Accepted Manuscript

A New Classification of Mandibular Asymmetry and Evaluation of SurgicalOrthodontic Treatment Outcomes in Class III Malocclusion
Yi-Jane Chen, Associate Professor, Chung-Chen Yao, Associate Professor, ZweiChieng Chang, Assistant Professor, Hsiang-Hua Lai, Shao-Chun Lu, Graduate
Student, Sang-Heng Kok, Professor
PII:

S1010-5182(16)00089-5

DOI:

10.1016/j.jcms.2016.03.011

Reference:

YJCMS 2326

To appear in:

Journal of Cranio-Maxillo-Facial Surgery

Received Date: 28 September 2015

Accepted Date: 18 March 2016

Please cite this article as: Chen Y-J, Yao C-C, Chang Z-C, Lai H-H, Lu S-C, Kok S-H, A New
Classification of Mandibular Asymmetry and Evaluation of Surgical-Orthodontic Treatment Outcomes in
Class III Malocclusion, Journal of Cranio-Maxillofacial Surgery (2016), doi: 10.1016/j.jcms.2016.03.011.
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A New Classification of Mandibular Asymmetry and Evaluation of

Surgical-Orthodontic Treatment Outcomes in Class III Malocclusion

Yi-Jane Chena, Chung-Chen Yaoa, Zwei-Chieng Changa, Hsiang-Hua Laia, Shao-Chun Lua,

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Sang-Heng Kokb

Department of Orthodontics and Dentofacial Orthopedics, School of Dentistry, National

Taiwan University, Taipei, Taiwan; Department of Dentistry, National Taiwan University

Department of Oral and Maxillofacial Surgery, School of Dentistry, National Taiwan

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University, Taipei, Taiwan; Department of Dentistry, National Taiwan University Hospital,

Taipei, Taiwan
Author

Position

Associate Professor

Chung-Chen Yao

Associate Professor

Zwei-Chieng Chang

Assistant Professor

Eddie Lai

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Yi-Jane Chen

Assistant Professor

Shao-Chun Lu

Graduate Student
Professor

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Sang-Heng Kok

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Hospital, Taipei, Taiwan

Correspondence:
Sang-Heng Kok, Ph.D.
Professor

School of Dentistry, National Taiwan University, Taipei, Taiwan

No. 1, Chang-Te Street, Taipei City, Taiwan 10048
TEL: 886-2-23123456 ext. 67338
FAX: 886-2-23831346
Email: E-mail: hkok@ntu.edu.tw (SHK)

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Abstract
Introduction: Facial asymmetry is a common manifestation in patients with Class III
malocclusion. The aims of this study were to classify mandibular asymmetry in Class III
patients and to evaluate treatment outcomes according to different characteristics of

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asymmetry.

Materials and methods: Three dimensional cone-beam CT images of 38 patients were

analyzed for menton deviation and discrepancies between bilateral structures of mandibular

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ramus and body. The patients were classified into 3 groups. Groups 1 and 2 exhibited a larger
distance of ramus to midsagittal plane on menton-deviated side. In group 1, menton deviation

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was greater than ramus asymmetry and the condition was reversed for group 2. Group 3 had
menton deviation contralateral to the side with larger transverse ramus distance. The features
of asymmetry were delineated and the outcomes after surgical-orthodontic treatment were
analyzed.

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Results: Group 1 exhibited a roll rotation of mandibular structures. Mandibular deviation of

group 2 patients was more of a horizontal shift nature rather than rotation. Group 3 patients
displayed a yaw rotation of mandible to the side with lesser growth in body and ramus. After

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treatment, menton deviation and body asymmetry were significantly improved in all 3 groups,

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but the effect of therapy on ramus asymmetry was less predictable, especially for group 3.
Conclusions: The classification system is simple and clinically useful and could form a base
for future studies on facial asymmetry.

Keywords: Class III malocclusion, Mandibular asymmetry, Bilateral sagittal split osteotomy,
Menton deviation, Ramus asymmetry

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1. Introduction
Facial asymmetry is a frequent manifestation in Class III malocclusions with mandibular
prognathism (Haraguchi et al., 2002). The morphological pattern of facial asymmetry is
complex due to the geometric interplay of dentition, bone, and soft tissues (Kusayama et al.,

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2003; Hayashi et al., 2004; Ishizaki et al., 2010; Cheong and Lo, 2011). Asymmetry of facial
skeleton may involve the morphology of structures per se and the positional deviation of

maxillo-mandibular complex or mandible only (Baek et al., 2007; Baek et al., 2012). Since

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facial asymmetry encompasses a wide variety of morphological traits, classification systems

have been proposed to help clarify the muddled clinical picture. Traditionally, frontal

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cephalometric radiographs were used in the diagnosis of jaw asymmetry (Reyneke et al., 1997;
Hwang et al., 2007; Kim et al., 2014). More recently, the development of cone-beam
computed tomography (CBCT) has highlighted the inadequacy of 2D radiography and 3D
imaging begins to play an important role in the diagnosis of craniofacial asymmetry (Maeda

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et al., 2006; Baek et al., 2012). However, regardless of the technique employed, classifications
of facial asymmetry recommended in the past were usually too complex and not easily
applicable in clinical practice. Moreover, their actual value in the guidance of effective

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treatment for facial asymmetry was not verified (Reyneke et al., 1997; Maeda et al., 2006;

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Hwang et al., 2007; Baek et al., 2012; Kim et al., 2014).

Surgical-orthodontic treatment is the mainstay in the management of skeletal
malocclusion. For asymmetric Class III malocclusion, bilateral sagittal split ramus osteotomy
(SSRO) has usually been used to correct mandibular protrusion and deviation. When cant of
occlusal plane is obvious and not manageable by orthodontic measures, Le Fort I osteotomy is
needed to facilitate roll rotation of maxillomandibular complex (Sekiya et al., 2010; Cheong
and Lo, 2011). In asymmetric setback via SSRO, the change in transverse ramaus angulation
was different between the chin-deviated and opposite sides (Pan et al., 2013), which may

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affect the symmetry of bilateral angle prominence and hemifacial widths. The side-shift/yaw
rotation of distal segment following SSRO is expected to assist the correction of mandibular
asymmetry. However, the effects exerted by the movement of proximal segments on the
outcome of asymmetry correction in skeletal Class III patients are still poorly understood.

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Although facial asymmetry is a three-dimensional phenomenon, clinical experiences show

that most patients notice transverse or horizontal discrepancy more readily than the vertical
and sagittal components. Therefore, in this study we focused our analysis on the patterns of

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transverse mandibular asymmetry and their treatment outcome. The purposes of the study
were twofold; the first was to develop an easy-to-use classification system to categorize

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mandibular asymmetry according to the relationship between menton deviation and transverse
ramus asymmetry. The second purpose was to evaluate the surgical-orthodontic treatment
outcomes and to examine how the movements of distal and proximal segments in SSRO were

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influenced by the asymmetry characteristics in different groups.

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2. Material and methods

2.1 Patients
The study included 38 Class III patients with facial asymmetry (22 males and 16 females;
mean age: 25.1 4.8 years). All patients received orthodontic treatment and orthognathic

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surgery performed by a single surgeon (SHK) from March 2011 to February 2013, at the

Department of Oral and Maxillofacial Surgery, National Taiwan University Hospital. Other
inclusion criteria were as follows: (1) no concomitant genioplasty, (2) no history of

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maxillofacial trauma, (3) no other congenital anomalies, (4) complete records of good quality,
including CBCT scan taken within 1 month before treatment (T1) and at the completion of

review board (201106053RB).

2.2 Treatment procedures

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treatment (T2, at least 6 months after surgery). The study was approved by the institutional

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All patients underwent pre-surgical orthodontic treatment for arch coordination and dental
decompensation. Model surgery and fabrication of surgical splints were done in the usual
manner. Twenty-two patients received bilateral SSRO only and in the other 16 patients

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two-jaw surgery (SSRO and Le Fort I osteotomy) was performed. The technique of SSRO

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followed Dal Ponts modifications of Obwegesers method (Dal Pont, 1961). Rigid fixation of
maxillary and mandibular osteotomies was accomplished by using titanium miniplates (Pan et
al., 2013). Post-surgical orthodontic treatment was initiated 2 weeks after surgery.

2.3 Data collection

CBCT images were acquired (120 kVp, 47.74 mAs; i-CAT, Imaging Sciences, Hatfield,
PA, USA) with a resolution of 0.4-mm voxel and analyzed using the Dolphin 3D software
(Dolphin Imaging & Management solutions, Chatsworth, CA, USA). To evaluate mandibular

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asymmetry, a reference plane joining points sella turcica, nasion, and basion was selected as
the midsagittal plane. The horizontal and coronal planes were perpendicular to the midsagittal
plane with the horizontal plane passing through the bilateral midpoints between porion and
orbitale and the coronal plane passing basion point.

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Table 1 shows the landmarks and reference lines used in this study. Menton (Me) and
bilateral landmarks including sigmoid notch (SN), coronoid process (CP), mandibular
foramen (MdF), and mental foramen (MtF) were identified via viewing the anatomic

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structures from different views (Fig. 1). Ramus contour points (RCs) were the most lateral
points of mandibular ramus on a series of horizontal planes of 3 mm interval from mandibular

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angle to mandibular notch (Fig. 1A). Using a least squares regression model, ramus line (RL)
was formed by approximating the projected points of consecutive RCs on the coronal plane
(Fig. 1B).

The distances from each of the landmarks to the reference planes were measured in mm

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by the same observer (SCL) (Table 2). Bilateral difference in measurements indicated the
asymmetry of the respective anatomic locus. A positive sign denoted larger measurement on
the side ipsilateral to menton deviation, and vice versa. Angulations of mandibular ramus

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were assessed in the coronal (Fig. 1B) and cranio-caudal (Fig. 1C) views. The mean distance

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of RCs to midsagittal plane was denoted as transverse ramus distance. The difference between
bilateral transverse ramus distances was denoted as ramus asymmetry. The distance of menton
to the midsagittal plane was denoted as menton deviation. The distance between mandibular
and mental foramina was denoted as ramus-body length. Occlusal plane cant was assessed by
difference between the distances of mesiobuccal cusps of bilateral maxillary first molars to
horizontal plane.

2.4 Classification of mandibular asymmetry

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Based on the direction and amount of menton deviation relative to ramus asymmetry, the
patients were classified into 3 groups (Fig. 2). In groups 1 and 2, menton deviation was
accompanied by a larger transverse ramus distance on the deviated side. While in group 1 the
amount of menton deviation was greater than that of ramus asymmetry, group 2 patients

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showed a smaller menton deviation in comparison to ramus asymmetry. Patients in group 3

exhibited an atypical asymmetry of larger ramus distance contralateral to the side of menton

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deviation.

2.5 Assessment of treatment outcomes

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T1 and T2 images were superimposed on the best fit of anterior cranial base, then T2
images were analyzed with the exact same reference planes as in T1 images (Cevidanes et al.,
2006; Gkantidis et al., 2015). The positional changes of mandibular landmarks were examined
to estimate the movements of proximal and distal segments by BSSO. Considering the

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similarity of asymmetry pattern in groups 1 and 2, patients of the two groups were combined
in the assessment of correlation between horizontal movement of distal segment and side shift

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of proximal segment.

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2.6 Statistical analysis

To evaluate measurement error, CBCT images of 10 randomly selected patients were

analyzed repeatedly at an interval of 2 weeks. Random error was calculated according to
Dahlbergs formula. Statistical analysis was performed using SPSS 19.0 (SPSS Inc, Chicago.
IL, USA). Paired t tests were run to check statistical significance of differences between
bilateral measurements, and between T1 and T2 for each of the 3 groups. The relationship
between horizontal movement of mandibular foramen and change in transverse ramus
distance was examined by regression analysis. P<0.05 was considered statistically significant.

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3. Results
3.1 Characteristics of mandibular asymmetry
Errors of measurements were under 0.7 mm and 1.0 degree for the linear and angular data
respectively. The severity of menton deviation differed among the 3 groups, the average

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deviations in groups 1, 2, and 3 were 6.28 3.49 mm (mean standard deviation) (n=13),
2.08 1.49 mm (n=9), and 3.38 2.47 mm (n=16), respectively. Group 1 patients exhibited
greater menton deviation than those of groups 2 and 3, and the difference reached the level of

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statistical significance (P<0.05).

Table 3 shows the measurements by hemiface and the differences between deviated and

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non-deviated sides in each of the 3 groups. Group 1 patients showed obvious menton
deviation (6.28 mm) and lesser ramus asymmetry (2.80 mm). The distances of mandibular
foramen (MdF) and mental foramen (MtF) to midsagittal plane were greater on the deviated
side, and the average differences were 3.56 mm and 9.67 mm respectively. It implied that the

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shift of mandibular body was larger than that of mandibular ramus, leading to severe chin
point deviation. These manifestations were accompanied by greater transverse ramus distance

non-deviated side.

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and coronal ramus angle on the deviated side and larger ramus-body length on the

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Group 2 patients presented lesser menton deviation (2.08 mm) but larger ramus
asymmetry (3.76 mm). Similar to group 1, the distances of MdF and MtF to midsagittal plane
were greater on the deviated side. However, the average difference between bilateral MdF-S
(3.61mm) and bilateral MtF-S (4.20 mm) were approximately the same, leading to a smaller
deviation of menton. Moreover, no significant difference of ramus-body length and coronal
ramus angle was found between the two sides.
Contrary to groups 1 and 2, group 3 patients exhibited smaller transverse ramus distance
on the deviated side. On the non-deviated side, MdF was more distant but MtF closer to the

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midsagittal plane than their respective counterparts on the deviated side, and ramus-body
length was greater. In the antero-posterior aspect, mandibular and mental foramina were more
anteriorly positioned on the non-deviated side, as revealed by the longer MdF-C and MtF-C,

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implying a horizontal rotation of mandibular structures.

3.2 Treatment outcomes

Table 4 shows the measurements at T1 and T2 on both the deviated and non-deviated

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sides. Fig. 3 shows the scatter plot of menton deviation and ramus asymmetry before and after
treatment in each of the 3 groups. Occlusal plane cant was corrected either through maxillary

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surgery or orthodontic means, whereas the mean change was not statistically significant in all
3 groups. After treatment, all 3 groups exhibited a significant decrease of horizontal ramus
angle on both sides, indicating a medial rotation of proximal segments in the horizontal plane
commonly found after SSRO.

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In group 1, menton deviation was significantly reduced and MtF-S decreased on the
deviated side and increased on the non-deviated side, indicating a favorable side-shift of the
distal segment in SSRO. Ramus asymmetry and disparity in MdF-S were also improved.

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deviated side.

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Coronal ramus angle increased 1.82 on the non-deviated side, but remained unchanged on the

Similar to group 1, reduction of menton deviation in group 2 was accompanied by a

favorable horizontal shift of bilateral mental foramina. Although ramus asymmetry was
improved, the positional change of MdF on either the deviated or non-deviated sides was not
significant. Coronal ramus angle remained unchanged on the deviated side and increased by
about 1 on the non-deviated side, although the change was not statistically significant.
In group 3, there were also significant reduction of menton deviation and correction in the
transverse positions of mental foramina. On the other hand, improvement in ramus asymmetry

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was not statistically significant. As shown in Fig. 3, ramus asymmetry remained unchanged or
even worsened in a significant number of group 3 patients.

3.3 Correlation between horizontal movements of distal and proximal segments

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To check if a horizontal shift of the posterior portion of distal segment was accompanied
by a corresponding transverse movement of the proximal segment in SSRO, the relationship
between horizontal movement of mandibular foramen and change in transverse ramus

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distance was examined using regression analysis. For the non-deviated side, the regression
equation was significant only in groups 1 and 2 (Y=0.764X-0.16, R2 = 0.63, P<0.001;

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Y=increase of transverse ramus distance, X=increase of MdF-S). In group 3 no significant

relation was found (P=0.965). Regarding to the deviated side, in all 3 groups the relation was

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not significant (P=0.47 for groups 1 and 2; P=0.29 for group 3).

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4. Discussion

Although facial asymmetry is usually three-dimensional, transverse disparity is more

easily recognized and most annoying to the patients. Facial asymmetry affects the lower face

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more commonly than the upper face (Severt and Proffit, 1997) and deviation of the mandible
is the major attribute of lower face asymmetry. In addition to chin deviation, discrepancy
between bilateral rami is also important in terms of mandibular asymmetry. In this study, we

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proposed a classification scheme based on the amount and direction of transverse ramus

asymmetry relative to menton shift. We found that the efficacy of asymmetry correction was

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significantly affected by the characteristics of mandibular deviation. The classification is

simple but useful in predicting the feasibility of surgical repositioning of proximal and distal
segments by BSSO for patients with Class III asymmetry.

In the past, attempts had been made to categorize facial asymmetry into different

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characteristic patterns. Reyneke et al. (1997) stratified the maxillomandibular complex into
three levels, the symphysis, body/ramus and maxilla, and categorized asymmetry according to
the levels of deviation. The classification only depicted different degree of deviation to the

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same side and failed to address atypical asymmetry in which different components shifted in
contrary fashion. Calculations of asymmetry indices or cluster analysis for some landmarks

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were used to classify facial asymmetry (Maeda et al., 2006; Hwang et al., 2007). However,
these studies provided little information about the direction in which individual anatomical
structure deviated. In a recent study, patients were classified into four groups based on
different asymmetric features: 1. side shift of mandibular body; 2. significant difference
between bilateral ramus height with menton deviated to the short side; 3. atypical asymmetry
with more prominence angle opposite to the side of menton deviation; 4. severe maxillary
canting and ramus height discrepancy with menton deviated to the short side (Baek et al.,
2012). The classification is somewhat similar to the scheme reported in the present study but

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our system is more focused on the transverse discrepancy of mandibular structures. More
lately, the complex relationship of menton deviation with transverse asymmetry (T),
maxillary cant (M), and lip cant (L) was discussed and a TML classification system based on
hard and soft tissue measurements from frontal cephalogram and clinical photograph was

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proposed (Kim et al., 2014). The various relationships between the three components make
the TML system too sophisticated for guiding treatment in clinical practice. More importantly,
previous studies did not provide evidence to authenticate the clinical value of their

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classifications.

In our study, mandibular asymmetry was classified into 3 groups. Group 1 exhibited a roll

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rotation displacement of mandibular structures. The larger ramus-body length on the

non-deviated side implied an asymmetric growth of the mandible, resulting in a swing of
mandible. Since menton is at the distal end of swinging arm, the amount of its shift is greater
than that of the more proximal ramus structures. In contrast, mandibular deviation of group 2

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patients was more of a horizontal shift nature rather than rotation. As to group 3 patients,
facial asymmetry was characterized by menton deviation to the narrower hemiface, and the
transverse ramus width was greater on the non-deviated side. The picture implied a yaw

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rotation of mandible to the side with lesser growth in body and ramus (Fig. 2C). These
features are similar to those of patients with atypical asymmetry reported by Baek et al.

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(2012).

Regarding to treatment outcomes, our results revealed that side-shift movement and yaw
rotation of the distal segment in SSRO is effective for the correction of asymmetry of
mandibular body. The average residual menton deviation was from 0.31 to 2.42 mm and
usually not clinically significant (Masuoka et al., 2007). Compared to menton deviation,
ramus asymmetry was more difficult to correct by SSRO, especially in group 3 patients. In
group 1, ramus asymmetry was significantly corrected together with a beneficial increase of
coronal ramus angle on the non-deviated side. We believe that the asymmetric features of

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group 1 patients respond most favorably to surgical correction and are similar to those of
T1M1L1 group in the TML classification system of Kim et al. (2014). Partial correction of
ramus asymmetry was also noted for group 2. As to group 3, the unpredictability in the
improvement of ramus discrepancy should be taken into consideration. In addition to yaw

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rotation of the distal segment, augmentation and/or bone trimming may be required for the
correction of residual ramus asymmetry.

When using SSRO for asymmetric setback, bony interferences between proximal and

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distal segments may occur (Yang et al., 2010). However, the readiness of horizontal swing of
proximal segment following a side shift of the distal segment has not been addressed in

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previous studies. The present study revealed that the correlation between horizontal
movement of the posterior part of distal segment and that of the proximal segment was
significant only on the non-deviated side in groups 1 and 2. It implies that outward movement
of proximal segment on the non-deviated side is more predictable than inward movement of

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ramus on the deviated side. This phenomenon may be attributed to the hindrance encountered
during the medial movement of proximal segment in SSRO. In recent years, virtual
simulation is increasingly used in orthognathic therapy (Aboul-Hosn Centenero and

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Hernandez-Alfaro, 2012; Hsu et al., 2013) and it has been shown that in patients with facial
asymmetry, digital planning is more precise than conventional method for the centering of

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distal segment of the mandible (De Riu et al., 2014). However, the positioning of proximal
segment was poorly elucidated in previous studies and the value of virtual surgical planning
in the correction of ramus asymmetry remains to be determined.
Severe mandibular deviation may be accompanied with greater maxillary vertical excess
in the opposite side (Baek et al., 2007). In patients with severe cant of maxilla, the left and
right maxilla have to be differentially impacted via Le Fort I osteotomy, possibly facilitating
roll rotation of the mandible (Ko et al., 2009). However, orthodontic intrusion of maxillary
molars is an alternative to maxillary surgery for patients with mild to moderate occlusal plane

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cant (Takano-Yamamoto and Kuroda, 2007). In the present study, the average cant of
maxillary occlusal plane and the percentage of patients receiving two-jaw surgery were
comparable among the 3 groups, implying that different traits of asymmetry seemed not to
influence the need of Le Fort I osteotomy. Actually, in our series, Le Fort I osteotomy was

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mostly done for the correction of maxillary deficiency in the sagittal and transverse aspects.
Orthodontic leveling of occlusal plane cant was usually considered first for patients not

requiring maxillary advancement or expansion (Yao et al., 2005; Papadopoulos and Tarawneh,

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2007).

Some limitations did exist in this study. The study was limited to hard tissues and

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retrospective in nature, and it included patients treated with one-jaw and two-jaw surgery.
Further investigations are required to analyze soft tissue drape of the face in patients with jaw
asymmetry before and after treatment. Nevertheless, our classification scheme was proved to
be clinically relevant and helpful in the planning of treatment for maxillomandibular

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asymmetry.

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5. Conclusion
Facial asymmetry is a frequent complaint among patients with Class III malocclusion. By
3D-CBCT analysis, the present study categorized mandibular asymmetry into 3 groups
according to the amount and direction of ramus asymmetry relative to menton deviation.

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Menton deviation and asymmetry of mandibular body were significantly improved but

correction of ramus discrepancy was less predictable, especially for patients with a narrower
lower face on the side of menton deviation. Patients should be forewarned about the possible

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need of secondary surgery to correct residual asymmetry. The classification developed in our
study is simple and clinically useful and could form a base for future studies on facial

Conflict of interest

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asymmetry.

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There is no conflict of interest in regard to this work.

Acknowledgement

This work was supported by a grant from National Taiwan University Hospital
(NTUH-103-S2381).

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Captions to illustrations
Fig. 1. Landmarks and reference lines for 3D-CBCT evaluation. (A) SN: Sigmoid notch; CP:
Coronoid process; MdF: Mandibular foramen; MtF: Mental foramen; RCs: Ramus contour

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points. (B) Me: Menton; RL: Ramus line; CRA: coronal ramus angle. (C) PSL: proximal
segment line, the line connecting CP and SN projected onto horizontal plane; HRA: horizontal

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ramus angle. For detailed description of definitions, please refer to Tables 1 and 2.

Fig. 2. Coronal and cranio-caudal views of representative 3D-CBCT images in the three

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patient groups with different asymmetry characteristics. (A) Group 1: larger ramus asymmetry
on the menton deviation side with the amount of menton deviation greater than the ramus
asymmetry. (B) Group 2: larger ramus asymmetry on the menton deviation side with the
amount of menton deviation lesser than the ramus asymmetry. (C) Group 3: larger ramus

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asymmetry contralateral to the side of menton deviation. Asterisks in the cranio-caudal views

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indicate the side with larger transverse ramus distance.

Fig. 3. Distribution of menton deviation and ramus asymmetry before (T1) and after (T2)

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treatment clustered by the 3 groups. Group characteristics are defined in the text and Figure 2.
Positive values of ramus asymmetry indicate larger measurement on the side of original
menton deviation and vice versa. Negative values of menton deviation after treatment indicate
a shift of menton to the opposite side.

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Definition

Nasion

Middle point of nasofrontal suture

Sella turcica

Center of sella turcica

Ba

Basion

Most anterior point of foramen magnum

Po

Porion

Most superior point of external auditory meatus

Or

Orbitale

Most inferior point of lower margin of orbit

SN

Sigmoid notch

Most concave point of sigmoid notch

CP

Coronoid process

Most superior point of coronoid process

MdF

Mandibular foramen

MtF

Mental foramen

Me

Menton

RCs

Ramus contour points

RL

Ramus line

PSL

Proximal segment line

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Landmarks/ reference lines

Most superior point of mandibular foramen

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Most superior point of mental foramen

Most inferior point on symphysis of mandible

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Abbreviation

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Table 1. Landmarks and reference lines used in the study

Consecutive points passing the lateral contour of mandibular ramus on a series of

horizontal planes with 3 mm interval from mandibular angle to mandibular notch.
Line approximating consecutive RCs projected onto coronal plane
Line connecting SN and CP projected onto horizontal plane

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Table 2. Measurements used in the study

Definition

Coronal ramus angle

Acute angle between the horizontal plane and RL

Horizontal ramus angle

Acute angle between the coronal plane and PSL

Transverse ramus distance

Mean distance of RCs to midsagittal plane

Ramus asymmetry

Difference between bilateral transverse ramus distances

Me-S

Distance from Me to midsagittal plane

MdF-S, MdF-C, MdF-H

Distances from MdF to midsagittal plane, coronal plane, and horizontal plane
respectively

MtF-S, MtF-C, MtF-H

Distances from MtF to midsagittal plane, coronal plane, and horizontal plane
respectively

Ramus-body length

Distance from MdF to MtF

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Occlual plane cant

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Measurement

Difference between the distances of mesiobuccal cusps of bilateral maxillary first

molars to horizontal plane

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Group 2

N - side

Difference

D - side

MdF-S

44.872.54

41.313.36

3.563.09

45.752.31

MdF-C

29.334.24

30.315.33

NS

29.194.18

MdF-H

40.635.27

40.604.14

NS

MtF-S

28.544.40

18.873.25

9.676.72

MtF-C

79.387.96

80.508.19

NS

MtF-H

73.796.81

74.316.04

Ramus-body length

62.935.65

Transverse ramus distance

Coronal ramus angle

Difference

D - side

N - side

Difference

42.142.88

3.612.03

42.892.45

45.532.42

-2.642.20

29.633.74

NS

29.704.55

32.063.91

-2.361.69

37.594.26

NS

36.583.61

36.324.36

NS

25.533.08

21.332.04

4.203.62

24.862.26

21.631.89

3.233.58

78.437.04

78.037.64

NS

81.457.65

83.737.26

-2.281.79

NS

77.506.53

76.815.40

NS

75.437.03

75.637.07

NS

64.995.05

-2.062.70

64.676.28

64.825.48

NS

67.226.32

69.405.02

-2.183.46

52.993.06

50.192.83

2.802.36

54.712.34

50.952.90

3.761.92

51.232.39

53.542.28

-2.311.81

82.114.22

76.623.23

5.495.26

79.294.40

78.542.44

NS

80.002.73

79.642.00

NS

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39.064.60

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Group 3

N - side

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D - side

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Group 1

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Table 3. Comparison of the measurements between deviated and non-deviated sides in the three groups

Values reached statistical significance (P<0.05) are shown; Positive values indicate larger measurement on the deviated side and vice versa;

NS: non-significant, D: deviated side, N: non-deviated side, Unit of linear measurement: mm, Unit of angular measurement: degree

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Table 4. Comparison of the measurements between T1 and T2 in the three groups

Group 2

T2

Difference

T1

Occlusal plane cant

1.520.99

0.960.75

NS

1.191.07

Menton deviation

6.283.49

2.422.21

-3.861.92

2.081.49

Ramus asymmetry

2.802.36

1.782.02

-1.021.34

MdF-S (D)

44.872.54

44.212.11

-0.660.91

MdF-S (N)

41.313.36

42.043.53

0.730.93

MtF-S (D)

28.544.40

25.483.87

-3.061.48

MtF-S (N)

18.873.25

21.692.33

2.821.49

Horizontal ramus angle(D)

86.405.62

78.876.33

-7.534.23

Horizontal ramus angle(N)

86.437.35

79.645.55

Coronal ramus angle(D)

82.114.22

Coronal ramus angle(N)

76.623.23

Difference

0.720.71

NS

1.210.89

0.720.44

NS

0.310.82

-1.771.51

3.382.47

1.251.65

-2.132.06

3.761.92

2.231.10

-1.521.59

-2.371.81

-1.901.68

NS

45.752.31

45.312.52

NS

42.892.45

42.832.63

NS

42.142.88

42.692.59

NS

45.532.42

45.332.50

NS

25.533.08

23.922.41

-1.611.26

24.862.26

23.672.17

-1.191.96

21.332.04

23.052.19

1.721.51

21.631.89

22.671.69

1.041.59

86.1213.24

74.6212.18

-11.504.22

86.374.71

79.234.63

-7.144.18

-6.795.42

84.1110.37

73.259.78

-10.867.32

84.725.83

77.235.61

-7.495.32

82.054.75

NS

79.294.40

79.395.61

NS

80.002.73

80.193.63

NS

78.441.84

1.822.19

78.542.44

79.623.27

NS

79.632.00

79.432.18

NS

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Group 3

T2

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T1

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Group 1

T1

T2

Values reached statistical significance (P<0.05) are shown; Positive values indicate larger measurement at T2 and vice versa; NS: non-significant.

T1: pre-treatment, T2: post-treatment, D: deviated side, N: non-deviated side, Unit of linear measurement: mm, Unit of angular measurement: degree

Difference

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