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Morphologic, functional, and occlusal

characterization of mandibular lateral
displacement malocclusion
Kyoko Ishizaki,a Koichi Suzuki,a Tomofumi Mito,a Eliana Midori Tanaka,b and Sadao Satoc
Yokosuka, Japan, and Bogotá, Colombia

Introduction: Mandibular lateral displacement (MLD) is clinically characterized by deviation of the chin, facial
asymmetry, dental midline discrepancy, crossbite in the posterior region, and high prevalence of internal
derangement of the temporomandibular joint. Morphologic and functional characteristics of MLD should be
clarified to correct and prevent this malocclusion. Methods: We examined the morphologic features, occlusal
scheme, and functional behavior of MLD in 116 patients. Facial morphology was examined with posteroante-
rior cephalograms, occlusion guidance on the articulator after face-bow transfer, and condylar movement with
the condylograph. Results: The superiorly inclined occlusal plane was associated with mandibular deviation in
the same direction. The posterior occlusal plane on the shifted side was significantly steeper than that on the
nonshifted side. Functional analysis of condylar movement showed a close relationship between the direction
of MLD and the direction of condylar lateral shift during opening and closing, and protrusion and retrusion. The
occlusal guidance inclination in the buccal segment of the nonshifted side was steeper than that in the shifted
side. Conclusions: The results suggested that reduced vertical height of the dentition on 1 side induced
mandibular lateral adaptation with contralateral condylar shift (asymmetry); this leads to condylar lateral shift
during functional movement. (Am J Orthod Dentofacial Orthop 2010;137:454.e1-454.e9)

M
andibular lateral displacement (MLD) is
relatively common in patients with malocclu-
sion. The occurrence of MLD is of particular
interest, since most types of malocclusion involve some
facial asymmetry. MLD is characterized by mandibular
deviation to 1 side evidenced by deviation of the chin
from the facial midline, crossbite in the posterior region,
and dental and skeletal midline discrepancies.1-4 It was
also reported that MLD patients with facial asymmetry
a
Postgraduate research fellow, Department of Craniofacial Growth and
Development Dentistry, Division of Orthodontics, Kanagawa Dental College,
Yokosuka, Japan.
b
Professor, Department of Orthodontics, Universidad Militar Nueva Granada,
Fundación C.I.E.O., Bogotá, Colombia; visiting researcher, Department of
Craniofacial Growth and Development Dentistry, Division of Orthodontics,
Kanagawa Dental College, Yokosuka, Japan.
c
Professor, chairman, and research associate, Department of Craniofacial
Growth and Development Dentistry, Research Institute of Occlusion Medicine,
Research Center of Brain and Oral Science, Division of Orthodontics,
Kanagawa Dental College, Yokosuka, Japan.
Supported by grants-in-aid for open research from the Japanese Ministry of
Education, Culture, Sports, Science and Technology.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Eliana Midori Tanaka, Department of Craniofacial Growth
and Development Dentistry, Division of Orthodontics, Research Institute of Oc-
clusion Medicine, Research Center of Brain and Oral Science, Kanagawa Dental
College, 82 Inaoka-Cho, Yokosuka, Kanagawa 238-8580, Japan; e-mail, satos@
kdcnet.ac.jp.
Submitted, April 2009; revised and accepted, October 2009.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.10.031
have internal derangement of the temporomandibular
joint (TMJ).5-7 For the clinicians, MLD is a challenging
anomaly and can sometimes be compromised in its
results, because it is difficult to treat orthodontically,
even with orthognathic surgery because of the asymmetry
of the skeletal frame. This might be attributed to a lack
of understanding of the morphologic and functional
characteristics of this malocclusion.
In recent craniofacial biology research, the general
consensus seems to be that the adaptation of skeletal
and dentoalveolar elements of the face after functional
displacement of the mandible leads to reestablishment
of the structural and functional balance of the orofacial
region.8 It was been suggested that the dentofacial com-
plex is obviously adaptable to the functional demand in
occlusal configuration and the change of occlusal func-
tion in growing facial bones.9,10 It was also pointed out
by Petrovic and Stutzman11 that the cant of the maxil-
lary occlusal plane is an important factor contributing
to mandibular positioning.
As we reported earlier, the cant of the occlusal plane is
closely associated with various dentoskeletal frames dur-
ing craniofacial growth and development.12-15 It was
speculated that horizontalization or flattening of the
maxillary occlusal plane induces functional forward
adaptation of the mandible followed by active
transformation of the TMJs. Our previous investigation3,5
indicated that the cant of the frontal occlusal plane

454.e1
454.e2 Ishizaki et al American Journal of Orthodontics and Dentofacial Orthopedics
April 2010

(OP) in MLD malocclusion tilted superiorly to the side

to which the mandible was shifted, often with TMJ
symptoms on the side with the shifted condyle. In this
context, it must be considered that the vertical and
transverse positions of the mandible associated with
the vertical height of the posterior teeth (posterior
vertical dimension) are important to understand MLD
malocclusion, although the interrelationship among
occlusal plane deviation, MLD, and functional
disturbances still remains to be elucidated.
These previous findings led us to reevaluate MLD
patients to consider a therapeutic functional approach
based on occlusal plane control by reestablishing the ap-
propriate occlusal vertical dimension on the affected
side; this is an effective treatment for the correction of
the facial asymmetry due to MLD, with consequent
improvement of occlusal and articular functions.
In this study, the morphologic, occlusal, and func-
tional characteristics and orthodontic approach to
MLD malocclusion are discussed.

MATERIAL AND METHODS

The Human Research Ethics Board at Kanagawa
Dental College approved this study, and informed con-
sent was read and signed by each participant.
Initial records of patients with nonhereditary cra-
niomandibular asymmetry before, during, and after
orthodontic treatment at the orthodontic department
of Kanagawa Dental College were selected. A total of
116 patients (average age, 20.8 6 7.8 years; 35 males:
age, 20.7 6 6.8; 81 females: age, 20.9 6 8.3 years) di-
agnosed as having MLD without pathologic conditions
that affect the TMJs, including congenital disorders
such as hemifacial microsomia, condylar hyperplasia,
rheumatoid arthritis, and osteoarthritis, participated in
this study. These patients’ facial morphology was ex-
amined by using posteroanterior cephalograms, occlu-
sion guidance on the articulator after face-bow
transfer, and condylar movement with a condylograph.
All patients were treated or intended to be treated for
their MLD malocclusion according to the treatment
protocol at Kanagawa Dental College based on vertical
dimension and occlusal plane control.
The morphologic characteristics of MLD were stud-
ied on the cephalograms as shown in Figure 1. The mid-
facial reference plane to assess facial asymmetry was
a line running through crista galli and anterior nasal
spine. The angle between the midfacial plane and the
line running through anterior nasal spine and menton
was defined as the degree of MLD. A positive value in-
dicated MLD to the left side and a negative value to the
right side. The angle between the perpendicular line of
Fig 1. Measurements on posteroanterior cephalograms
in MLD subjects: OP, frontal occlusal plane; AG, frontal
mandibular plane; MA, mastoid plane; CI, condylar incli-
nation; ZP, zygomatic plane; Z, point at lateral border of
center of zygomatic arch; Co, condylion: most postero-
superior point of condylar process; Ar, articulare: point
of intersection of the dorsal contour of the mandibular
condyle and the temporal bone.
the midfacial plane and the line running through the oc-
clusal surface of the bilateral maxillary first molars was
defined as the OP. The angle between the perpendicular
line of the midfacial plane and the line connecting the
right and left antegonial notches was defined as the fron-
tal mandibular plane (AG). The angle between the per-
pendicular line of the midfacial plane and the line
connecting the right and left mastoid processes of the
temporal bone was defined as the frontal mastoid plane.
Positive values of OP and AG indicated that these planes
inclined superiorly toward the left side.
Since the condyle follows the growth of the whole
ramus, to evaluate condylar deviation, the lateral ramus
line, which was the tangent line from the cross point of
the condylar process tracing and the tracing of the mas-
toid process to the lateral shape of gonial tracing, was
drawn as an indicator of condylar inclination.16 Then,
the central points of the oval shape of right and left zy-
gomatic arches were connected as the zygomatic plane.
The distance between the zygomatic arches and the
cross point of the zygomatic plane and the condylar
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 4
inclination was measured. The distance between right
and left was subtracted to indicate condylar deviation,
with a positive value indicating deviation to the right
side and vise versa. It is easily recognized by correlation
figures showing negative values for MLD right and pos-
itive values for MLD left.
The mounted maxillary casts were transferred to
a 3-dimensional (3D) digitizer (Gamma GmbH, Klos-
terneuburg, Austria). The tooth guidance surfaces
were designed for protrusion and laterotrusion. The start
and end points of the occlusal guidance were called
functional points Fl and F2 (Fig 2). F1 and F2 were lo-
cated on the mesial and distal marginal ridges of the
maxillary central incisors and the mesial marginal
ridges of the maxillary lateral incisors, canines, premo-
lars, and first molars. The F1 points were created in
maximum intercuspation with mandibular incisal
edges, cusps of the canines, and buccal cusps of the pre-
molars and the first molars in contact and are the starting
points for eccentric movements.
The most eccentric contact right before disocclusion
is F2. It is located next to the incisal edge on the lingual
surface of the maxillary front teeth. The F2 points in the
premolars and molars was close to the cusp tip, usually
not coinciding with it. A line connecting Fl and F2
showed an angulation to the axis-orbital plane refer-
enced by anatomic face-bow transfer by using the
anatomic hinge axis points and the left incisura infraor-
bitalis for mounting the maxillary casts in an articulator
(SAM Präzisionstechnik, Munich, Germany). A 3D dig-
itizer recorded the coordinates of both functional points
after a mobile pin was placed on the respective spot.
Calibration of the digitizer preceded every recording.
The digitizer had a measuring accuracy of 0.01 mm,
and each point was recorded 3 times. The corresponding
inclinations of the maxillary second molars were mea-
sured for study purposes. A mobile measuring pin was
manually moved to Fl and F2, and the digitizer recorded
the coordinates of these points with reference to the
axis-orbital plane. The inclinations of the guidance
were then calculated from the coordinates, providing
the average of the 3 measurements with reference to
the axis-orbital plane.
Occlusal planes were also calculated by connecting
the inclinations of the F1 points with reference to the
axis-orbital plane. Three occlusal planes were mea-
sured. The conventional occlusal plane was the line con-
necting F1 of the central incisor and first molar, the
anterior occlusal plane was that of the central incisor
and first premolar, and the posterior occlusal plane
was that of the second premolar and second molar.
The 3D condylar paths of the patients were recorded
during opening and closing movements of the mandible
Ishizaki et al 454.e3
Fig 2. Functional points and occlusal guidance in the
dentition. Functional points F1 and F2 are located on
the mesial and distal marginal ridges of the incisors
and the mesial marginal ridges of the maxillary lateral in-
cisors, canines, premolars, and first molars. The F1s are
created while in maximum intercuspation and are the
starting points for eccentric movements. The F2s are
the most eccentric contacts right before disocclusion.
and analyzed with a computerized condylography
(Cadiax, Gamma Dental, Klosterneuburg, Austria) sys-
tem. The condylography system consisted of a cranial
attachment and a mandibular face-bow. A functional
clutch was fixed to the labial surface of the mandibular
dentition, and mandibular movements were confirmed
to have no interference. The mandibular face-bow was
then connected to the clutch. Two-dimensional condylar
movement in the sagittal plane was recorded on digi-
tizers, which were attached to the cranial face-bow
and placed over the TMJ region bilaterally.
Lateral deviation of the condyle during mandibular
functional movement was detected by the stylus at-
tached to the mandibular face-bow. After positioning
the stylus on the hinge axis, condylar movements in
both TMJs were recorded 3-dimensionally from a refer-
ence position established by using unforced chin-point
guidance.17
To investigate the lateral shift of the condyle during
opening movement (DY shift), the condylar paths in the
transverse plane were observed on the condylographic
tracing. As shown in Figure 3, there were several types
of DY shift that indicated medial (inward) and lateral
(outward) deviation.
The DY shift was seen in different conditions of man-
dibular functional movement, which was evaluated by
condylographic axis movement. They were classified
into 3 groups according to mandibular lateral translation
(MLT): (1) MLTwith closed lock (closed lock DY), which
454.e4 Ishizaki et al American Journal of Orthodontics and Dentofacial Orthopedics
April 2010
American Journal of Orthodontics and Dentofacial Orthopedics Ishizaki et al 454.e5
Volume 137, Number 4

Table I. Occlusal plane differences betwen sides of den- Table II. Occlusal guidance differences betwen sides of
titions with MLD dentitions with MLD
Shifted side (mm) Nonshifted side (mm) Shifted side Nonshifted side
Occlusal Difference (mm) (mm)
planes Mean SD Mean SD (mm) P Difference
Tooth Mean SD Mean SD (mm) P
1-6 11.35 4.12 10.49 3.66 0.86
1-4 10.35 4.36 9.63 4.17 0.72 Central incisor 55.48 10.09 55.07 9.32 0.41
5-7 18.05 12.29 13.81 5.85 4.24 * Lateral incisor 51.10 10.48 53.62 12.01 2.52
6-7 20.39 12.13 15.22 5.28 5.17 * Canine 45.22 8.47 49.13 9.63 3.91 *
First premolar 27.78 11.77 33.25 11.63 5.47 *
1-6, Central incisor to first molar; 1-4, central incisor to first premolar; Second premolar 18.18 10.40 24.97 11.21 6.79 *
5-7, second premolar to second molar; 6-7, first molar to second molar. First molar 8.36 6.88 13.23 8.83 4.87 *
*P \0.05 (Welch analysis). Second molar 7.83 9.64 10.14 6.63 2.31

*P \0.01 (Student t test).

showed lateral translation with severely limited condylar
movement during opening and closing movements; (2)
MLT with overrotation (overrotation DY), which showed
lateral translation with excess condylar rotation in maxi-
mum opening position; and (3) MLT without closed
lock and overrotation, which showed lateral translation
(DY MLT) relatively close to the reference.
Statistical analysis
Statistical analyses were performed with the SPSS
program for Windows (version 15, SPSS, Chicago,
Ill). The mean values and standard deviations for all
measured variables of occlusal plane inclination, occlu-
sal guidance inclination, and condylar movements
(open/close, protrusion/retrusion, and mediotrusion/
medioretrusion) were calculated for each subject. In ad-
dition to standard descriptive statistical calculations, the
Student and Welch t tests were used to detect differences
of outcome measurements between the 2 groups: shifted
and nonshifted sides in MLD (Tables I-V), and the
statistical significance levels were established at
P \0.05 and P \0.01. Percent distribution of the 4
patterns of lateral translation including the
relationship between MLD and 6Y-shift directions
was also calculated (Tables VI, VII).
The Pearson product-moment correlation coeffi-
cients were calculated to determine different associa-
tions between variables related to MLD malocclusion
(OP, AG, and condylar deviation). The statistical sig-
nificance of correlation was set at P \0.01 (Table
VIII).
Data were analyzed in the total sample, and no clas-
sification was made according to sex, because there was
:
no significant difference in the variables between the
sexes.
RESULTS
Analysis of posteroanterior cephalograms of MLD
patients showed a high correlation between the OP incli-
nation and the MLD. A superiorly inclined occlusal
plane was associated with MLD in the same direction,
suggesting that the side of the dentition with less verti-
cal height induced mandibular adaptation with a lateral
shift to the side. Inclination of the AG also indicated sig-
nificant correlation with MLD and a correlation coeffi-
cient of 0.607. In addition to these, analysis of the
relationship of the OP and AG showed a high correlation
with a correlation coefficient of 0.595, indicating that
the occusal plane inclination was strongly related to
a 3D shift of the mandible toward the side with less
vertical dimension (Table VIII).
Condylar shift and the AG inclination, and condylar
shift and MLD were also significantly correlated with
relatively low correlation coefficients: 0.227 and
0.129, respectively (Table VIII). These findings sug-
gested that condylar deviation in MLD was toward the
opposite direction from the MLD side, and the mandible
was not simply laterally shifted but also rotated in a 3D
manner.
On the articulator-mounted cast, sagittal inclination of
the occlusal planes and the occlusal guidances (F1-F2) of
each tooth were measured; the results are shown in Tables
I and II. There were no significant differences in the OP
inclination between the shifted and nonshifted sides

Fig 3. Different types of MLT visualized on condylographic tracings during opening and closing
movements: A, MLT with severely limited condylar movement (closed lock DY); B, MLT with exces-
sive condylar rotation in maximum opening position (overrotation DY); C, MLT without limitation and
overrotation (DY MLT) occurred in relatively close position to the reference position.
454.e6 Ishizaki et al American Journal of Orthodontics and Dentofacial Orthopedics
April 2010

Differences in values of condylar movement

Table III. Table IV. Differences in values of condylar movement
(opening/closing) between sides of dentitions with (protrusion/retrusion) betwen the sides of dentitions
MLD with MLD
Shifted side Nonshifted side Shifted side Nonshifted side
(mm) (mm)
Difference Mean SD Mean SD SD Difference P
Mean SD Mean SD (mm) P
†
Quantity (mm) 9.77 3.05 8.10 3.08 1.67
†
Quantity (mm) 16.68 2.83 15.21 2.67 1.47 SCI (at S 5 3 mm) 49.46 10.84 45.23 10.82 4.23 *
SCI (at S 5 3 mm) 53.75 10.30 53.49 10.43 0.26 SCI (at S 55 mm) 49.61 8.83 45.85 8.54 3.76 *
SCI (at S 5 5 mm) 54.09 9.24 52.65 9.53 1.44 SCI (at S 5 10 mm) 45.40 6.73 42.92 7.74 2.48
SCI (at S 5 10 mm) 46.68 9.31 44.94 9.42 1.74 ‡
TCI (at S 5 3 mm) –1.47 4.88 3.52 9.63 4.99
TCI (at S 5 3 mm) 0.00 10.08 3.25 13.78 3.25 †
TCI (at S 5 5 mm) –2.00 5.30 1.68 5.00 3.68
TCI (at S 5 5 mm) –1.11 4.18 1.63 6.97 2.74 * TCI (at S 5 10 mm) –1.76 3.63 0.15 2.22 1.91
† ‡
TCI (at S 5 10 mm) –1.50 3.74 1.19 3.68 2.69 S-E difference 0.62 0.72 0.33 0.36 0.29
‡
S-E difference 0.82 0.79 0.43 0.49 0.39
Quantity, Distance between the reference position and maximum
Quantity, Distance between the reference position and maximum opening position; SCI, sagittal condylar inclination; S, starting point;
opening position; SCI, sagittal condylar inclination; S, starting point; TCI, transversal condylar inclination; S-E difference, difference
TCI, transversal condylar inclination; S-E difference, difference between start and end points.
between start and end points. *P \0.05 (Student t test); †P \0.01 (Student t test); ‡P \0.01 (Welch
*P \0.05 (Student t test); †P \0.01 (Student t test); ‡P \0.01 (Welch analysis).
analysis).

Table V. Differences in values of condylar movement

(mediotrusion/medioretrusion) betwen the sides of den-
with respect to conventional OP (central incisor-first
titions with MLD
molar) and anterior OP (central incisor-first premolar).
However, the posterior OPs (second premolar-second Shifted side Nonshifted side
molar and first molar-second molar) on the shifted side Mean SD Mean SD Difference P
were significantly steeper than those on the nonshifted
†
side. These results coincided well with those obtained Quantity (mm) 11.78 3.81 10.43 2.54 1.35
†
SCI (at S 5 3 mm) 50.60 10.74 45.87 9.81 4.73
for the OP inclination, which showed an OP superiorly
SCI (at S 5 5 mm) 49.78 9.45 45.87 8.32 3.91 *
inclined to the shifted side. SCI (at S 5 10 mm) 44.57 7.25 41.79 5.15 2.78
Measurement of occlusal guidance showed that, TCI (at S 5 3 mm) 3.52 5.81 8.01 9.03 4.49 ‡
‡
although there were no significant differences between TCI (at S 5 5 mm) 3.41 4.75 6.90 7.98 3.49
‡
the shifted and nonshifted sides in the incisors, buccal TCI (at S 5 10 mm) 3.46 3.78 7.10 5.60 3.64
S-E difference 0.85 0.91 0.60 0.82 0.25
segments from the canine through the first molar had
significantly steeper inclinations on the nonshifted side. Quantity, Distance between the reference position and maximum
Measurement results of quantity of condylar move- opening position; SCI, sagittal condylar inclination; S, starting point;
ment, sagittal condylar inclination at several distances TCI, transversal condylar inclination; S-E difference, difference
between start and end points.
(3, 5, and 10 mm of translation); transversal condylar *P \0.05 (Student t test); †P \0.01 (Student t test); ‡P \0.01 (Welch
inclination (same as the Bennett angle), and difference analysis).
of start and end points of condylar movement are shown
in Tables III, IV, and V. Measurement of condylar
movement during opening and closing, protrusion and During mediotrusive movement, sagittal condylar
retrusion, and mediotrusion showed that the shifted inclination in the nonshifted side had the same tendency
side of the condyle moved significantly more than as opening and closing, and protrusion and retrusion
the nonshifted side. The sagittal condylar inclination movements, and transversal condylar inclination in the
in the nonshifted side tended to have a steeper shifted side of the condyle showed significantly smaller
inclination than that in the nonshifted side (Table III). values relative to the other side (Table V). The start and
The shifted side of the condyle during symmetric con- end difference had a larger value in the shifted side than
dylar movement (open/close, protrusion/retrusion) had in nonshifted side, suggesting that the joint on the
a tendency to move outward; this showed negative shifted side was looser.
values of transversal condylar inclination and was sig- There were 4 types of lateral translation behavior in
nificantly different from the nonshifted side (Tables III opening and closing movements of the condyle: no DY
and IV). shift, DY shift with limited movement (\8 mm), DY
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 4
Table VI. Comparison of occurrence 6Y, joint derangement, and overrotation in MLD
Subjects (n 5 115) Except closed lock and overrotation (n 5 71)
n % n %
DY 58 50.4 58
No DY 13 11.3 13
Closed lock 26 22.6 — —
Overrotation 18 15.7 — —
*Data from Mito et al.19
shift with excess movement, and DY shift with normal
quantity. Distribution of these patterns is shown in
Table VI. Approximately 90% of MLD patients had
DY shift. Excluding the DY shift with limited and ex-
cess movements, because these groups indicated the
possibility of closed lock and loosening of TMJ, DY
shift with normal quantity was 81.6%, whereas the no
DY shift was only 18.4%. These results suggested that
the DY shift is 1 functional indicator for MLD.
The results regarding the relationship between the
direction of MLD and the direction of DY shift indi-
cated that 77.6% of the subjects coincided in both direc-
tions, suggesting that MLD was caused by not only
mandibular shift, but also condylar shift (Table VII).
DISCUSSION
We demonstrated that MLD is not due to simple
mandibular lateral shift, but, rather, the mandible was
3-dimensionally rotated along with condylar displace-
ment to the contralateral side. Therefore, it was specu-
lated that decreasing or increasing the dental vertical
height on 1 side because of multiple factors (bad pos-
tural habits such as 1-sided mastication, posterior dis-
crepancy resulting in difference in eruption between
both sides, and difference in restorative material height
between both sides leading to occlusal interferences or
external trauma history), resulting in inclination of the
OP, can be a potential risk factor for dysfunctional lat-
eral shift of the mandible to the side of less vertical di-
mension.18 Contralateral displacement of the condyle
causes DY shift during symmetrical condylar move-
ment such as opening and closing, probably because
the displaced condyle compromises the integrity and
synchronism of the condyle-disc assembly. Also, the de-
ranged condition of the displaced condyle achieves
a normal relationship in terms of functional movement
and results in DY shift of the condyle (Fig 3).
In our previous results regarding MLD and temporo-
mandibular disorders, 65% of the MLD group had TMJ
discomfort, and 84.6% of the symptoms were present in
the shifted side of the TMJ, but the prevalence of TMJ
Ishizaki et al 454.e7
General orthodontic patients* (n 5 1658)
n %
81.6 168 10.1
18.4 1217 73.4
162 6.7
111 9.8
Table VII. Coincidence of directions of MLD and 6Y
Subjects (n 5 58)
n %
MLD with DY 58
Coincidence of MLD and DY 45 77.6
Noncoincidence of MLD and DY 13 22.4
symptoms in nonshifted side was only 23.1%.5 Also,
our previous studies with MRI and condylograph
showed that the disc-condyle relation in the deranged
joint results in different types of DY shift, with a close
relationship between the direction of DY shift and
direction of disc displacement.6,19 Disc displacement
in the anteromedial, anterolateral, lateral, or medial
directions caused DY shift to the direction that leads
to a normal relationship of the disc-condyle assembly.
It is not known how MLD is related to internal de-
rangement of TMJ. As shown in this study, the mandible
rotates to the side of the lower vertical dimension ac-
companied by a shift of the condyle to the contralateral
side. Therefore, the shifted side of the condyle is more
compressed in the glenoid fossa during mastication
and parafunction, whereas the nonshifted side is in a dis-
tractive unloaded situation (Fig 4). It can be speculated
that the compression side of the TMJ is more suscepti-
ble to develop internal derangement.
The occlusal plane is an important element in posi-
tioning and adapting the mandible. Continuous horizon-
talization of the sagittal occlusal plane during the
growing processes induces forward adaptation of the
mandible by anterior rotation, consequently establish-
ing a Class III skeletal frame, whereas a steep occlusal
plane induces Class II skeletal problems. As shown in
this study, the OP in MLD was inclined superiorly to-
ward the shifted side; this resulted in less vertical height
of the shifted side than of the contralateral side (Table I).
Therefore, the mandible rotated in a 3D way accompa-
nied by tilting of the AG to the same direction as shown
in Figure 4. Strong correlation between the OP and AG
inclinations suggests that, in the development of MLD,
454.e8 Ishizaki et al American Journal of Orthodontics and Dentofacial Orthopedics
April 2010

Table VIII. Associations tested

Correlation
Association coefficient (r)*

Frontal occlusal plane inclination and mandibular 0.498

deviation
Antegonial plane inclination and mandibular 0.607
deviation
Frontal occlusal plane inclination and antegonial 0.595
plane inclination
Condylar shift and antegonial plane inclination 0.227
Condylar shift and mandibular deviation 0.129

*P \0.01 (Pearson product-moment correlation coefficient).

vertical dimension differences between the right and left

sides cause lateral shifting of the mandible followed by
functional asymmetry. In addition to these, the condyles
were shifted to the contralateral side (Fig 4). From these
observations, it can be postulated that this kind of man-
dibular rotation might cause strong compression in the
shifted side of the condyle and secondarily cause inter-
nal derangement of the TMJ and osteoarthritic changes
in the condyle. However, in some cases, it was sug-
gested that various pathologic conditions that affect
the TMJ can manifest as facial asymmetries, including
congenital disorders such as hemifacial microsomia,
condylar hyperplasia, internal derangements, rheuma-
toid arthritis, and osteoarthritis causing advanced joint
degeneration that can cause shortening of the condyle
with subsequent skeletal asymmetry.20
Schmid and Mongini21 also postulated that cranio-
mandibular structural asymmetry can be congenital or
hereditary, or can be acquired from traumatic infections.
During growth, quantitative and qualitative alterations
of the functional loads applied to the bones might mod-
ify their developmental pattern and lead to asymmetry.
Although the etiology of skeletal asymmetry is not
well understood and has been associated with crossbites
and occlusal interferences, occlusal alterations can lead
to mandibular displacement in maximum intercuspidation
and, consequently, to apparent asymmetry.22 Therefore
a distinction can be drawn among structural asymmetries,
displacement asymmetries, and mixed types.21
Occlusal alterations such as interferences or differ-
ences in the vertical height of the dentition with lateral
shifting of the mandible appear to be the approach from
an occlusal point of view to restore occlusal and articu-
lation function. Some case reports of MLD have shown
that patients can be successfully treated based on these
considerations by orthodontic treatment without surgi-
cal intervention.12,23
The results from occlusal guidance measurement
showed that the nonshifted side of the occlusal guidance
Fig 4. Schematic drawing of development of MLD. The
OP in MLD is inclined superiorly on the shifted side, indi-
cating that the vertical height of the shifted side is less
than that of the contralateral side. The mandible rotated
3-dimensionally, accompanied by tilting of the AG in the
same direction. The condyles shifted to the contralateral
side. This kind of mandibular rotation can cause strong
compression on the shifted side of the condyle and
also internal derangement of the TMJs and osteoarthritic
changes of the condyle. OP, Frontal occlusal plane; AG,
frontal mandibular plane.
inclination in the buccal segment was steeper than in the
shifted side (Table II). This is probably 1 reason for
MLD, because too steep an inclination on 1 side of
the buccal teeth interferes with the mandibular adapta-
tion to that side and induces unilateral chewing at the
flat guidance side (contralateral side).
Therefore, based on these observations, 2 possible
mechanisms were suggested for explaining the develop-
ment of MLD. First, the difference in vertical height of
the dentition on both sides creates an occlusal fulcrum
on the posterior molar of the higher side. In this situation,
biting forces lead to a distractive load against the TMJ
on the opposite side.24,25 It was suggested that the tilting
OP followed by mandibular displacement including
condylar displacement can lead to internal derangement
of the TMJ or asymmetrical condylar growth. Second,
a difference in occlusal guidance between the 2 sides
causes a slight mandibular shift with a consequent
unilateral chewing habit. This generates more occlusal
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 4
load on the chewing side and prevents eruption of teeth on
the chewing side, tilts the OP superiorly to the same side,
and compresses the condyle against the glenoid fossa on
the chewing side.
CONCLUSIONS
Our results suggest that MLD is a problem that in-
volves many factors such as occlusal vertical dimension,
occlusal plane inclination, internal derangement of
TMJs, functional DY shift of the condyle during func-
tion, occlusal guidance, and facial asymmetry. All these
characterizations, together with the clinical implica-
tions, should be considered in the treatment protocol
for MLD malocclusion and addressed for differential
control of the occlusal plane in both sides. Also, an early
approach to MLD problems is a priority, and the DY shift
of the condyle during function is a useful indicator to
detect MLD in growing children.
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