ONLINE ONLY

Three-dimensional computed tomography

analysis of mandibular morphology in patients
with facial asymmetry and mandibular
prognathism
Kug-Ho You,a Kee-Joon Lee,b Sang-Hwy Lee,c and Hyoung-Seon Baikd
Seoul, Korea

Introduction: The purpose of this study was to investigate the dimensional changes in each skeletal unit in the
mandibles of patients with facial asymmetry and mandibular prognathism. Methods: The patients consisted
of 50 adults with mandibular prognathism, divided into the symmetry group (n 5 20) and the asymmetry group
(n 5 30) according to the degree of menton deviation. Three-dimensional computed tomography scans were
obtained with a spiral computed tomography scanner. Landmarks were designated on the reconstructed
3-dimensional surface models. The lines to represent condylar, coronoid, angular, body, and chin units
were used. Ramal and body volumes were measured in the hemi-mandibles. Results: In the asymmetry
group, condylar and body unit lengths were significantly longer, and coronoid unit length was significantly
shorter on the nondeviated side than on the deviated side (P \0.01). Angular and chin unit lengths were not
significantly different between the 2 sides (P .0.05). Ramal volume was significantly greater on the nondevi-
ated side (P \0.01), but body volume was not significantly different between the 2 sides (P .0.05).
Conclusions: Both condylar and body units appeared to contribute to mandibular asymmetry, with a more
central role of the condylar unit. (Am J Orthod Dentofacial Orthop 2010;138:540.e1-540.e8)

F
acial symmetry is defined as the correspondence
in size, form, and arrangement of the facial fea-
tures on opposite sides of the median sagittal
plane.1 Facial asymmetry is not uncommon. In groups
with dentofacial deformities, previous studies reported
incidences of facial asymmetry of 34% in the United
States2 and 25% in Hong Kong,3 and, especially in
groups with skeletal Class III, 42.3% in Korea4 and
40% in the United States.2 In spite of the high preva-
lence, reliable diagnostic measures for the assessment
of the etiology of facial asymmetry have not been estab-
lished, possibly due to the 3-dimensional (3D) complex-
ity of the problem. In particular, the assessment of the
asymmetry in each part of the craniofacial region might
help to understand the etiology.5,6
From the College of Dentistry, Yonsei University, Seoul, Korea.
a
Postgraduate student, Department of Orthodontics.
b
Associate professor, Department of Orthodontics.
c
Professor, Department of Oral and Maxillofacial Surgery.
d
Professor, Department of Orthodontics.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts of companies described in this article.
Reprint requests to: Hyoung-Seon Baik, Department of Orthodontics, College
of Dentistry, Yonsei University, Sinchon-Dong 134, Seodaemun-Gu, Seoul
120-749, South Korea; e-mail, baik@yuhs.ac.
Submitted, October 2009; revised and accepted, April 2010.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.04.025
Two-dimensional (2D) x-ray films such as poster-
oanterior cephalograms,7-9 submentovertex views,10,11
and panoramic views12 have several limitations, such
as magnification, distortion, and unclearness. In poster-
oanterior cephalograms, projection errors are caused by
vertical head rotation,13 and width measurements have
not been dependable in the diagnosis of facial asymme-
try.14 Moreover, conventional and digital panoramic im-
ages are not expected to offer reliable information on
the exact dimensions.15
To overcome these limitations, paired coplanar x-ray
images16 and 3D cephalometric techniques17 have been
used. However, 3D images reconstructed from 2D x-ray
images are also subject to the limitations of 2D x-rays re-
lated to the orientation of head position and the definition
of reproducible landmarks on each x-ray film. Therefore,
orthodontic diagnosis using 3D computed tomography
(CT) has recently been brought into attention18,19 for
the following reasons: (1) actual measurement without
distortion regardless of head posture is possible20,21;
(2) real anatomic surface landmarks, not projected
landmarks, are used for the dimensional measurements;
and (3) it enables volumetric measurements of an
object. Hence, 3D CT is considered an effective tool to
understand asymmetry.19
Previous 2D studies on facial asymmetry reported
that the mandible appears to be the dominant factor in
540.e1
540.e2 You et al American Journal of Orthodontics and Dentofacial Orthopedics
November 2010

facial asymmetry.2,22 Accordingly, some 3D studies on Table I. Patient characteristics in the symmetry and
facial asymmetry focused on the characteristics of the asymmetry groups
mandible, reporting the differences of the linear Variable Mean SD Minimum Maximum
measurements such as ramal height and body length
between the nondeviated and deviated sides in Symmetry group
asymmetric mandibles.5,6,23 In spite of ample evidence Age (y) 25.1 4.2 20.0 33.0
ANB ( ) 3.3 2.6 0.4 8.7
of the gross morphologic change in the asymmetric
Pog to N (mm) 8.7 3.8 5.1 18.0
mandible, information on the role of each skeletal unit perpendicular (mm)
in the development of mandibular asymmetry is MD (mm) 1.2 0.5 0.4 2.0
scarce. According to Moss and Rankow,24 the mandible Asymmetry group
is a composite of relatively independent skeletal units Age (y) 22.6 6.2 19.5 40.0
ANB ( ) 2.8 2.6 0.0 10.1
including alveolar process, coronoid process, angular Pog to N (mm) (y) 7.0 3.4 5.1 13.0
process, body, condylar process, and chin. Examining perpendicular (mm)
the asymmetric mandible by the skeletal units might MD (mm) 7.7 3.4 4.0 15.5
be helpful for understanding the etiology of mandibular
MD, The degree of menton deviation.
asymmetry. The purpose of this study was to measure
the dimensional changes in each skeletal unit in the man- data were reconstructed into 3D images (176 HU thresh-
dibles of patients with facial asymmetry and mandibular old value) using V-works software (version 4.0,
prognathism. CyberMed, Seoul, Korea). The mandibles were separated
from the whole images, and the teeth above the alveolar
bone in the mandibles were removed.
MATERIAL AND METHODS Landmarks (Table II and Fig 1) were designated on
Clinical and 2D radiographic examinations were the reconstructed 3D surface model, and their positions
carried out on patients who visited the Yonsei Univer- were verified on the axial, coronal, and sagittal slices.
sity Dental Hospital, Seoul, Korea, between 2005 and The following bilateral measurements were made (Fig 1):
2009. The patients consisted of 50 adults with skeletal (1) condylar unit length: Consup-F; (2) coronoid
Class III with mandibular prognathism (ANB, \0 ; unit length: Corsup-F; (3) angular unit length: F-Gomid;
Pog to N perpendicular, .5.0 mm), no systemic disease, (4) body unit length: F-MF; (5) chin unit length:
and no degenerative disease of the temporomandibular MF-Pog; (6) condylar width: Conmed-Conlat; (7) ramal
joint. Because the chin is strongly related to the percep- height: Consup-Gomid; (8) body length: Gomid-Me;
tion of facial asymmetry, facial asymmetry was defined (9) hemi-mandibular volume: the mandibular volume
by the degree of menton deviation (MD) from the mid- was divided into 2 hemi-mandibular volumes by the
sagittal reference line.22,25 The midsagittal reference plane connecting Me, B, and G; and (10) ramal and
line was defined with the methods recommended by body volumes: hemi-mandibular volume was divided
Grummons and Kappeyne van de Coppello.9 The sym- into ramal and body volumes by the plane connecting
metry group consisted of 20 adults (10 men, 10 women) Gomid, Jlat, and Jmed. The data were measured in units
whose MDs were less than 2 mm from the midsagittal of 0.01 mm and 0.01 3 103 mm3.
reference line. The asymmetry group consisted of 30
adults (15 men, 15 women) whose MDs were more
than 4 mm from the midsagittal reference line.22 The Statistical analysis
patient characteristics in the symmetry and asymmetry To examine intraobserver and interobserver errors,
groups are listed in Table I. we randomly selected 20 patients, and all linear and
The 3D CT scans were obtained by using a spiral CT volumetric measurements were performed bilaterally
scanner (CT Hispeed Advantage/GE Medical System, on 2 occasions, the initial assessment and the reassess-
Milwaukee, Wis) with a 512 3 512 matrix, 120 kV, ment after 2 weeks, by 3 observers (graduate students).
and 200 mA. The thickness of the axial image was The 2 assessments by each observer were analyzed with
3.0 mm, and the table speed was 6 mm per second. The the intraclass correlation for intraobserver reliability,
patients were positioned with the Frankfort horizontal and the first and second assessments of 3 observers,
plane perpendicular to the floor and the facial midline respectively, for interobserver reliability. The method
coinciding with the long axis of the CT machine. The errors were calculated according to Dahlberg’s formula,
gantry had 0 inclination. The digital imaging and com- Se 5 O(D2/N) (D, the difference between double
munication in medicine (DICOM) images were created measurements, and N, the number of paired double
in 1.0-mm slice thicknesses after scanning. The DICOM measurements).26 The Shapiro-Wilks test for normality
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 5
Table II. Description of mandibular landmarks
Landmark
Consup (condylion superius)
Conmed (condylion medialis)
Conlat (condylion lateralis)
Corsup (coronoid superius)
F (fossa of mandibular foramen)
Jlat
Jmed
Gopost (gonion posterius)
Gomid (gonion midpoint)
Goinf (gonion inferius)
MF (mental foramen)
Me (menton)
Pog (pogonion)
B (supramentale)
G (genial tubercle)
showed that all measurements were normally distrib-
uted. Because the 2-sample t test showed that MD and
the differences in the measurements between the male
and female groups were not significantly different, no
differentiation was made for sex. The 2-sample t test
was used to compare the measurements between the
symmetry and asymmetry groups, and the paired t test
was used to compare the measurements between the
nondeviated and deviated sides. In the asymmetry
group, 1-way analysis of variance (ANOVA) was used
to compare the differences in the skeletal unit lengths,
and the Tukey test was used to show the differences in
the skeletal unit lengths with significant differences.
The Pearson correlation analysis was used to determine
correlations between MD and the measurements. Statis-
tical evaluations were performed at the 5% level of
significance with SPSS for Windows (version 17.0,
SPSS, Chicago, Ill).
RESULTS
Intraclass correlation coefficients ranged from 0.907
to 0.969 for intraobserver reliability, and from 0.905 to
0.921 for interobserver reliability, indicating high reli-
ability of the measurements used in this study. The intra-
observer measurement errors ranged from 0.24 to 0.64
mm for linear measurements and from 43.23 to 92.23 mm3
for volumetric measurements. The interobserver
measurement errors were from 0.41 to 0.98 mm for
linear measurements, and 51.93 to 100.98 mm3 for
volumetric measurements.
The asymmetry group showed significantly greater
differences in condylar unit length (P \0.01), body
unit length (P \0.01), coronoid unit length (P \0.05),
You et al 540.e3
Definition
The most superior point of the condylar head
The most medial point of the condylar head
The most lateral point of the condylar head
The most superior point of the coronoid process
The most inferior point on the fossa of the mandibuar foramen
The most lateral and deepest point of the curvature formed at the junction of
the mandibular ramus and body
The most medial and deepest point of the curvature formed at the junction of
the mandibular ramus and body
The most posterior point on the mandibular angle
The midpoint between Gopost and Goinf on the mandibular angle
The most inferior point on the mandibular angle
The entrance of the mental foramen
The most inferior midpoint on the symphysis
The most anterior midpoint on the symphysis
The midpoint of the greatest concavity on the anterior border of the
symphysis
The midpoint on genial tubercle
condylar width (P \0.01), ramal height (P \0.01), body
length (P \0.05), hemi-mandibular volume (P \0.01),
and ramal volume (P \0.01) between the nondeviated
and deviated sides, compared with the symmetry group
(Table III), confirming the overall asymmetrical mor-
phology of the mandible.
In asymmetry group, condylar and body unit lengths
were significantly longer, and coronoid unit length was
significantly shorter on the nondeviated side than on the
deviated side (P \0.01; Table IV). Angular and chin
unit lengths were not significantly different between the
2 sides (P .0.05; Table IV). One-way ANOVA showed
a significant difference in the skeletal unit lengths
(P\0.01). The Tukey test showed only that the difference
in angular unit length was not significantly different from
the difference in chin unit length (P .0.05). The differ-
ence in condylar unit length was significantly greater
than the difference in body unit length (P\0.01). Condy-
lar width was significantly wider, and ramal height and
body length were significantly longer on the nondeviated
side (P \0.01; Table IV).
MD was significantly correlated with the differences
in condylar unit length (Fig 2, A), body unit length
(Fig 2, B), ramal height, and body length (P \0.01;
Table IV). In the correlations between the skeletal units,
the difference in body unit length was significantly cor-
related with the differences in condylar unit length
(P\0.05) and coronoid unit length (P\0.01) (Table V).
Hemi-mandibular and ramal volumes were signifi-
cantly greater on the nondeviated side than on the
deviated side (P \0.01), but body volume was not sig-
nificantly different between the 2 sides (Table VI). MD
was significantly correlated with the differences in
540.e4 You et al American Journal of Orthodontics and Dentofacial Orthopedics
November 2010

Fig 1. Landmarks and measurements used in this study: A, a, condylar unit length; b, coronoid unit
length; c, angular unit length; d, body unit length; e, chin unit length. B, f, condylar width; g, ramal
height; h, body length.

Table III. Comparison of the differences in the measurements between the symmetry and asymmetry groups (2-sample
t test)
Symmetry group Asymmetry group

Measurement Mean SD Mean SD P value

Condylar unit length diff (mm) 0.45 1.66 5.69 4.10 \0.001†
Body unit length diff (mm) 0.18 1.47 3.23 2.52 \0.001†
Coronoid unit length diff (mm) 0.38 1.48 1.43 1.94 0.035*
Angular unit length diff (mm) 0.11 1.20 0.06 1.01 0.597
Chin unit length diff (mm) 0.12 0.93 0.11 1.19 0.955
Condylar width diff (mm) 0.34 1.49 2.24 1.96 \0.001†
Ramal height diff (mm) 0.65 1.19 5.57 3.74 \0.001†
Body length diff (mm) 0.59 1.59 2.01 2.15 0.010*
Hemi-mandibular volume diff (3103 mm3) 0.01 0.38 0.90 1.21 \0.001†
Ramal volume diff (3103 mm3) 0.03 0.38 0.95 0.89 0.001†
Body volume diff (3103 mm3) 0.02 0.52 0.05 0.72 0.205

*P \0.05; †P \0.01; diff, nondeviated side minus deviated side.

hemi-mandibular and ramal volumes (P\0.01; Table VI).
The difference in ramal volume was significantly
correlated with the differences in ramal height and
condylar unit length (P \0.01), but the difference in
body volume was not significantly correlated with the
difference in body length (P .0.05) (Table VII). Taken
together, a schematic diagram of the asymmetric mandi-
ble is shown in Figure 3.
DISCUSSION
Although the condylar cartilage is an important
growth site in the mandible, sharing histologic
characteristics with other long bones, its exact role in
the development of mandibular prognathism or asymme-
try is not known.27 To examine asymmetric mandibles
according to the skeletal units, linear measurements to
represent the condylar, coronoid, angular, body, and
chin units were used in this study. The mandibular and
mental foramina are important reference points located
at the junction of the skeletal units.28 Park et al28 tested
3 potential points (T, tip of the lingula; F, fossa of the
foramen; and C, an imaginary central point of the fora-
men entrance) to represent the exact location of the man-
dibular foramen, and suggested that point F is a good
American Journal of Orthodontics and Dentofacial Orthopedics You et al 540.e5
Volume 138, Number 5

Table IV. Comparison of the linear measurements between the nondeviated and deviated sides (paired t test), and cor-
relation with MD (Pearson correlation analysis) in the asymmetry group
Nondeviated side Deviated side Difference Correlation
with MD
Measurement (mm) Mean SD Mean SD Mean SD Minimum Maximum P value (P value)

Condylar unit length 50.39 3.86 44.70 4.69 5.69 4.10 0.16 14.29 \0.001* 0.658 (\0.001*)
Body unit length 63.92 4.62 60.69 4.47 3.23 2.52 0.50 9.53 \0.001* 0.624 (\0.001*)
Coronoid unit length 38.91 4.21 40.34 4.64 1.43 1.94 5.70 3.66 \0.001* 0.185 (0.329)
Angular unit length 20.37 2.54 20.43 2.62 0.06 1.01 1.81 1.96 0.734 0.045 (0.814)
Chin unit length 32.15 1.73 32.05 1.84 0.11 1.19 1.91 1.80 0.632 0.028 (0.885)
Condylar width 22.13 2.74 19.89 3.13 2.24 1.96 0.31 7.84 \0.001* 0.275 (0.142)
Ramal height 64.60 4.32 59.03 5.29 5.57 3.74 3.48 15.08 \0.001* 0.621 (\0.001*)
Body length 90.58 5.49 88.57 5.50 2.01 2.15 2.99 7.69 \0.001* 0.554 (0.001*)

*P \0.01; MD, the degree of menton deviation; difference, nondeviated side minus deviated side.

Fig 2. Scatter plots showing the degree of MD relative to the differences in A, condylar unit length
and B, body unit length.

reference point for the mandibular foramen in 3D images.
The mental foramen is the point where primary intra-
membranous ossification starts,29 and it is proposed that
the mental foramen is a good reference point for dividing
the mandibular corpus into body and chin units.28 There-
fore, we defined the skeletal unit lengths on the basis of
point F and the mental foramen.
In the asymmetry group, condylar and body unit
lengths were significantly longer on the nondeviated
side than on the deviated side, but chin unit length
was not significantly different between the 2 sides.
Moreover, MD was significantly correlated with the dif-
ferences in condylar and body unit lengths. These re-
sults suggested that both the condylar and body units
contribute to mandibular asymmetry, which is similar
to the development of mandibular prognathism.28 How-
ever, the difference in condylar unit length was signifi-
cantly greater than the difference in body unit length.
Therefore, the condylar unit appears to play a more cru-
cial role for mandibular asymmetry and prognathism
than the body unit, as proposed by Park et al.28 Consid-
ering individual variations, however, it is important to
plan a treatment strategy according to the patient’s
pattern of mandibular asymmetry.
Unlike the condylar and body units, angular unit
length was not significantly different between the 2
sides, and coronoid unit length was significantly shorter
on the nondeviated side. These results indicate that
540.e6 You et al American Journal of Orthodontics and Dentofacial Orthopedics
November 2010

Table V. Correlation between the differences in the skeletal unit lengths in the asymmetry group (Pearson correlation
analysis)
Correlation coefficient Coronoid unit Angular unit Body unit Chin unit
(P value) length diff length diff length diff length diff

Condylar unit length diff 0.058 (0.759) 0.226 (0.229) 0.435 (0.016*) 0.081 (0.671)
Coronoid unit length diff 0.265 (0.157) 0.484 (0.007†) 0.292 (0.118)
Angular unit length diff 0.304 (0.102) 0.059 (0.756)
Body unit length diff 0.259 (0.167)

*P \0.05; †P \0.01; diff, nondeviated side minus deviated side.

Comparison of the volumetric measurements between the nondeviated and deviated sides in the asymmetry
Table VI.
group (paired t test)
Nondeviated side Deviated side Difference Correlation
with MD
3 3
Measuremens (x10 mm ) Mean SD Mean SD Mean SD Minimum Maximum P value (P value)

Hemi-mandibular volume 37.17 5.40 36.27 55.58 0.90 1.21 0.46 3.34 \0.001* 0.553 (0.002*)
Ramal volume 11.97 23.88 11.03 25.47 0.95 0.89 0.02 2.96 \0.001* 0.642 (\0.001*)
Body volume 25.20 34.54 25.25 35.66 0.05 0.72 1.43 1.69 0.729 0.118 (0.535)

*P \0.01; difference, nondeviated side minus deviated side.

Correlation between the differences in the volumetric and linear measurements in the asymmetry group
Table VII.
(Pearson correlation analysis)
Correlation coefficient Condylar unit Coronoid unit
(P value) Ramal height diff length diff length diff Body length diff

Ramal volume diff (mm3) 0.801 (\0.001*) 0.727 (\0.001*) 0.129 (0.495)
Body volume diff (mm3) 0.019 (0.921)

*P \0.01; diff, nondeviated side minus deviated side.

mandibular asymmetry might be caused by or lead to
differential changes among the skeletal units, with the
central role played by the condylar and body units.
The skeletal unit might be subject to the appositional
change possibly associated with the muscles and
other soft tissues. It has been reported that the coronoid
unit is affected by the temporalis muscle,24,30 and
the angular unit by the masseter and medial pterygoid
muscles.24 It was reported that the volumes of the
temporalis23 and masseter23,31 muscles were not
significantly different between the 2 sides in patients
with facial asymmetry. However, the cause-and-effect
relationship between the skeletal units and the muscles
is not yet clear. Considering the complex action of the
muscle attachment along with the muscular volume
and activity, further studies regarding soft tissues are
needed.
Our results showed that body length was signifi-
cantly longer on the nondeviated side; this contrasted
with the findings by Baek et al.6 A significant correlation
between body length and MD implies a possible role of
body elongation in the pathogenesis of asymmetry.
Hence, our next question was whether the elongation
in either the body or the ramus is associated with the
actual increase in volume, which implies regional
hypertrophy.
In spite of reduced coronoid unit length on the non-
deviated side, ramal volume was greater on the nonde-
viated side. The increase in condylar unit length and
condylar width might have contributed to the increase
in ramal volume. On the contrary, there was no signifi-
cant difference in body volume between the 2 sides.
Legrell and Isberg32 reported that disk displacement
could cause mandibular asymmetry in growing rabbits,
leading to excessive inferiorly directed bone growth
along the lower border of the mandibular body with
shortening of the mandibular ramus. This might explain
no significant difference in body volume between the 2
sides. Additionally, our findings further suggested the
possibility that the elongation in the ramus was related
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 5
Fig 3. Schematic diagram of morphologic changes on
the nondeviated side compared with the deviated side
in the mandibles of patients with facial asymmetry and
mandibular prognathism: a, coronoid unit length; b, con-
dylar unit length; c, angular unit length; d, body unit
length; e, chin unit length; N-S, not significant.
to the increase in osteogenesis, whereas the body
appeared to have been elongated without an actual in-
crease in volume. Hence, it could be postulated that
the condylar unit, compared with the other units, plays
a central role in the affected side of the mandible in
aspects of both length and volume.
It is difficult to describe the precise etiology of
asymmetry based on these findings because of some
limitations. The spatial position of the mandible was
not defined in this study. For instance, possible model-
ing in the mandibular fossa or the changes in the cranial
base could have influenced the resultant phenotype—ie,
the MD. Second, the muscles and other soft tissues were
not considered; this is significant for interpretation of
the form-and-function relationship. A longitudinal
change at each skeletal unit, along with histologic inves-
tigations might be helpful for understanding the patho-
genesis of skeletal asymmetry.
CONCLUSIONS
In patients with facial asymmetry and mandibular
prognathism, 3D assessments of the skeletal units
were conducted in the mandibles. Both the condylar
and body units appeared to contribute to mandibular
asymmetry, with a more central role of the condylar
unit. Therefore, it is necessary to carefully evaluate
these skeletal units when planning a treatment strategy
for the correction of mandibular asymmetry and
prognathism.
You et al 540.e7
REFERENCES
1. Peck H, Peck S. A concept of facial esthetics. Angle Orthod 1970;
40:284-318.
2. Severt TR, Proffit WR. The prevalence of facial asymmetry in the
dentofacial deformities population at the University of North
Carolina. Int J Adult Orthod Orthognath Surg 1997;12:171-6.
3. Samman N, Tong AC, Cheung DL, Tideman H. Analysis of 300
dentofacial deformities in Hong Kong. Int J Adult Orthod Orthog-
nath Surg 1992;7:181-5.
4. Yoon KS, Jung YS, Kang GC, Park HS. Facial asymmetry with
mandibular prognathism: a new trial of classification and interpre-
tation. J Korean Assoc Oral Maxillofac Surg 2004;30:108-20.
5. Kwon TG, Park HS, Ryoo HM, Lee SH. A comparison of cranio-
facial morphology in patients with and without facial asymme-
try—a three-dimensional analysis with computed tomography.
Int J Oral Maxillofac Surg 2006;35:43-8.
6. Baek SH, Cho IS, Chang YI, Kim MJ. Skeletodental factors af-
fecting chin point deviation in female patients with Class III mal-
occlusion and facial asymmetry: a three-dimensional analysis
using computed tomography. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2007;104:628-39.
7. Letzer GM, Kronman JH. A posteroanterior cephalometric evalu-
ation of craniofacial asymmetry. Angle Orthod 1967;37:144-58.
8. Vig PS, Hewitt AB. Asymmetry of the human facial skeleton.
Angle Orthod 1975;45:125-9.
9. Grummons DC, Kappeyne van de Coppello MA. A frontal asym-
metry analysis. J Clin Orthod 1987;21:448-65.
10. Berger H. Problems and promises of basilar view cephalograms.
Angle Orthod 1961;31:237-45.
11. Forsberg CT, Burstone CJ, Hanley KJ. Diagnosis and treatment
planning of skeletal asymmetry with the submental-vertical radio-
graph. Am J Orthod 1984;85:224-37.
12. Habets LL, Bezuur JN, Naeiji M, Hansson TL. The orthopanto-
mogram, an aid in diagnosis of temporomandibular joint prob-
lems. II. The vertical symmetry. J Oral Rehabil 1988;15:465-71.
13. Koh EH, Lee KH, Hwang HS. Effects of vertical head rotation on
the posteroanterior cephalometric measurements. Korean J
Orthod 2003;33:73-84.
14. Pirttiniemi P, Miettinen J, Kantomaa T. Combined effects of errors
in frontal-view asymmetry diagnosis. Eur J Orthod 1996;18:
629-36.
15. Van Elslande DC, Russett SJ, Major PW, Flores-Mir C. Mandib-
ular asymmetry diagnosis with panoramic imaging. Am J Orthod
Dentofacial Orthop 2008;134:183-92.
16. Baumrind S, Moffitt FH, Curry S. The geometry of three-
dimensional measurement from paired coplanar x-ray images.
Am J Orthod 1983;84:313-22.
17. Grayson B, Cutting C, Bookstein FL, Kim H, McCarthy JG. The
three-dimensional cephalogram: theory, technique, and clinical
application. Am J Orthod Dentofacial Orthop 1988;94:327-37.
18. Park SH, Yu HS, Kim KD, Lee KJ, Baik HS. A proposal for a new
analysis of craniofacial morphology by 3-dimensional computed
tomography. Am J Orthod Dentofacial Orthop 2006;
129:600.e23-34.
19. Hwang HS, Hwang CH, Lee KH, Kang BC. Maxillofacial 3-di-
mensional image analysis for the diagnosis of facial asymmetry.
Am J Orthod Dentofacial Orthop 2006;130:779-85.
20. Cavalcanti MG, Vannier MW. Quantitative analysis of spiral com-
puted tomography for craniofacial clinical applications. Dento-
maxillofac Radiol 1998;27:344-50.
21. Chang HS, Baik HS. A proposal of landmarks for craniofacial
analysis using three-dimensional CT imaging. Korean J Orthod
2002;32:313-25.
540.e8 You et al
22. Haraguchi S, Takada K, Yasuda Y. Facial asymmetry in sub-
jects with skeletal Class III deformity. Angle Orthod 2002;
72:28-35.
23. Kwon TG, Lee KH, Park HS, Ryoo HM, Kim HJ, Lee SH. Rela-
tionship between the masticatory muscles and mandibular skele-
ton in mandibular prognathism with and without asymmetry.
J Oral Maxillofac Surg 2007;65:1538-43.
24. Moss ML, Rankow RM. The role of the functional matrix in man-
dibular growth. Angle Orthod 1968;38:95-103.
25. Ahn JS, Lee KH, Hwang HS. Relationship between perception of
facial asymmetry and posteroanterior cephalometric measure-
ments. Korean J Orthod 2001;31:489-98.
26. Dahlberg G. Statistical methods for medical and biological stu-
dents. New York: Interscience Publications; 1940.
27. Sicher H. Growth of the mandible. Am J Orthod Oral Surg 1947;
33:30-5.
American Journal of Orthodontics and Dentofacial Orthopedics
November 2010
28. Park W, Kim BC, Yu HS, Yi CK, Lee SH. Architectural character-
istics of the normal and deformity mandible revealed by
three-dimensional functional unit analysis. Clin Oral Investig
Epub ahead of print. 2009 Oct 13.
29. Lee SK, Kim YS, Oh HS, Yang KH, Kim EC, Chi JG. Prenatal de-
velopment of the human mandible. Anat Rec 2001;263:314-25.
30. Isberg A, Eliasson SE. A cephalometric analysis of patients with
coronoid process enlargement and locking. Am J Orthod Dentofa-
cial Orthop 1990;97:35-40.
31. Seo Sa, Baik Hs, Hwang Cj, Yu HS. Analysis of masseter muscle in
facial asymmetry before and after orthognathic surgery using 3-di-
mensional computed tomography. Korean J Orthod 2009;39:18-27.
32. Legrell PE, Isberg A. Mandibular height asymmetry following ex-
perimentally induced temporomandibular joint disk displacement
in rabbits. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1998;86:280-5.