80
Chapter
Mandibular Asymmetry: Diagnosis and
Treatment Considerations
Brian B. Farrell, Myron R. Tucker
F acial asymmetry is a typical finding in the majority of individ
uals. When present, it is most often located in the lower third
of the face.1 Consequently, correction of dentofacial deformities
frequently involves the management of asymmetry. This is impor
tant to note when planning for orthognathic surgery in that patients
are able to appreciate correction of their asymmetry more so than
the change in profile achieved with surgery. When evaluating man
dibular asymmetry, deviation of the chin is more easily recognized
than a discrepancy involving the angles of the mandible. Therefore,
surgical correction may involve only genioplasty to correct chin
position, with maintenance of asymmetry of the mandibular angles
being acceptable.
Long-standing skeletal asymmetry can lead to dental compensa
tion and soft tissue changes. Some degree of abnormality in each
dimension will occur as a result of warping, bending, or distortion
of both the hard and soft tissues. A three-dimensional (3D) perspec
tive is required when evaluating facial asymmetry. The terms roll,
pitch, and yaw have been used to describe rotation of the dental
arches in patients with asymmetry. Roll is frontal cant of the occlusal
plane, whereas pitch is the angle of occlusion in a sagittal dimension
and yaw is rotation of the arch of the maxilla and mandible to the
cranial base. The midlines may be on the central axis, but excessive
yaw creates increased fullness on one side of the face with the con
verse appearing flat. The shift in arch form creates full tooth show
to the commissure and a void in the opposite buccal corridor.
Earlier surgical intervention may be aimed at correcting the cause
of the asymmetry to prevent continued exacerbation of the defor
mity. A stable asymmetric deformity allows definitive management
of the malocclusion with conventional osteotomies. Although subtle
asymmetries may be corrected by routine orthodontic preparation
and orthognathic surgery, complex asymmetries involve detailed
treatment planning, increased orthodontic effort, and more extensive
surgery to achieve satisfactory functional and esthetic results.
MANDIBULAR ASYMMETRY
DEFICIENCIES
Deviation of the mandible can result from either deficiency or
excess. In the case of mandibular deficiency, the mandible will
deviate to the affected side secondary to decreased growth, degen
erative changes, or trauma. Decreased growth often occurs as a
result of a congenital or developmental anomaly. Hemifacial micro
somia and Parry-Romberg syndrome are two such examples that are
characterized by decreased hard and soft tissue growth resulting in
asymmetry.
Acquired anomalies such as osteoarthritis and progressive rheu
matoid arthritis may cause degeneration of the condyle and result in
collapse of mandibular length through resorption of the condyle.
Such remodeling creates loss of height with decreased projection of
the remaining mandible. The loss of vertical dimension typically
results in an open bite on the contralateral side as the dentition
fulcrums on the affected side.
Trauma to the mandibular condyle is an acquired defect to con
sider when evaluating facial asymmetry. Fractures involving the
condyle and neck can decrease ramus height and create deviation of
the mandible. Return of sound functioning following injury to the
condyle is the most important principle in acute management,
whether it be by open or closed reduction. Failure to establish range
of motion can lead to progressive degenerative changes or restricted
growth in an immature individual since translation of the condyle is
responsible for growth in the mandible.2 Limited movement of the
condyle within the fossa will result in restricted growth and lead to
progressive asymmetry of the mandible.3
EXCESSIVE GROWTH
Mandibular asymmetry may also result from excess growth.
Increased unilateral growth often causes deviation of the skeletal
and dental midline away from the affected side. Unilateral pro
gnathism results in deviation in a horizontal vector. This simple
excessive growth creates a class III malocclusion of the canine
and molar on the affected side. Unilateral condylar hyperplasia is
classified as either hemimandibular elongation or hemimandibular
hyperplasia.4,5
Hemimandibular Elongation
Hemimandibular elongation is associated with lengthening of the
condyle and ramus. The affected side of the mandible is longer than
the normal side but is not associated with prognathism. The progres
sive changes produced by overgrowth of the condyle result in devia
tion of the chin. Enlargement of the condyle is not evident, and
despite the elongation, the height of the face on the affected and
unaffected sides is similar. Minimal distortion of the remaining
mandible and overlying soft tissue occurs with hemimandibular
elongation. A midline discrepancy is evident secondary to the exces
sive unilateral growth, and a crossbite relationship can develop on
the contralateral side as the mandible deviates laterally. Subtle com
pensation of the arches can occur with the elongation, although the
arch forms are generally well aligned.
The radiographic findings accompanying hemimandibular elon
gation can be subtle. The panoramic radiograph may illustrate dental
and skeletal deviation with respect to the midline structures of the
maxilla (nasal crest and septum). Elongation of the condyle and
ramus may be identified in pronounced cases. Lateral cephalometric
films will demonstrate superimposition of the dentition and inferior
borders of the lower jaw as the elongation is expressed horizontally.
The posteroanterior (PA) cephalometric image is the most diagnostic
plain film for identification of hemimandibular elongation. The
671
672 Current Therapy in Oral and Maxillofacial Surgery
A
B
Fig. 80-1 n Asymmetry associated with hemimandibular hyperplasia.
The increased vertical growth creates disparity at the inferior borders
of the mandible. The skewed appearance is exacerbated by the
decreased facial height on the unaffected side.
image provides skeletal assessment of the asymmetry since chin
deviation, midline shift, and contrasting length of the mandibular
rami are visualized.
Hemimandibular Hyperplasia
Hemimandibular hyperplasia is enlargement of one side of the man
dible involving the condyle, neck, ramus, and body. A pronounced
vertical discrepancy of the mandible is evident clinically as the
increased growth creates downward bowing. The opposite half of
the mandible is affected by the unilateral hyperplasia as the inferior
border is rotated laterally and upward. The result is a distorted facial
appearance created by increased length on the affected side with
decreased height on the normal side (Fig. 80-1). The skeletal asym
metry results in soft tissue distortion, with an oblique appearance
created by the commissure of the lip similarly being displaced
inferiorly.
The dentition is affected by the increased vertical growth of the
mandible. An accentuated curve of Spee develops on the ipsilateral
side as downward growth of the mandible drags the teeth inferiorly
(Fig. 80-2). The rapid vertical development typically creates an open
bite because compensatory maxillary growth cannot keep pace.
Development of the hyperplasia before puberty may allow the devel
opment of a canted occlusal plane if not controlled with a functional
hybrid appliance. Hemimandibular hyperplasia is typically identi
fied following the adolescent growth spurt as a result of continued
A
B
Fig. 80-2 n Occlusal influence of hemimandibular hyperplasia. The
increased vertical growth creates displacement of the mandibular
dentition and results in an open bite and accentuated curve of Spee.
Fig. 80-3 n Panorex film illustrating unilateral enlargement of the man-
dible involving the condyle, ramus, and body associated with hemi-
mandibular hyperplasia. The downward bowing of the inferior border
is a result of the increased vertical growth. The compensatory changes
in occlusion are noted with an accentuated curve of Spee in the man-
dibular arch. Supra-eruption of the maxillary dentition is not evident.
growth of the affected mandible after growth on the opposite side
has ceased.
Unilateral enlargement of the body, ramus, and condyle is seen
radiographically on a panoramic film (Fig. 80-3). A dramatic increase
in bone volume is noted with hemimandibular hyperplasia. The
appearance of the inferior border of the mandible is characteristic,
with the affected side illustrating the downward bowing and the
opposite side possessing a straighter slope running from the angle
to the symphysis. The rounded angle is accentuated as the broad
curvature extends from the ramus to the body. The body of the
mandible opposite the hyperplasia possesses a flattened and thinned
shape, as though it is being stretched by the overgrowth. The con
trast between the enlarged, thickened, rounded hyperplastic half and
 Mandibular Asymmetry: Diagnosis and Treatment Considerations
Fig. 80-4 n Lateral cephalometric film illustrating the lack of superim-
position of the dentition and inferior border of the mandible. The verti-
cal discrepancy between the right and left sides creates the appearance
of multiple rows of teeth and distinct inferior borders. A radiographic
artifact based on head positioning can create the appearance of
asymmetry.
the shortened, thinned, straight side exacerbates the warped contrast
of the asymmetry.
A lateral cephalometric film will illustrate failure of the dentition
and inferior borders of the mandible to superimpose as a single
entity as a result of the vertical disparity (Fig. 80-4). The increased
vertical growth evident skeletally is typically greater than that
appreciated in the occlusion. This information is valuable in
guiding surgical treatment in that management of the occlusion by
traditional mandibular ramus surgery will require additional correc
tion via inferior border recontouring or augmentation efforts on the
opposite side.
DIAGNOSIS
The examination should detail the dentofacial deformity and the
influence of asymmetry on the skeleton, dentition, and soft tissue.
The changes directly associated with the asymmetry should be
noted, in addition to effects that are the result of skeletal and dental
compensation.
Imaging plays a valuable role in assessing skeletal asymmetry.
Plain films, including a Panorex, lateral cephalogram, PA cephalo
gram, and submental vertex image, aid in characterizing the ana
tomic changes associated with the asymmetry and are valuable
resources for planning treatment. Severe asymmetries may warrant
additional imaging studies, including computed tomography (CT)
and 3D reconstructions. The detailed imaging improves visualiza
tion of the condyle, where the source of the asymmetry typically
arises.
Panoramic radiographs provide an opportunity to evaluate the
condylar architecture and discrepancies within the ramus or body of
the mandible. One must be aware, however, that distortion of the
image may occur as a result of inappropriate positioning in the
radiographic unit and create the impression of an enlarged mandible.
Staff experience in obtaining routine panoramic films makes the
likelihood of an artifact slim. An imaging artifact can be excluded
if the size of the mandibular molars is comparable on the affected
and unaffected sides.
673
Fig. 80-5 n Posteroanterior cephalometric film demonstrating exces-
sive vertical growth of the mandible as a result of hemimandibular
hyperplasia. Lateral flaring of the mandible opposite the overgrowth
results in decreased lower facial height, which accentuates the asym-
metry and discrepancy within the face. The open-bite malocclusion is
caused by downward growth of the mandible.
The lateral cephalometric film is a mainstay in preparing for
orthognathic surgery. Simple unilateral prognathism or hemiman
dibular elongation isolated to a horizontal plane is not readily identi
fied on the lateral image, however. Vertical asymmetries are depicted
as superimposition of distinct inferior borders and an occlusal plane
discrepancy with multiple rows of teeth. The difference in the infe
rior borders is often greater than that noted in the occlusal plane,
thus indicating the potential need for recontouring of the inferior
border in addition to ramus surgery to correct the occlusion. Caution
is also necessary to avoid radiographic artifact with the lateral ceph
alometric image. Clinicians should be mindful that individuals may
have ear canals at varying heights creating the misperception of
asymmetry. Finally, periodic interpretation of lateral cephalographic
tracings will also aid in determining the timing of surgical inter
vention, whether it be related to documenting skeletal maturity or
progressive change.
The PA cephalometric film will generally highlight the skeletal
discrepancy in both its horizontal and vertical dimensions (Fig.
80-5). The positioning of the mandibular dental midline against the
opposing arch and the central skeletal axis of the mandible will be
illustrated. Corresponding dental and skeletal midline asymmetry
may allow surgical correction to be isolated to ramus osteotomies.
The addition of an anterior segmental osteotomy of the inferior
border to further correct chin positioning may be warranted if the
imaging illustrates greater skeletal deviation than noted dentally.
The PA cephalometric film allows interpretation of any dental com
pensation attributed to the asymmetry in the transverse plane, similar
to incisor angulation on a lateral cephalometric image. The trans
verse orientation of the teeth as a result of natural and orthodontic
efforts can be appreciated as the dentition attempts to keep up with
the skeletal skewing.
The submental vertex image helps identify anatomic characteri
stics associated with the asymmetry. The bowing and warping of the
mandible as a result of asymmetric growth can be visualized for both
674 Current Therapy in Oral and Maxillofacial Surgery
Fig. 80-6 n Submental vertex film illustrating the disparity of the man-
dible as a result of an asymmetric deformity. The divergent nature of
the right ramus favors setback via a vertical ramus osteotomy, whereas
the left is best managed with a sagittal ramus osteotomy.
diagnostic and treatment considerations. The submental vertex film
(Fig. 80-6) aids in selection of osteotomy design for mandibular
setback based on the shape of the ramus. A U-shaped mandible is
best suited for a sagittal osteotomy, whereas a vertical ramus osteo
tomy is recommended with a divergent V-shaped ramus. A divergent
ramus allows passive positioning of the condylar segment lateral to
the mandible on a setback. Performance of sagittal osteotomy on a
flared V-shaped mandible will create segment interference and
lateral displacement of the proximal segments following mandibular
repositioning.
CT provides extensive information on dentofacial deformities.
The images provided in a CT scan help augment information gath
ered through examination and plain films. The ability to view an
asymmetry in multiple dimensions helps in understanding the ana
tomic distortion that has occurred. The capacity to distinguish altera
tions in the architecture of the ramus and body of the mandible on
both the affected and unaffected sides aids in identifying possible
challenges that may exist intraoperatively. The improved visualiza
tion of the condyle helps one understand the cause of the mandibular
asymmetry, such as excessive growth or condylar remodeling. In
addition, imaging may reveal previously unidentified injuries to the
condyle not readily discernible on plain films.
Reconstructed CT images provide perspective on the deformity
and the influence that the asymmetry has on the skeletal and dental
elements. 3D reconstructed images can illustrate the anatomic
changes on the affected side and associated compensation (Fig.
80-7). The visual representation provides an opportunity to demon
strate the deformity to the patient, as well as the necessary move
ments required to produce symmetry. Continuing advancements in
radiology and CT afford the opportunity to develop treatment pre
dictions and create templates for surgical guidance.
Stereolithographic models may be obtained from the recon
structed images to gain additional insight into the deformity. The
model allows a reference for calculating the movements necessary
to achieve symmetry. The decision to perform additional surgery
consisting of resection or augmentation of the inferior border in the
body or angle may be guided by the anatomic reproduction. The
stereolithographic model can also be used for model surgery to assist
Fig. 80-7 n Three-dimensional reconstructed computed tomography
scan of a patient with facial asymmetry. The distortion of the mandible
is more clearly defined than on plain films. The detailed imaging aids
in understanding the extent of the asymmetry in multiple dimensions
and serves as a guide for treatment planning. Thinning of the left ramus
mediolaterally will require modification of the sagittal ramus osteotomy
during correction of the deformity. (From Hupp JR, Ellis E, Tucker MR:
Contemporary oral and maxillofacial surgery, ed 5, St. Louis, 2008,
Mosby.)
in planning the need for additional skeletal correction of any bony
asymmetry that may persist after addressing the malocclusion.
Diagnostic stone models of the dentition record the skeletal mal
occlusion that exists as a result of asymmetric mandibular growth.
The variation in arch form and compensation within both the man
dibular and maxillary arches can be assessed. Horizontal asymmetry
of the mandible will result in lingual tipping of the dentition as the
bone deviates laterally from the central axis. The maxillary arch will
flare laterally to compensate for the skeletal change in the mandible.
Progress models provide an indication of the orthodontic decompen
sation, as well as arch compatibility for correction of the malocclu
sion. Mounted diagnostic models are valuable when attempting to
determine the status of the asymmetry. Progression of the asym
metry can be plotted through records of the occlusion. Persistent
changes in the occlusion over an interval (12 to 18 months) indicate
continued progression of the asymmetry, and surgery should be
delayed until stability can be confirmed. An occlusal record with
minimal change in an individual who has achieved skeletal maturity
is probably an indication that surgical treatment may proceed.
Imaging to evaluate progression of the asymmetry is accom
plished through a nuclear medicine bone scan. A technetium-99m
bone scan is frequently used to determine metabolic activity in the
condyles (Fig. 80-8). The bone scan is sensitive to increased activity
but is not specific for degeneration or excessive growth. The imaging
study serves as a guide for determining the status of the asymmetry
for planning treatment.6 Increased uptake of the labeled marker on
the affected side indicates activity and probably continued progres
sion of the asymmetry. The presence of increased uptake may
warrant delaying surgical correction until stability of the asymmetry
can be documented. Activity on the scan with persistent worsening
of the deformity may indicate that earlier surgical efforts are neces
sary to address the source of the excessive growth at the head of the
condyle or to stabilize a degenerative process.
 Mandibular Asymmetry: Diagnosis and Treatment Considerations
16 17
TMJ
20 21
Fig. 80-8 n Technetium-99m bone scan. A nuclear medicine bone
scan evaluates metabolic activity in the condyles. The bone scan is
sensitive to increased activity and serves as a guide for determining the
stability of the asymmetry.
TREATMENT
SURGICAL PLANNING
Determination of stability is the initial step in managing an asym
metric dentofacial deformity. The presence of a deformity requires
a thorough history to help establish the nature and progression of
the asymmetry. The opportunity to label the asymmetry as stable or
progressive based on the interview is an early indicator of the timing
of treatment. Acute changes will probably require more diagnostic
effort than will deviation that has been like this for years. The
information gathered through examination and imaging creates an
initial reference to which additional studies may be compared. The
decision to delay or initiate surgery is derived from recall examina
tions and repeated imaging illustrating either pronounced or minimal
change, respectively. Surgery is best delayed until progression of the
asymmetry has ceased and stability has been documented through
periodic monitoring. Stability is typically established by document
ing the absence of change in the dentition and bone over an extended
time. A period ranging from 6 months to several years may be war
ranted to monitor for continued change based on the history of the
deformity.
Delaying the initiation of comprehensive orthodontic treatment
should be considered until progression of the deformity has ceased,
although early interceptive orthodontics may be necessary to prevent
compensatory changes in the dentition. Functional appliances are
used to limit the extent of the asymmetry, encourage growth, and
prevent compensatory changes in the maxilla. Orthodontic efforts to
control compensation in the maxilla may allow surgical intervention
to be isolated to the mandible. A presurgical orthodontic phase
focused on alignment and coordination of arch form provides addi
tional time for monitoring the stability of the asymmetry.
Conventional ramus surgery performed during progressive
changes within the condyle will probably result in a compromised
outcome. Any symmetry obtained following correction of the defor
mity will be influenced by continued growth or degeneration.
Relapse of the advanced osteotomy may occur with persistent
675
loss of vertical ramus height in patients with active condylar degen
eration. Degenerative changes within the condyle should be stabi
lized by conservative efforts to limit the remodeling before surgery
to correct the malocclusion. Continued lengthening at the head of
the condyle in cases of excessive growth will result in return of the
deformity.
The dynamic changes creating the asymmetry may warrant either
a wait it out approach with continued monitoring or early surgical
intervention focused on the underlying cause. In patients requiring
the latter, intracapsular surgery may be necessary to correct asym
metries that stem from deficient or excessive growth. Deviation of
the mandible from deficient growth is the result of restricted transla
tion of the condyle. Addressing the functional ankylosis through
intra-articular surgery is the goal of early intervention in a growing
individual to improve the chance for favorable growth and limit the
severity of the resultant deformity.2 Following surgery, functional
appliances are then implemented to aid in modifying growth by
repositioning of the mandible once range of motion has returned.
In a growing patient, recontouring of the condyle or condylec
tomy with reconstruction via a costochondral graft may be required
to return range of motion and improve the chance for more favorable
growth. In contrast, reconstruction with a total joint prosthesis may
be a treatment option in a skeletally mature patient for elimination
of joint pathology and establishment of symmetry.
Condylar surgery may be necessary even when the deformity is
not progressive. An enlarged condyle may restrict translation, com
promise growth, and further exacerbate the asymmetry.
Intervention on the condyle may be required to prevent continued
excessive proliferation of an asymmetry that stems from overgrowth.
In this situation, partial condylectomy should be considered. This
procedure involves eliminating the growth center of the mandible
by removing the head of the condyle (approximately 5mm). Once
the condyle has been reduced, mandibular growth should cease,
thereby creating a static situation in which one can plan correction
of the residual asymmetry.
Traditional model surgery can be used to transfer the workup to
the operating room for correction of an asymmetric skeletal malo
cclusion. The absence of compensation within the maxillary arch
will allow a template for repositioning the asymmetric mandible in
isolated lower jaw surgery. A semi-adjustable articulator can be used
to plan surgical movements involving the maxilla and mandible for
correction of multidimensional deformities. A model table is used
to calculate measurements completed after diagnostic mounting and
repositioning of the models to quantify both the existing deformity
and movements required to achieve correction of the malocclusion.
Fabrication of an intermediate splint transfers the desired skeletal
movements intraoperatively to create a symmetric reference. Surgery
in the opposite arch addresses the residual asymmetry and finalizes
the occlusion as it is repositioned to the stabilized symmetrical refer
ence established with the initial osteotomy. An error that occurs
within the process of conventional model surgery (inaccurate face
bow or bite registration, improper mounting, inadequate references,
inexact movements) may result in failure to correct the asymmetry.
Surgery may be completed without difficulty but the result may be
compromised even prior to entering the operating room as the antici
pated plan is skewed based on improper surgical workup.
Advances in imaging technology and three-dimensional analyses
have improved the precision in surgical correction of complex
dentofacial deformities (Fig. 80-9). Reconstructed images used ini
tially to enhance the appreciation of the multidimensional nature of
deformities can be applied to the surgical workup. Laser scanning
of diagnostic models enhances the occlusal anatomy currently
limited with present CT scan modalities. The fine details of
676 Current Therapy in Oral and Maxillofacial Surgery

C
D
Fig. 80-9 n Three-dimensional imaging and virtual planning. A, Imaging will allow an improved
perspective on the multidimensional nature of an asymmetric dentofacial deformity to aid in diag-
nosis and planning of surgical correction. The detail of the occlusal anatomy is input into the CT
scan with laser scanning of the dental casts to accurately depict the malocclusion. B, Skeletal
cephalometric analysis to skeletal references will quantify the deformity and assist in planning the
necessary movements required to correct the asymmetry. C and D, Computer-simulated osteoto-
mies (right, through a sagittal ramus osteotomy and left an inverted L) establish the final occlusion
and symmetry. Virtual planning will illustrate potential interferences with anticipated segment
positioning and limited bone contact at the osteotomy site that will require grafting. Three dimen-
sional planning will depict that additional measures (anterior segmental osteotomy of the inferior
border) are required to establish skeletal symmetry not obtained through conventional ramus
osteotomies. (Courtesy of Dr. R. Bryan Bell.)

the occlusion are input into the 3D data to generate a computer
rendering of the skeletal deformity and malocclusion. Imaging soft
ware permits virtual osteotomies to be created that can be manipu
lated and repositioned according to the anticipated surgical plan. The
intended movement of the mandible or maxilla respectively can be
inspected in all planes (e.g., cant, yaw, etc.) to gauge symmetry and
to skeletal reference points and modified accordingly. The simula
tion may provide valuable anatomic information that can aid in
surgical preparation through an improved understanding of the
movements required to address the deformity and subsequently
applied intraoperatively. The virtual osteotomy may illustrate an
interference with repositioning of segments, a gap at an osteotomy
site that may necessitate bone grafting, or persistent skeletal asym
metry that will require additional efforts despite correction of the
malocclusion.
Transfer of the virtual plan established through computer simula
tion to the operating room is possible through fabrication of a milled
occlusal splint. The CAD CAM wafer is prepared to the occlusal
 Mandibular Asymmetry: Diagnosis and Treatment Considerations 677

Fig. 80-10 n Correction of the deformity associated with hemimandibular hyperplasia. Leveling of
the occlusal plane and management of the skeletal asymmetry require extensive surgery on the
maxilla and mandible. Differential repositioning of the maxilla, unequal movement in the ramus
osteotomies, resection of the inferior border, and asymmetric wedge resection of the chin are
necessary to create symmetry. The movements needed for correction of the asymmetry are deter-
mined through imaging studies and three-dimensional model surgery. (From Hupp JR, Ellis E,
Tucker MR: Contemporary oral and maxillofacial surgery, ed 5, St. Louis, 2008, Mosby.)

relationship that has been created through computer simulation of
the virtually repositioned jaw against the unaltered arch. The splint
is processed and delivered to the surgeon bypassing the typical labo
ratory steps required with traditional model surgery. The final splint
used to set the occlusion after mobilizing the second osteotomy,
whether on the maxilla or mandible, can be milled from the com
pleted virtual plan or traditional model surgery on diagnostic casts.
The execution of the planned surgery through computer simula
tion will translate to a surgeon possessing a greater understanding
of the deformity, knowledge of the skeletal movements necessary to
correct the asymmetry, and confidence in the outcome delivering
satisfactory results. Virtual planning with computer simulation will
continue to evolve and can improve the accuracy of surgical treat
ment for complex dentofacial asymmetry.
SURGICAL CORRECTION OF ASYMMETRIES
Correction of the malocclusion that results from mandibular asym
metry is accomplished through conventional osteotomies. Isolation
of the deformity to the mandible establishes the maxilla as the refer
ence for repositioning. Sound orthodontic preparation is vital to
create arch form and alignment in the maxilla and mandible, respec
tively. Positioning the teeth ideally within the arches will unmask
the skeletal discrepancy and make the malocclusion more pro
nounced. Completing decompensation to the fullest extent provides
the opportunity to maximize the surgical movement for correction
of the underlying asymmetry. Persistence of the asymmetry after
correction of the malocclusion can result from a skeletal discrepancy
more extensive than that seen in the dentition. Severe deformities
may require additional recontouring or osteotomies to correct asym
metry that is not completely resolved with surgical intervention for
the occlusion (Fig. 80-10).
The versatility of sagittal ramus osteotomy for correction of
mandibular deficiency or excess enables the technique to be the
primary procedure for the management of mandibular asymmetry.
The osteotomy can be used for correction of asymmetries ranging
from mild to severe. It can also be used when the asymmetry will
require unequal movements at the osteotomy sites. Deviation of the
mandible resulting from deficiency will require greater advancement
on the affected side to provide skeletal symmetry and approximation
of the dental midlines. Surgery aimed at correction of mandibular
hyperplasia with asymmetry may ultimately result in a net advance
ment on the unaffected side as the excessive side is reduced and the
symphysis is rotated toward the central axis of the face.
Distorted anatomy of the mandible may increase the complexity
of the osteotomy. Thinning of the ramus mediolaterally with warping
of the body and severe asymmetry may prevent performance of
a traditional osteotomy. The initial superior cut on the lingual aspect
of the mandible requires greater vertical or downward orientation
than does a typical oblique tangential cut into the retrolingual
depression (Fig. 80-11). Frequently, however, the most technique-
sensitive aspect of the osteotomy involves the inferior border cut.
The displaced inferior border requires more soft tissue reflection
to allow better visualization and access. The inferior border may
be rolled under in cases of elongation, thereby increasing the
difficulty of ensuring a proper cut through the inferior border.
This is an important point because the incidence of unfavorable
fractures increases without a sound osteotomy through the inferior
border.
The skeletal variation found in patients with mandibular asym
metry may also alter the position of the inferior alveolar nerve as it
courses through the mandibular canal. Elongation and thinning of
the mandible can position the canal closer to the superior border of
the ramus and posterior body and make the nerve susceptible to
injury from traditional placement of the saw or burr. This is espe
cially evident during the inferior border cut since extra effort is
required to ensure a sound split.
Once the asymmetric mandible is split, alignment and fixation of
the osteotomies will be more complex than that of traditional orthog
nathic surgery. Alignment of the inferior borders during reorienta
tion of the segments remains the focus to ensure stability of the
678 Current Therapy in Oral and Maxillofacial Surgery
A The proximal segment can be rotated subtly, but a vertical ramus
B however, to avoid recontouring through the cortex because remodel
Fig. 80-11 n The altered anatomy created by the asymmetry requires
modification of the traditional ramus osteotomy. Because of the thin
nature of the ramus, the osteotomy must be performed superiorly into
the shallow retrolingular depression through to the body of the man-
dible to take a more vertical orientation. The osteotomy through the
inferior border can also become more complex as a result of the asym-
metric growth.
correction. Movement in multiple directions occurs because the
segments can have different rotational and vertical changes. Rotation
of the asymmetric deformity can result in lateral flaring of the distal
segment. The vertical changes can also create a superior border
discrepancy, similar to that noted on mandibular setbacks managed
with sagittal ramus surgery. Reduction of the superior border may
be necessary to aid in visualization during fixation. This reduction
will also help avoid periodontal issues distal to the last molar.
Additional technical considerations may be required to orient the
proximal and distal segments. Recontouring of the segments may
be necessary to ensure passive positioning of the proximal segment.
Failure to relieve any bony interference may displace or torque the
condyle within the fossa and potentially lead to pain and dysfunction
postoperatively.7 Reduction of interference should be completed on
the proximal and laterally displaced distal segment to eliminate
flaring of the condylar segment. Failure to eliminate interference
will cause lateral displacement of the condyle once bicortical screws
are placed within the body of the mandible (Fig. 80-12). In addition,
the condyle can be displaced medially if compression of the proxi
mal segment occurs after repositioning (Fig. 80-13).
The decision to perform sagittal ramus surgery versus transoral
vertical ramus osteotomy for correction of mandibular hyperplasia
with asymmetry is based on presurgical predictions, review of
imaging, and intraoperative considerations. A vertical ramus osteo
tomy may be the method of choice for correction of the asymmetry
based on the extent of setback required and the underlying anatomy
of the mandible.8 The vertical osteotomy may be performed through
a transoral or an extraoral submandibular approach. The presence of
a divergent V-shaped ramus is best managed with a vertical ramus
procedure (Fig. 80-14). The flared anatomy allows the proximal
condylar segment to rest passively lateral to the repositioned distal
segment. Ensuring sound overlap of the proximal and distal seg
ments is vital to achieving stability and fixation at the osteotomy.
osteotomy is not feasible if the setback is minimal. Passive reposi
tioning of the segments is necessary to prevent displacement of the
condyle. Any interference between the segments is managed with a
recontouring burr to reduce the bony irregularities on both surfaces
(lingual to the proximal segment and facial to the distal segment)
simultaneously. Rigid fixation can be applied through percutaneous
access after gentle seating of the condyle.
Skeletal asymmetry may persist after orthognathic surgery aimed
at correcting a malocclusion. Deviation of the chin is often a concern
for patients and may persist after sagittal or vertical ramus osteo
tomy. Increased awareness of the deformity in the frontal plane war
rants additional surgical effort to ensure that the results are esthetically
acceptable. As mentioned, correction of dental asymmetry through
midline approximation may not overcome the underlying skeletal
discrepancy. Additional correction via genioplasty may be required
to achieve skeletal symmetry of the chin. Imaging studies help estab
lish a surgical treatment plan for reorienting the chin. Subtle overpro
jection or irregularities may be reduced by recontouring with rotary
instruments or reciprocating rasps. One should exercise caution,
ing of medullary bone may be unpredictable and the overlying soft
tissue drape may become uneven. For chin asymmetries in which
recontouring will not suffice, genioplasty provides the opportunity to
correct residual asymmetry in multiple planes. The sliding osteo
tomy can be repositioned inferiorly under the mandible to establish
symmetry not achieved with conventional ramus surgery. Correction
of a vertical discrepancy may require an asymmetric wedge resection
to level the anterior mandible. Liberal soft tissue dissection to expose
the anterior mandible is performed within the boundaries of the
mental foramen. Reflection posterior to the mental nerve is important
to avoid the creation of a short osteotomy. Scoring of the cortex is
done before performing the osteotomy to establish a reference for
anticipated movements. The bony symmetry can be evaluated fol
lowing stabilization by visual inspection and palpation over the
wings of the osteotomy. The soft tissue can be returned over the
bony reorientation to gauge the expected form and contours.
Resection of the inferior border is necessary to correct the down
ward displacement of the mandible evident in hemimandibular
hyperplasia (Fig. 80-15). Generous soft tissue reflection is necessary
to help in visualization of the skeletal deformity. Exposure of the
bone allows intraoperative comparison of the affected and unaf
fected sides referenced to the treatment plan established through the
preoperative evaluation. It is very infrequent that an asymmetry is
overcorrected. Resection of the inferior border is best managed in
 Mandibular Asymmetry: Diagnosis and Treatment Considerations 679

A B C

D E
Fig. 80-12 n Displacement of the distal segment creates interference at the osteotomy. The interfer-
ence (arrow) will prevent passive repositioning of the proximal segment. Placement of fixation will
result in displacement of the condyle laterally. Passive seating of the proximal segment is prevented
by interference by the distal segment. Fixation will create lateral displacement of the condyle as
the proximal segment fulcrums off the interference. Fixation is performed once passive positioning
of the segments is achieved through elimination of the interference.

conjunction with the sagittal ramus osteotomy before establishing
fixation. Consideration should be given to extending the Dalpont cut
of the sagittal osteotomy as anteriorly as possible to allow visualiza
tion of the nerve before osteotomy of the inferior border. Resection
of the proximal segment is performed by rotating the segment supe
riorly while stabilizing it with an instrument. Rotation provides
improved visualization of the inferior border to the angle for resec
tion with a reciprocating saw. Management of bone removal from
the inferior aspect of the distal segment depends on the proximity
of the inferior alveolar nerve. The resection can be completed
without lateralization of the nerve if the required bone removal does
not encroach on the path of the mandibular canal. The need for
substantial bone removal from the inferior border typically requires
exposure of the inferior alveolar nerve within the distal segment.
The nerve is identified at the mental foramen and a corticotomy is
performed posteriorly for lateralization of the nerve. The course of
the nerve within the remaining distal segment is readily identified
through the sagittal osteotomy. The nerve can then be reflected
superiorly for completion of the inferior border resection on the
distal segment. The ample exposure of the mandible provided by
reflection of the soft tissue allows the osteotomy on the distal
segment to be completed from the angle to the chin. Recontouring
of the mandible with rotary burrs or reciprocating rasps may be
required to eliminate irregularities.
Augmentation of the mandible may be necessary for a deformity
that creates decreased facial height. The vertical discrepancy associ
ated with hemimandibular hyperplasia may require resection of the
inferior border on the affected side with simultaneous augmentation
680 Current Therapy in Oral and Maxillofacial Surgery

A B

C D
Fig. 80-13 n The condyle can be displaced medially with fixation. Positional screws or a bone
shim may be necessary to eliminate torque on the proximal segment. Use of a lag screw in an area
of sound bone contact is encouraged to ensure rigidity at the osteotomy because tightening of the
positional screw may be the head of the screw against the lateral cortex and not necessarily engag-
ing the distal segment.

on the unaffected, yet distorted side. Bone may be obtained through
resection of the hyperplastic inferior border or harvesting of corti
cocancellous bone from the hip. The graft can be secured to the
inferior border of the shortened side with rigid fixation. The stability
of the augmentation is difficult to predict under the influence of the
soft tissue. Resorption and subsequent remodeling of the augmenta
tion with autogenous bone cannot be calculated. Implants may
provide improved rigidity under the influence of the soft tissue and
pterygomasseteric sling but possess potential limitations as a result
of being a foreign body, causing restriction of mobility, or creating
palpable steps.
Two-jaw surgery may be required if compensation in the maxilla
has arisen as a result of deviation of the mandible. Rapidly progres
sive vertical changes in the mandible may create an open bite on the
affected side or, if left unattended, a canted occlusal plane as the
maxillary teeth supra-erupt. Early interceptive orthodontics may
prevent a response in the maxilla to the progressive deformity in the
mandible. Correction of the canted occlusal plane requires surgery
on the maxilla, in addition to surgery on the deformity within the
mandibular arch. The vertical changes in the maxilla will require
asymmetric repositioning to level the occlusal plane. The maxillary
osteotomy must address the traditional focus of vertical reposition
ing established with exposure of the incisors at rest. Leveling of the
occlusal plane may require superior repositioning on the affected
side or down-grafting on the unaffected side. The principles of sta
bility with orthognathic movement of the maxilla must be taken into
account to ensure a sound stable final result. Superior repositioning
of a Le Fort osteotomy possesses much greater stability than does
inferior repositioning, which resides at the opposite end of the stabil
ity hierarchy.9
 Mandibular Asymmetry: Diagnosis and Treatment Considerations
B muscles to the newly established occlusion. The residual soft tissue
Fig. 80-14 n Mandibular ramus anatomy for mandibular setback. A
submental vertex (SMV) radiograph illustrates parallel orientation of the
ramus mimicking a U shape. The anatomy of the mandible favors sagit-
tal ramus osteotomy. SMV radiography depicts a divergent ramus (V
shaped) best suited for mandibular setback via vertical ramus osteo
tomy as the proximal segment telescopes lateral to the repositioned
mandible.
POSTOPERATIVE CARE
Postoperative care following surgical intervention to correct asym
metric dentofacial deformities is similar to that for conventional
orthognathic surgery. A tape dressing is frequently placed after
closure to help the soft tissue drape against the bony correction on
the chin. Next, a compression dressing is used for several days to
eliminate dead space. Significant postoperative swelling may occur,
so the edema should be expected to mask the bony correction for
weeks. Even though the final bony and soft tissue changes are typi
cally not apparent for an extended time, correction of the asymmetry
is generally appreciated early in the postoperative period.
Neuromuscular reprogramming is important postoperatively
after correction of an asymmetric malocclusion. Elastic guidance is
frequently required to overcome memory within the muscles follow
ing surgery. The guidance elastics aid in education of the mind and
681
B
Fig. 80-15 n Generous exposure is necessary for visualization and
access to correct the skeletal deformity. Resection of the inferior border
is completed after lateralizing the inferior alveolar nerve from the distal
segment.
influence will frequently deviate the mandible until reprogramming
is accomplished.
CASE REVIEWSDENTOFACIAL
DEFORMITY WITH ASYMMETRY
MANDIBULAR HYPERPLASIA WITH ASYMMETRY
AND MAXILLARY COMPENSATION
Unilateral prognathism creates horizontal deviation of the lower
third of the face to the left. A subtle cant of the occlusal plane is
evident with increased gingival exposure on the right during anima
tion (Fig. 80-16, A). Orthodontic decompensation achieves sound
arch form and alignment with the mandibular midline to the left.
A PA cephalometric film illustrates the skeletal asymmetry with
deviation of the mandible and canting of the occlusal plane
(Fig. 80-16, B).
A facial view following correction of asymmetric dentofacial
deformity highlights improved symmetry and esthetics with anima
tion (Fig. 80-16, D). After treatment, occlusion with solid coupling
and stability was achieved (Fig. 80-16, E). A PA cephalometric film
illustrates the symmetry achieved through conventional maxillary
and mandibular surgery (Fig. 80-16, F). Additional measures (genio
plasty) were not necessary to achieve symmetry because the dental
and skeletal asymmetry were coincident.
682 Current Therapy in Oral and Maxillofacial Surgery

A D

B E

C F
Fig. 80-16 n Pretreatment photographs. A, Unilateral prognathism causing horizontal deviation to
the left in the lower third of the face. B, Posteroanterior (PA) cephalometric film showing the skeletal
asymmetry with deviation of the mandible and canting of the occlusal plane. C, Subtle cant of the
occlusal plane is evident with increased gingival exposure on the right during animation. D, Post-
treatment photograph showing improved symmetry and esthetics with animation. E, PA cephalo-
metric film showing the symmetry achieved with conventional maxillary and mandibular surgery.
F, Post-treatment occlusion with solid coupling and stability. (From Hupp JR, Ellis E, Tucker MR:
Contemporary oral and maxillofacial surgery, ed 5, St. Louis, 2008, Mosby.)

ASYMMETRIC DENTOFACIAL DEFORMITY
The examination and PA cephalometric film illustrate deviation of
the mandible to the left with compensation of the maxillary arch
toward the skeletal asymmetry (Fig. 80-17, A and B). The image
allows reference of the dental to the skeletal midline to aid in plan
ning the surgical correction. The addition of an anterior segmental
osteotomy may be necessary if the skeletal asymmetry is more
pronounced than the dental discrepancy.
Midline deviation and unilateral crossbite with mandibular
hyperplasia and asymmetry are apparent (Fig. 80-17, C to E).
Compensation in the maxillary arch is evident as flaring of the teeth
laterally in an effort to control the skeletal discrepancy.
 Mandibular Asymmetry: Diagnosis and Treatment Considerations 683

A B

D E F

G H I

J K L
Fig. 80-17 n Pretreatment photographs. A and B, A facial photograph (A) and posteroanterior (PA)
cephalometric film (B) show deviation of the mandible to the left with compensation of the maxil-
lary arch toward the skeletal asymmetry. C to E, Intraoral photographs showing midline deviation
and unilateral crossbite with mandibular hyperplasia and asymmetry. F and G, Post-treatment
facial photographs show good facial esthetics. H, Panorex radiograph illustrating the surgical cor-
rection. I, PA cephalometric film showing improved symmetry of the skeletal and dental elements.
J to L, Intraoral photographs showing the final occlusion with good midline approximation, anterior
coupling, and posterior interdigitation.

Correction of asymmetry establishes good facial esthetics (Fig.
80-17, F and G), and the final occlusion has good midline approxi
mation, anterior coupling, and posterior interdigitation.
A postoperative Panorex view illustrates the surgical correction
(Fig. 80-17, H). The anatomic characteristics of the mandible and
the rotational movement necessary for correction of the asymmetry
dictated performance of a vertical ramus osteotomy with setback on
the right and net advancement via sagittal ramus osteotomy on the
left. Additional correction of asymmetry in the chin required a
sliding anterior segmental osteotomy. A midline vertical segmental
osteotomy was performed simultaneously in the mandible to narrow
the arch form and limit interference from the distal segment within
the ramus. A PA cephalometric film illustrates improved symmetry
of the skeletal and dental elements (Fig. 80-17, I). Figure 80-17,
J to L, shows the final results.
684 Current Therapy in Oral and Maxillofacial Surgery

PEARLS AND PITFALLS

Correction of asymmetric dentofacial deformities involves thor-
ough data collection, imaging studies, treatment planning, and a
broad understanding of orthognathic surgical techniques.
The timing of surgical intervention depends on the stability of the
asymmetry.
Early intervention may be necessary to improve growth potential
from restricted movement or to eliminate progressive asymmetry.
Late surgical correction may be considered once the dynamic
changes causing the asymmetry have ceased.
In either situation, a mandibular osteotomy alone may not com-
pletely resolve the skeletal asymmetry. Adjunctive procedures such
as genioplasty and inferior border resection may be required to
establish facial symmetry.
Advances in imaging technology and three-dimensional analyses
have improved the accuracy of asymmetry correction through
computer simulation and transfer of the virtual plan to the operat-
ing room through milled splints.
Asymmetric dentofacial deformities managed with thoughtful
preparation and technique will result in functional and esthetic
success.

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