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 Table of Contents  
Year : 2017  |  Volume : 51  |  Issue : 3  |  Page : 185-191

Nonsurgical correction of facial asymmetry and occlusal plane cant in a nongrowing female: Acase report

1 Senior Resident, Department of Orthodontics and Dentofacial Orthopedics, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh, India
2 Prof, Department of Orthodontics and Dentofacial Orthopedics, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh, India
3 PG Student, Department of Orthodontics and Dentofacial Orthopedics, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh, India

Date of Submission31-Jan-2017
Date of Acceptance04-Apr-2017
Date of Web Publication17-Jul-2017

Correspondence Address:
Aditi Gaur
Department of Orthodontics and Dentofacial Orthopaedics, Dr. Z. A. Dental College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jios.jios_10_17

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The present article describes a case report of a 19-year-old female with facial asymmetry and chin deviation towards the right. Sequential extraction of all four first premolars was performed for midline correction and alignment of blocked out lateral incisors. After the teeth were aligned in the arch, asymmetric elastics were used for correction of the canine and molar relation. Improved facial and dental esthetics were achieved after orthodontic treatment. The posttreatment results were maintained 1year after the treatment. Orthodontic treatment can successfully improve facial appearance in patients with mild facial asymmetry, thus eliminating the need for orthognathic surgery in such cases.

Keywords: Asymmetric elastics, facial asymmetry, nonsurgical

How to cite this article:
Gaur A, Maheshwari S, Verma SK, Mian F. Nonsurgical correction of facial asymmetry and occlusal plane cant in a nongrowing female: Acase report. J Indian Orthod Soc 2017;51:185-91

How to cite this URL:
Gaur A, Maheshwari S, Verma SK, Mian F. Nonsurgical correction of facial asymmetry and occlusal plane cant in a nongrowing female: Acase report. J Indian Orthod Soc [serial online] 2017 [cited 2019 May 25];51:185-91. Available from: http://www.jios.in/text.asp?2017/51/3/185/210902

  Introduction Top

The phenomenon of facial asymmetry can be described as differences in size or relationship between right and left sides of the face. Minor facial asymmetry is common and can be observed in every individual.[1] Facial asymmetry affects lower half of the face more than upper face.[2] The appearance of facial asymmetry as abnormal depends on individual perception. Mild to moderate facial asymmetry can be managed by camouflage orthodontic treatment. Severe skeletal asymmetry most often requires a surgical management protocol.[3] Not all adult facial asymmetry patients are candidates for surgical correction; therefore, patient assessment and selection remain major issues in diagnosis and treatment planning.[4]

This case report describes orthodontic management of an adult female with ClassI skeletal profile, facial asymmetry, and mandibular deviation to the right. Orthodontic treatment was considered for the patient to correct the malocclusion and relieve the interferences being created by blocked out dentition.

  Diagnosis and Etiology Top

A 19-year-old female patient reported to the Department of Orthodontics with the chief complaint of noticeable facial asymmetry and irregularly positioned teeth. On evaluating patient history, no medical disorder or dental history was inferred from the details provided by the patient and her parents. On extraoral examination, it was observed that the patient had mesoprosopic, asymmetrical face with convex profile, and competent lips[Figure1]. The patient had a mesofacial appearance and the facial height on right side was shorter as compared to the left side, on frontal examination. The smile of the patient was asymmetric with a nonconsonant smile arc and an increase in lateral negative space on right side. Incisor visibility on posed smiling was 80%. Acant of occlusal plane was observed in the patient during smiling[Figure2]. Occlusal plane canting was also recorded during rest position using a ruler[Figure3]. On evaluating the lower border of the mandible, there was shift of the mandible toward the right. The left lower border of the mandible(extending from midpoint of chin to the angle of the mandible) was longer than the right lower border when observed during submental view examination[Figure4]. While conducting functional examination, no temporomandibular joint symptoms were detected. On assessing the path of closure, mandible deviation toward the right was noticed due to premature contacts on the lingually blocked lateral incisors. However, the patient also had marked skeletal asymmetry as the mandibular midline(menton) was shifted toward right from the mid-sagittal reference plane. On intraoral examination, it was observed that the patient had maxillary dental midline deviated to the right by 4mm from the facial midline and mandibular dental midline deviated to the same side by 8mm. Both skeletal and dental midlines were shifted when compared with the mid-sagittal reference plane. Maxillary and mandibular right lateral incisors were palatally and lingually blocked out, respectively. The patient had a ClassII molar relation on the right side and a ClassIII molar relation on the left side. The patient had an overjet of 2mm and a deep bite. Ascissor bite was present with respect to maxillary and mandibular first premolars on the right side.
Figure 1: Pretreatment photographs

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Figure 2: Pretreatment smile photographs

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Figure 3: Occlusal plane canting

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Figure 4: Submental view photograph

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Cephalometric findings showed that the patient had a normal growth pattern(FMA-23°) and a ClassI skeletal base(ANB-3°). The maxillary and mandibular incisors were normally positioned with respect to the cranial base[Figure5] and [Table1]. Orthopantomogram of the patient showed asymmetry in the mandible[Figure6]. Acomputed tomography(CT) scan was recorded which revealed severe skeletal discrepancy with asymmetric vertical and sagittal dimensions of mandibular ramus on the left and right sides. The volumetric three-dimensional scan showed a deficient mandible and associated soft tissue on right side of the face[Figure7]. Aposteroanterior(PA) cephalogram was taken to evaluate the asymmetry in the case. The PA cephalometric analysis showed that the linear distance of menton from mid-sagittal reference plane was 3mm toward right, antegonial notch on the right side deviated from mid-sagittal reference plane by 36mm, whereas on the left side, it was 39 mm[Figure8] and [Table2].
Figure 5: Pretreatment cephalogram

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Table 1: Cephalometric comparison

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Figure 6: Pre treatment OPG

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Figure 7: Pre treatment volumetric CT scan

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Figure 8: Pre Treatment PA cephalogram

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Table 2: Posteroanterior cephalometric comparison

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Treatment objectives

The aims of the treatment were as follows:

  • To correct facial asymmetry
  • Alignment and leveling of the arches
  • Midline correction
  • Correction of occlusal plane canting
  • Achieving ClassI molar and canine relation bilaterally
  • To achieve optimum soft tissue profile.

Treatment alternatives

Based on the diagnosis and treatment objectives, following treatment alternatives were considered:

  • Mandibular orthognathic surgery involving vertical ramus osteotomy followed by orthodontic mechanotherapy
  • Orthodontic treatment with extraction of all four first premolars and using asymmetric mechanics as camouflage treatment.

The patient refused to go for orthognathic surgery and wanted minimally invasive procedure. Thus, orthodontic treatment was initiated to give the best possible results to the patient.

Treatment progress

A removable deprogramming splint was given to the patient to provide disocclusion and readaptation of the musculature. The splint was continued for fourweeks. Bonding was done in both arches using MBT prescription 022 slot metal brackets. Left maxillary first premolar and right mandibular first premolars were extracted before alignment. Retraction of canine and midline correction was done using coil spring in maxillary and mandibular arches. Postmidline correction first premolar extraction was performed on the opposite sides[Figure9]. Space closure was completed in both arches. Acombination of asymmetric elastics with ClassII on the left side and ClassIII elastics on the right side were used to achieve a ClassI occlusion. The elastics were continued with heavy stainless steel wires for fourweeks, so as to avoid any change in the occlusal plane. Bracket repositioning and final finishing and detailing were performed using 014 NiTi wires. The appliances were removed after a period of 27months and retainers were placed in both arches. Posttreatment radiographs were recorded and analyzed[Figure10],[Figure11],[Figure12],[Figure13].
Figure 9: Canine retraction phase

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Figure 10: Post treatment photographs

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Figure 11: Post treatment Cephalogram

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Figure 12: Post treatment OPG

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Figure 13: Posteroanterior cephalogram analysis

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Treatment results

A ClassI occlusion with ideal overjet and overbite was achieved. Maxillary and mandibular midlines were coincident. Posttreatment functional examination was done which showed the absence of functional shift on closure. There was an improvement in the facial esthetics and smile of the patient[Figure14].
Figure 14: Comparison of facial asymmetry retreatment and posttreatment

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  Discussion Top

Management of cases with facial asymmetry depends on the severity of the discrepancy, the treatment needs of a case, and the esthetic awareness of the patient.

Facial asymmetry involves a combination of dental, skeletal, and soft tissue factors. Acomprehensive diagnosis is important in patients with facial asymmetry so as to formulate a treatment plan suited for each patient.[5],[6] A clinician has to keep in consideration the treatment needs and desire of the patient before deriving the treatment plan for a case.

CT provides three-dimensional details of the craniofacial skeleton and has been used for evaluating facial asymmetry. CT imaging helps in diagnosis and localizing the area of asymmetry, thus helping in surgical treatment planning of patients with facial asymmetry.[7] Cone-beam CT is a better alternative to CT scan as it reduces the radiation exposure to the patient when recording three dimensional images.[8]

Facial asymmetry may develop in an individual due to congenital, traumatic, or developmental deformities.[9] Developmental deformities may be associated with idiopathic causes which might gradually progress into definite facial asymmetry.[10]

In the present case, the patient had severe facial asymmetry with cant of occlusal plane, asymmetric vertical heights, and mandibular deviation toward the right side. The patient had ClassII occlusion on the right side and a ClassIII occlusion on the left side. This disturbance in occlusion could have been the cause of early mandibular shift developing into a true case of skeletal asymmetry.[11] Furthermore, the patient had lingually blocked incisors which caused occlusal interference, leading to guidance of mandible toward the right side.

Cases with mild to moderate facial asymmetry may be managed by minimal orthodontic treatment depending on the etiology of asymmetry and the ultimate treatment goal for the case.[12] More severe asymmetries require a combination of orthodontic and orthognathic management.[13]

Orthognathic surgery is an invasive procedure and is associated with the disadvantages of surgical risks and costs.[14] In the present case, the patient did present with the surgical treatment alternative, but the patient was not willing to undergo any extensive surgery. Deprogramming splints are designed to unlock the occlusion to remove interference due to premature contacts. The condyles are then allowed to return to their correct seated position in centric relation if the condition of the articular components permits. In the present case, a splint was given to establish optimum position of mandible to maxilla in centric relation before definitive occlusal therapy. It was observed that there was improvement in facial symmetry after 4weeks of splint therapy, after which fixed orthodontic treatment was initiated.

In our case, we extracted the premolars so as to gain space for alignment and correction of midline. Once the position of the incisors was corrected and the interferences were removed, there was significant improvement in the position of the mandible. The mandibular arch of the patient was asymmetric and the buccal segment on the right side of the arch was lingually inclined. Correction of the inclination of the posterior dentition also resulted in achieving improved symmetry of occlusion.

Asymmetric elastics were continued for a month to allow settling of occlusion into a ClassI relationship. Intermaxillary asymmetric elastics should be continued for a short period because excessive use of these elastics can result in occlusal plane canting and temporomandibular disorders(TMDs).[15]

Superimposition on PA cephalogram showed a change position of menton and improvement in the facial asymmetry although the underlying skeletal asymmetry was quite evident in the radiograph[Figure15]. Cephalometric superimposition showed an increase in the mandibular plane angle[Figure16]. The inclination of incisors was maintained at normal position. The ideal soft tissue profile of the patient was maintained.
Figure 15: Posteroanterior cephalometric superimposition

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Figure 16: Cephalometric superimposition

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Considerable improvement in the facial appearance of the patient was achieved at the end of the treatment. There was a notable reduction in the facial asymmetry. The patient was given retainers to maintain the corrected midline and the vertical dimension.

Stability of orthodontic treatment in adults for the correction of unilateral posterior crossbite is questionable. It has been reported that adaptive remodeling changes occur in the temporomandibular joint during growth and thus change in condylar position due to orthodontic treatment could lead to instability.[16] Previous studies have shown that the condyle assumes a concentric position after orthodontic treatment. Furthermore, orthodontic treatment was not shown to increase TMD.[17],[18] Long-term follow-up of clinical cases is required to establish the efficacy of orthodontic treatment in adult cases with facial asymmetry.

The case was evaluated after 1year and records were taken. The treatment results were stable1year after treatment[Figure17]. There was a mild relapse in the midline discordance. Amodified retainer was given to the patient to prevent further relapse and the patient was recalled for follow-up.
Figure 17: Photographs after 1 year

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  Conclusion Top

This patient had a facial asymmetry with ClassI skeletal profile and was successfully treated by orthodontic treatment. Ideal overjet, overbite, and good alignment were achieved. There was a significant improvement in the facial and dental appearance of the patient. Mild to moderate cases of facial asymmetry can be treated by camouflage orthodontic treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

BisharaSE, BurkeyPS, KharoufJG. Dental and facial asymmetries: A review. Angle Orthod 1994;64:89-98.  Back to cited text no. 1
SevertTR, ProffitWR. The prevalence of facial asymmetry in the dentofacial deformities population at the University of North Carolina. Int J Adult Orthodon Orthognath Surg 1997;12:171-6.  Back to cited text no. 2
KoEW, HuangCS, ChenYR. Characteristics and corrective outcome of face asymmetry by orthognathic surgery. JOral Maxillofac Surg 2009;67:2201-9.  Back to cited text no. 3
JungSK, KimTW. Treatment of unilateral posterior crossbite with facial asymmetry in a female patient with transverse discrepancy. Am J Orthod Dentofacial Orthop 2015;148:154-64.  Back to cited text no. 4
BurstoneCJ. Diagnosis and treatment planning of patients with asymmetries. Semin Orthod 1998;4:153-64.  Back to cited text no. 5
JacksonTH, MitroffSR, ClarkK, ProffitWR, LeeJY, NguyenTT. Face symmetry assessment abilities: Clinical implications for diagnosing asymmetry. Am J Orthod Dentofacial Orthop 2013;144:663-71.  Back to cited text no. 6
NurRB, Çakan DG, ArunT. Evaluation of facial hard and soft tissue asymmetry using cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2016;149:225-37.  Back to cited text no. 7
SilvaMA, WolfU, HeinickeF, BumannA, VisserH, HirschE. Cone-beam computed tomography for routine orthodontic treatment planning: A radiation dose evaluation. Am J Orthod Dentofacial Orthop 2008;133:640.e1-5.  Back to cited text no. 8
Cohen MM Jr. Perspectives on craniofacial asymmetry. III. Common and/or well-known causes of asymmetry. Int J Oral Maxillofac Surg 1995;24:127-33.  Back to cited text no. 9
ShahSM, JoshiMR. An assessment of asymmetry in the normal craniofacial complex. Angle Orthod 1978;48:141-8.  Back to cited text no. 10
IshizakiK, SuzukiK, MitoT, TanakaEM, SatoS. Morphologic, functional, and occlusal characterization of mandibular lateral displacement malocclusion. Am J Orthod Dentofacial Orthop 2010;137:454.e1-9.  Back to cited text no. 11
TurpinDL. Camouflage might not mean compromise. Am J Orthod Dentofacial Orthop 2003;123:241.  Back to cited text no. 12
LeganHL. Surgical correction of patients with asymmetries. Semin Orthod 1998;4:189-98.  Back to cited text no. 13
AnhouryPS. Nonsurgical treatment of an adult with mandibular asymmetry and unilateral posterior crossbite. Am J Orthod Dentofacial Orthop 2009;135:118-26.  Back to cited text no. 14
JansonG, de FreitasMR, ArakiJ, FrancoEJ, BarrosSE. ClassIII subdivision malocclusion corrected with asymmetric intermaxillary elastics. Am J Orthod Dentofacial Orthop 2010;138:221-30.  Back to cited text no. 15
PirttiniemiPM. Associations of mandibular and facial asymmetries - A review. Am J Orthod Dentofacial Orthop 1994;106:191-200.  Back to cited text no. 16
CarltonKL, NandaRS. Prospective study of posttreatment changes in the temporomandibular joint. Am J Orthod Dentofacial Orthop 2002;122:486-90.  Back to cited text no. 17
SadowskyC. The risk of orthodontic treatment for producing temporomandibular mandibular disorders: A literature overview. Am J Orthod Dentofacial Orthop 1992;101:79-83.  Back to cited text no. 18


  [Figure1], [Figure2], [Figure3], [Figure4], [Figure5], [Figure6], [Figure7], [Figure8], [Figure9], [Figure10], [Figure11], [Figure12], [Figure13], [Figure14], [Figure15], [Figure16], [Figure17]

  [Table1], [Table2]


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