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From the Department of Plastic and Reconstructive Surgery and Chang Gung Craniofacial Research Center, Chang Gung Memorial
Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.
Received: Feb. 15, 2011; Accepted: Apr. 25, 2011
Correspondence to: Dr. Lun-Jou Lo, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou.
5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan (R.O.C.) Tel.: 886-3-3281200 ext. 2855; Fax: 886-3-3285818;
E-mail: lunjoulo@cgmh.org.tw
You-Wei Cheong, et al 342
Facial asymmetry
sides of a ‘normal’ face with their respective mirror asymmetry among the normal population in Asia
images, three faces can be visualized; the original than in Western countries.
face, the two left sides, and the two right sides. Often
these three faces from the same individual are dis- Etiology of facial asymmetry
tinctly different.(3) An example using 3-dimensional Facial asymmetry may be associated with class I
photography is demonstrated in Fig. 1. occlusion, but is more frequently associated with
It has been reported that in cases of minor facial class II and III occlusions. In some instances the
asymmetry, the right hemiface is usually wider that asymmetry is secondary to condylar hyperplasia or
the left hemiface with the chin deviated to the left.(4) hypoplasia, ankylosis of the temperomandibular
Facial asymmetry affects the lower face more fre- joint, displaced condylar fractures, or hemifacial
quently than the upper face. Severt and Proffit microsomia. The etiology of facial asymmetry for
reported frequencies of facial laterality of 5%, 36% many other cases is, however, still unknown. Facial
and 74% in the upper, middle and lower thirds of the asymmetry can be summarized and divided into
face.(5) The lower part of the face deviates more fre- three main categories, (1) congenital, originating pre-
quently and at greater distances than the upper and natally; (2) developmental, arising during growth
middle parts. One explanation is that the period of with inconspicuous etiology; and (3) acquired,
growth of the mandible is longer. Chew et al reported resulting from injury or disease, as shown in the
asymmetry in 35.8% of 212 patients with dentofacial Table 1.(8-10) Kawamoto et al divided the causes of an
deformities, with the majority of cases in patients idiopathic laterally deviated mandible into 2 cate-
with class III occlusal deformity.(6,7) He suggested gories.(11) The first group involves alteration of the
that special attention be paid to class III patients to cranial base and glenoid fossa which leads to dis-
detect any asymmetry. Class III is more common in placement of the mandible. This includes muscular
Asians than in Caucasians, so is a reasonable torticollis, unilateral coronal craniosynostosis and
assumption that there are more patients with facial deformational plagiocephaly.(12-15) The second catego-
A B C
Fig. 1 (A) This 3-dimensional photograph of a normal adult man taken by a 3 dMD system shows a grossly symmetrical face. The
face image was adjusted in the standard frontal view. The facial midline was defined, and a mirror image technique was performed.
(B) This is a manipulated image in which the right side of the face was replaced by a mirror image of the left side. Likewise (C) this
is an image of the two right sides of the face. (B) and (C) represent perfectly symmetric faces. The original image and the two
manipulated images look different. Comparisons between (B) and (C) show apparent differences, notably in the cheek fullness,
mouth angles, and chin.
Table 1. Etiology of Facial Asymmetry of the temporomandibular joint, which in turn causes
Congenital Developmental Acquired mandibular deviation and facial asymmetry. (21-24)
Trauma, arthritis and infection within the temporo-
Cleft lip and palate Cause unknown Temperomandibular joint
mandibular joint can lead to ankylosis of the joint.(25)
ankylosis
In a growing child, this condition can lead to unilat-
Tessier craniofacial cleft Facial trauma eral mandibular underdevelopment on the affected
Hemifacial microsomia Childhood radiotherapy side.(26) Cohen used the term ‘hemi-asymmetries’ in
Neurofibromatosis Fibrous dysplasia
discussion of craniofacial asymmetry. He further
classified these conditions into hemi-hyperplasia,
Torticollis Other facial tumors
hemi-hypoplasia, hemi-atrophy and other miscella-
Craniosynostosis Unilateral condylar neous entities.(27)
hyperplasia
Vascular disorders Romberg’s disease Clinical implications
Based on the craniofacial structures involved,
Others Others
facial asymmetry can be classified into dental, skele-
tal, soft tissue and functional components. Common
causes of dental asymmetry are early loss of decidu-
ry involves condylar anomalies which result in ous teeth, a congenital missing tooth or teeth, and
hypoplastic or hyperplastic growth of the condyle. habits such as thumb sucking. Skeletal asymmetry
Examples include condylar fracture, condylar hyper- may involve one bone such as the maxilla or
plasia, and condylar arthritis and hemifacial microso- mandible, or it may affect a number of skeletal struc-
mia.(16,17) tures on one side of the face, as in hemifacial micro-
The developmental type of facial asymmetry is somia. When one side of osseous development is
idiopathic and non-syndromic in nature, and is not affected, the contralateral side will most inevitably
uncommonly seen in the general population. The be influenced resulting in compensational or distort-
asymmetry is not observed at birth or in infancy, and ed growth. Muscular asymmetry can occur in condi-
appears gradually, usually becoming apparent in the tions such as hemifacial microsomia and cerebral
teenage years. There is no obvious history of facial palsy. Abnormal muscle function, as in masseter
trauma or detectable disease causing the asymmetry. hypertrophy, can itself cause an asymmetrical
One possible source is habitual chewing on one side, appearance of the face, as well as contribute to dental
which is responsible for increased skeletal develop- and skeletal asymmetry because of abnormal muscle
ment on the ipsilateral side.(18) Persistent sleep on one pull. Fibrosis of the sternocleidomastoid muscle as
side may be another cause. Haraguchi et al suggested seen in torticollis may create evident craniofacial
that the etiology of facial asymmetry can be divided deformation if left untreated for a period of time.(15)
between those with genetic origins and those with Not only facial but also endocranial morphology is
environmental origins.(19) Neurofibromatosis is one affected and distorted. The deformation becomes
cause of facial asymmetry caused by genetic factors. more severe with time. Functional asymmetry may
It is also noted that in cleft lip and palate, the pathol- result from the mandible being deflected laterally if
ogy more often occurs on the left side and this phe- occlusal interferences prevent proper intercuspation
nomenon probably has a genetic basis.(20) Intrauterine in the centric position. These functional deviations
pressure on the fetus head, as well as pressure in the may be caused by a constricted maxillary arch or a
birth canal during parturition can cause molding of local factor such as a malpositioned tooth. In some
the skull bones and facial bones, causing observable cases, temporomandibular joint derangement, such
craniofacial asymmetry. However this problem is as an anteriorly displaced disc, may result in a mid-
usually transient and the skull and facial bones return line shift during mouth opening caused by interfer-
to their normal shape within a few weeks to few ence in mandibular translation on the affected side.
months. Non-hereditary conditions that cause facial However, a combination of these factors is often pre-
asymmetry include osteochondroma of the mandibu- sent. Proper evaluation is needed to arrive at the cor-
lar condyle, which may affect the form and function rect diagnosis. Reyneke et al recommended a classi-
fication system based on the positions of three tric occlusion. Asymmetry due to occlusal interfer-
anatomical areas, namely the maxilla, mandibular ence may result in a mandibular functional shift on
body and mandibular symphysis, in relation to the initial tooth contact. The shift can be either in the
facial midline, as well as the presence of occlusal same direction or opposite direction of the dental or
canting. The authors provided a simple method to skeletal discrepancy and may actually accentuate or
identify an appropriate orthodontic and surgical mask the asymmetry. In addition, functional asym-
approach for each specific type of asymmetry.(10) metry related to temporomandibular joint derange-
Clinically detectable facial asymmetry may be ment should be excluded. The presence of a canted
associated with more occult abnormalities elsewhere occlusal plane could be the result of a unilateral
in the facial skeleton. For example clinically evident increase in the vertical length of the mandibular
chin deviation may be associated with significant ramus and condyle. The maxilla and temporal bone
horizontal and vertical asymmetry in paired skeletal supporting the glenoid fossa could be at different
landmarks in the upper, middle and lower face. This levels on each side of the head. Clinically the canted
might complicate planning by distorting the refer- occlusal plane is readily detected by asking the
ence plane.(28) Facial asymmetry may cause a number patient to bite on a tongue blade to determine how it
of problems in patients, including undesirable relates to the inter-pupillary plane. At times, patients
cosmesis, malocclusion, altered movement of the tilt their heads with a canted orbital level to compen-
temporomandibular joint and other temporomandibu- sate the lower facial asymmetry, and orbital canting
lar joint problems such as pain and clicking. improves after correction of the facial asymmetry.
Vertical skeletal asymmetry associated with a
Evaluation of facial asymmetry progressively developing unilateral open bite may be
Patients with facial asymmetry are evaluated the result of condylar hyperplasia or neoplasia.
through clinical assessment, photography, cephalog- Asymmetry in the bucco-lingual relationship, e.g. a
raphy, and sometimes 3-dimensional computed unilateral posterior cross bite, should be carefully
tomography. Clinical examination reveals asymmetry assessed to determine whether the cause is skeletal,
in the sagittal, coronal and vertical dimensions. It dental or functional. Dental arch asymmetries could
remains the most important diagnostic tool in the occur because of local factors such as early loss of a
evaluation of facial asymmetry. Clinical assessment deciduous tooth or they could be associated with the
starts with ascertaining the patient’s chief complaint rotation of the entire dental arch and its supporting
and evaluating the medical history. Clinical examina- skeletal base. Assessment of the overall shape of the
tion involves visual inspection of the entire face, maxillary and mandibular arches from an occlusal
palpation to differentiate soft tissue and bony view may disclose not only side to side asymmetries
defects, comparison of the dental midline with the but also differences in the bucco-lingual angulation
facial midline, inspection of symmetry between the of the teeth. It is important to realize that expansion
bilateral gonial angle and mandibular body lower of the dental arch in the presence of skeletal constric-
border, determination of the amount of gingival show tion may adversely affect the stability of the correc-
per side, and evaluation of malocclusion, occlusal tion. Arch asymmetry could also be due to rotation
canting, inclination of the anterior teeth, open bites, of the entire maxilla or mandible. In addition to bilat-
maximal interincisal opening, mandibular deviation, eral structural comparison, deviation of midline
and the temporomandibular joint. However body structures such as the dorsum and tip of the nose, the
posture, mannerisms and hairstyle may hide asym- philtrum and the chin point needs to be determined.
metry and mislead the treatment plan. (29) Most In many cases, clinical examination needs to be
patients notice horizontal or transverse discrepancy supplemented by other diagnostic modalities such as
more often than vertical and sagittal asymmetry. dental casts, face bow transfer and various imaging
The dental midline should be evaluated in the techniques to accurately localize the asymmetric
following positions: opening mouth, in centric rela- structures. In radiographic assessment, a number of
tion, at initial contact, and in centric occlusion. True projections are available to identify the location and
dental and skeletal asymmetry will show similar cause of facial asymmetry. The lateral view on
midline discrepancies in centric relation and in cen- cephalometry provides limited useful information on
asymmetry in the ramal height, mandibular length the crista galli. This vertical line approximates the
and gonial angle. It is limited by the fact that the anatomic midsagittal plane of the head. The nasion
right and left structures are superimposed on each and the anterior nasal spine are noted to fall very
other and there are different distances from the film near this plane 90% of the time. (30) Perpendicular
and x-ray source resulting in significant differences lines from the bilateral structures can now be drawn
in magnification. On the other hand, the panoramic and the distance from the midsagittal reference line
view can be a useful projection. The skeletal and can be measured and compared to determine discrep-
dental structures of the maxilla and mandible are ancies in height as well as the distances between the
subjectively assessed with relative ease. The pres- bilateral structures and the midline. In addition, the
ence of gross anomalies, and supernumerary or miss- maxillary and mandibular dental midlines are com-
ing teeth can be detected. The shape and height of pared to the skeletal midline. Stereophotogrammetry
the mandibular ramus and condyles on both sides can using two or more cameras, configured as a stereo-
be compared. The cephalometric postero-anterior pair to generate a 3-dimensional image of the face by
projection is a valuable tool in the study of the right triangulation, has been reported. This provides a use-
and left structures since they are located at equal dis- ful three-dimensional assessment of facial soft tissue
tance from the film and x-ray source (Fig. 2). The asymmetry before and after orthognathic surgery.(31)
postero-anterior view can be obtained at the centric More recent devices for 3-dimensional photography
occlusion and open mouth positions to determine the have been used (Fig. 3). The image can be used for
extent of functional deviation. It is recommended comparison and quantitative measurement. The pre-
that a horizontal line be drawn through the bilateral cision and accuracy of the 3-dimensional pho-
zygomatico-frontal sutures to act as the horizontal tographs have been validated. (32-34) The soft tissue
axis in the construction of the horizontal and mid- images captured from 3-dimensional photogramme-
sagittal reference planes. A vertical line perpendicu- try are comparable to those obtained from traditional
lar to this horizontal axis is drawn to pass through cephalogrammetry.(35) Other radiographic modalities
A B
Fig. 2 A posteroanterior view on cephalography of a patient with right temperomandibular joint ankylosis after release and resec-
tion of the right condyle shows marked deviation of the mandible to the right side and soft tissue asymmetry (A). The patient
received a LeFort I osteotomy for leveling, a left sagittal split of the mandibular ramus for rotation, a release of the right tempero-
mandibular joint and lengthening of the right ramus using a costochondral graft, and a genioplasty for lengthening and advance-
ment, showing improvement of the skeletal as well as soft tissue contour and symmetry (B).
A B
Fig. 3 The 3-dimensional photograph shown in Figure 1A was used to overlap the mirror image of the left side of face on the right
side of the face (A). A color map illustrates the differences in depth, showing asymmetry or deformity of the facial contour on both
sides. Quantitative differences are shown on the right upper inset scale map. A mirror image of the right side of the face overlapping
the left side of the face and the differences are shown in (B).
in the assessment of facial asymmetry include orthodontic treatment alone. Asymmetric extraction
tomography and computed tomography (CT). CT sequences and asymmetric mechanics can be
scans both in 2-dimensional and 3-dimensional employed to correct dental arch asymmetry.
views can provide excellent details necessary for Prosthodontic restoration may be indicated in pro-
proper diagnosis and treatment. In addition, three nounced tooth irregularities. Mild functional devia-
dimensional CT images can also provide information tion can be managed by minor occlusal adjustments.
for the fabrication of three-dimensional acrylic skele- More severe deviations may need orthodontic treat-
tal models to facilitate evaluation and surgical plan- ment to align the teeth to obtain proper function. In
ning.(36) Cone beam CT scanning has become popular addition to routine presurgical anteroposterior ortho-
in many dental and maxillofacial centers. dontic decompensation, intentional transverse ortho-
dontic decompensation may also be required in
Planning and management patients with asymmetry.(37) Unilateral vertical maxil-
Decisions about intervention for dentofacial lary excess and mandibular asymmetry are usually
deformities depend on patient awareness of the aes- associated with an occlusal cant. This explains why
thetic problem, the extent of the occlusal deformity, most asymmetries cannot be treated with single-jaw
and concomitant sagittal or vertical jaw imbalance.(28) surgery.
Facial asymmetry may involve dental, skeletal and More severe asymmetries require a combination
soft tissue components and a combination of ortho- of orthodontic and orthognathic management.
dontic treatment and orthognathic surgery may be Clinical practice has shown that surgical correction
indicated. Treatment of facial asymmetry in preado- of the maxillomandibular bony complex may not dif-
lescent children is often difficult with unpredictable fer appreciably for etiologically different asymme-
results. Growth modification with functional appli- tries with similar clinical presentations, except that
ances has been problematic and the use of a bite- more emphasis is placed on the frontal view during
block rarely prevents the need for other treatment the planning. (10) Correct surgical treatment begins
modalities.(29) A growing patient with mild asymme- with a proper diagnosis with accurate evaluation of
try and a functional condyle should receive early all facial dimensions. Failure to recognize asymme-
orthodontic treatment and be allowed to finish try until after surgery is viewed by most patients as
growth before surgery is undertaken. poor treatment. However the surgical correction of
True dental asymmetry can be managed by facial asymmetry is challenging because the asym-
metry may involve hard and/or soft tissue in any muscle, and soft-tissue tension. The degree of soft
combination of dimensions. It may involve the max- tissue movement as a response to skeletal structure
illa, mandible, symphysis, other parts of the dentofa- mobilization may be difficult to predict accurate-
cial skeleton or any combination of these. It is the ly.(6,43,44)
effective treatment of the hard tissues that brings Orthognathic surgery can be combined with
about the most dramatic change, as soft tissue gener- bone contouring such as a mandibular angle reduc-
ally follows underlying bones. Otherwise isolated tion, mandibular inferior border ostectomy, genio-
soft tissue deformities are usually corrected during or plasty, and bony augmentation as well as soft tissue
after skeletal correction.(38) Another problem in the contouring such as buccal fat pad and masseter mus-
correct planning of treatment is the aspect of growth cle reduction in the same operation. Minor touch-up
and development. As a consequence, the planning procedures, e.g. fat graft injection or subcutaneous
and extent of surgical correction should be tailored, liposuction, can be performed as secondary proce-
and secondary surgery could be needed. Unilateral dures, depending on the requirements (Fig. 4). Choi
condylar hyperplasia with excessive growth may per- et al reported on bimaxillary orthognathic surgery
sist until the age of 23 years. Romberg disease may combined with a face lift procedure plus the use of a
progress further after 18 years of age. Trauma and resorbable fixation device.(45) Ferguson described the
tumor causing asymmetry could be late-onset. Minor definitive surgical correction of hemimandibular
trauma to the temperomandibular joint in childhood hyperplasia with complete mobilization of the inferi-
could be unnoticed clinically, but gradually become or alveolar nerve bundle.(46) Anghinoni et al described
evident. the use of a midline mandibular osteotomy to modify
Bimaxillary surgery involving a Le Fort I the transverse mandibular arch in the management of
osteotomy and bilateral sagittal split osteotomy is mandibular asymmetry.(47)
usually required in the surgical management of facial Multiplanar distraction osteogenesis has been
asymmetry. A “single-splint” surgical technique is applied in the craniofacial region and this technique
preferred by a number of surgeons.(39,40) The maxillo- is used to correct mandibular hypoplasia. Precise and
mandibular complex is mobilized, the final occlusal predictable results with distraction osteogenesis
splint put on and intermaxillary fixation applied. The require accurate placement of an osteotomy or cor-
position of the maxillomandibular complex is adjust- ticotomy, distraction device placement, vector plan-
ed intraoperatively to achieve the best aesthetic ning, and selection of a distractor as well as consid-
result. The predetermined ideal position may need to eration of the effects of the masticatory muscles and
be adjusted to compensate for soft tissue deformities, surrounding soft tissues that may deviate the tooth
especially in patients with hemifacial microsomia. bearing segment toward an unexpected position.
Intraoperative use of a face bow facilitates the posi- McCarthy et al reported that only a single osteotomy
tioning of the maxillomandibular complex in the and two pin sites are required in the execution of
midline.(41) multiplanar distraction osteogenesis.(48) It has been
Surgical planning of two-jaw orthognathic proved that distraction for lengthening the mandibu-
surgery requires 3-dimensional consideration in the lar ramus also increases the soft tissue by increasing
sagittal, coronal and horizontal planes. Ideally, the the volume of the medial pterygoid muscle, and this
dental midline and skeletal midline are aligned to the may somewhat improve the facial symmetry in
facial midline. The intercommissural plane should be patients with hemifacial microsomia.(49) Ko et al doc-
parallel to the inter exocanthal plane.(40) Altug-Atac et umented increased length of the mandibular ramus
al stated that there is no 1:1 relationship between the after one year with improvement of chin and oral
changes in ramus height and improvement in paral- commissure positions.(50)
lelism of lip commissures to the orbital plane.(42) The
reason why it is difficult to predict the lip position Summary
after orthognathic surgery seems to be that soft-tissue When patients complain of facial asymmetry
changes in the upper and lower lips after orthognath- and seek treatment, it is important to search for
ic surgery occur because of movement of the under- underlying causes. This entails a thorough history,
lying hard tissue, continuity of the orbicularis oris physical examination, and imaging studies. An
A B
Fig. 4 A 23-year old woman with Romberg’s disease on the right side of the face shows marked deficiency of bone and soft tissue
on the right side (A). The maxillary and mandibular midline has been shifted to the right side, with a canted dental occlusal plane.
She received a maxillary and mandibular osteotomy for restoration of the facial midline and occlusal plane, followed by reconstruc-
tion with fat injection to the right side of face, and finally a touch up operation for refinement of facial symmetry (B).
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