asymmetry. Therefore, it was hypothesized that eye
canting might be an affecting factor of facial asymmetry
and is clinically meaningful. However, eye canting was
not a signicant factor affecting the assessment of facial
asymmetry (Tables VI and VII). In addition, nose
deviation and otobasion canting were not signicant
factors.
The Bonferroni post-hoc analysis (Table V) showed
that only chin deviation was different between the
groups. We suggest that chin deviation is the most inu-
encing factor in assessing facial asymmetry. The differ-
ence in body inclination and gonial angle showed some
dissimilarity between groups I and III, and between
groups II and III. There were differences lip canting be-
tween groups I and III. Chin deviation, body inclination
difference, gonial angle difference, and lip canting are
all associated with asymmetry of the mandible in the
lower third of a face. Asymmetry of the lower third of
the face, the mandibular area, tends to be perceived
more than asymmetry in the upper or middle third of
the face. Lip canting was reported to be associated
with mandibular asymmetry as well as maxillary height
differences and occlusal plane canting.
42
At the resting
position, lip canting (deviated labial comissure or
alar base) on 1 side often indicates vertical skeletal
asymmetry.
43
The Pearson correlation coefcient and stepwise
linear regression analysis were used to examine the fac-
tors affecting the assessment of facial asymmetry
(Tables VI and VII). The factors signicantly related
to facial asymmetry in descending order according to
the Pearson correlation coefcients were chin
deviation, body inclination difference, gonial angle
difference, lip canting, and ramus inclination difference.
Regression analysis showed that chin deviation and
gonial angle difference are factors signicantly affect-
ing facial asymmetry (Table VII). The body inclination
difference was excluded after stepwise linear regression
analysis because it was closely related to chin deviation.
Table V. Differences in photometric measurements
among the groups
Group I vs
group II
Group I vs
group III
Group II vs
group III
Eye canting
Otobasion canting
Lip canting *
Gonial anting
Nose deviation
Chin deviation *

Ramus inclination difference
Body inclination difference

Gonial angle difference *

Asymmetry index of H-Go
Asymmetry index of V-Go
According to 1-way ANOVA, H-Go and V-Go indicate horizontal and
vertical Go.
Bonferroni post-hoc analysis: *P\0.05;

P\0.001.
Table VI. Correlation coefcients between the assess-
ment of facial asymmety and photographic measure-
ments
Measurement r P value
Eye canting 0.09 NS
Otobasion canting 0.07 NS
Lip canting 0.33 0.00

Gonial canting 0.05 NS

Nose deviation 0.05 NS
Chin deviation 0.59 0.00

Ramus inclination difference 0.21 0.02*

Body inclination difference 0.48 0.00

Gonial angle difference 0.44 0.00

Asymmetry index of H-Go 0.14 NS

Asymmetry index of V-Go 0.02 NS
NS, not signicant. *P\0.05;

P\0.001.
American Journal of Orthodontics and Dentofacial Orthopedics Lee et al 29
Volume 138, Number 1
Asymmetric indexes of Go and linear measurements
were not signicantly affecting factors. Only the angu-
lar measurements affected the assessment of facial
asymmetry. With all these signicant affecting factors,
mandibular factors were overwhelming in surveying
facial asymmetry. This nding has been suggested in
several studies.
8,26,39
Lee et al
44
and Ahn and Hwang
2
reported that the
mandibular chin point deviation has the most effect
on facial asymmetry assessment. Severt and Proft
45
found that most differences were in the lower third of
the lateral facial surface. In the normal population,
the lowest mean frequency of asymmetry was observed
in the orbital region (\2%), followed by the nose (7%)
and mouth (approximately 12%).
39
In addition, Severt
and Proft
45
reported the frequencies of facial asymme-
try in the facial portions: 5%, 36%, and 74% in the up-
per, middle, and lower thirds of the face, respectively.
Therefore, they concluded that most asymmetry
occurred in the mandible. Vig and Herwitt,
23
Shah
and Joshi,
10
Grayson et al,
46
and Peck et al
26
suggested
that craniofacial asymmetry becomes more severe from
the deep portion to the supercial portion by the refer-
ence plane as the sagittal plane, such as from the
cranium to the mandible. Many studies reported that,
overall, gonion and tragion were the most asymmetric
landmarks, and endocanthion was the most symmetric
landmark. These results are consistent with previous
studies.
In our study, the observers were experts. Therefore,
the results should be helpful in diagnosis and treatment
planning. However, nonexperts opinions and patients
perceptions are important because the decision about
treatment for asymmetry is up to each patient.
Therefore, nonexperts assessments of facial asym-
metry are worthwhile. Bonnie
43
suggested that the
differences in the detection of occlusal canting in
a clinical examination depend on the degree of canting
and not necessarily on the level of expertise of the ob-
servers. Therefore, the experts assessments of facial
asymmetry might be similar to those of nonexperts.
However, since their study was restricted to lip canting,
further studies on the difference in the assessment of
facial asymmetry on the overall facial aspects between
experts and nonexperts are needed.
CONCLUSIONS
We examined the soft-tissue characteristics of
asymmetric patients assessed by orthodontists to deter-
mine the soft-tissue factors affecting the recognition of
facial asymmetry. In the view of experts, chin deviation,
body inclination difference, gonial angle difference, and
lip canting had signicant differences in the 3 groups
according to the assessment of facial asymmetry. In
group III, containing patients with severe asymmetry re-
quiring treatment, the mean values were 3.1

, 3.6

, 7.1

,
and 6.1

for lip canting, chin deviation, body inclination

difference, and gonial angle difference, respectively.
Chin deviation and gonial angle difference affected
the assessment of facial asymmetry. Overall, we believe
that these results will help clinicians make differential
diagnoses and treatment plans for patients with facial
asymmetry.
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