Midline Final / Orthodontic Courses by Indian Dental Academy

TREATMENT OF MIDLINE
DISCREPANCIES AND SKELETAL

ASYMMETRIES

INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

INTRODUCTION
Midline coordination and relative symmetry
are basic to an appreciation of facial harmony
and balance.
Although a subtle asymmetry of the midlines
is within normal limits, significant midline
discrepancies can be quite detrimental to
dentofacial esthetics.

Stedmans Medical Dictionary defines
symmetry as equality or correspondence
in form of parts distributed around a
center or an axis, at the two extremes or
poles, or on the two opposite sides of the
body.
Clinically, symmetry means balance while
significant asymmetry means imbalance.
Facial asymmetry, was probably first
observed by the artists of early Greek
staturary
Mammals have marked asymmetry as to the
placement of the viscera in the body cavity.
Also functional as well as morphological
asymmetries, e.g. right and left handedness,
preference for one eye or one leg.
Some asymmetries are embryonically
rooted and are associated with asymmetry
in the central nervous system.

Each human being a unique individual.
Variations in the size, shape and relationship
of the dental, skeletal and soft tissue facial
structures are important in providing each
individual with his or her own identity.
Perfect bilateral body symmetry is largely a
theoretical concept that seldom exists in
living organisms

Asymmetry in craniofacial areas can be
recognized as differences in the size or
relationship of the two sides of the
face.
This may be the result of discrepancies
either in the form of individual bones,
or a malposition of one or more bones
in the craniofacial complex. The
asymmetry may also be limited to the
overlying soft tissues.

Peck and Peck evaluated bilateral facial
symmetry in 52 exceptionally well-balanced
white adults and observed that there is less
asymmetry and more dimensional stability as the
cranium is approached.
In a study, Vig and Hewitt evaluated 63
posteroanterior cephalograms of normal
children 918 years of age.
Normal, in this case, meant that the child
exhibited no clinically evident facial asymmetry
An overall asymmetry was found in most of the
children with the left side being larger.
The cranial base, and mandibular regions
exhibited a left side excess while the
maxillary region showed a larger right
side.
The dento-alveolar region exhibited the
greatest degree of symmetry.
Vig and Hewitt concluded that compensatory
changes seem to operate in the development of
the dentoalveolar structures and enable
bilateral symmetrical function and maximum
intercuspation to occur, thus minimizing the
effects of the underlying asymmetry

Results from a study by Miller et al
indicate that the maxillary midline is
situated in the exact middle of the
mouth (using the philtrum as a guide)
in approximately 70% of
individuals, but that the maxillary
and mandibular midlines coincide
in only one fourth of the
population.
Midline correction should be undertaken
from the initiation of treatment and once
all midlines are coordinated they should
be maintained as a guide for any further
force systems used in completing the case

Differential diagnosis and appropriate inter and
intraarch mechanotherapy is necessary.

Careful attention to midline coordination and
attendant facial symmetry can aid the
practitioner in achieving the following:
1. Maximum intercuspation and function
2. Stability in the finished result
3. The promotion of anterior dental and
facial esthetics
4. A decrease in the potential for TMJ
dysfunction
5. Maximizing self-satisfaction by
achieving an increased number of ideal
orthodontic results

Etiology of midline
discrepancies and Asymmetry
Includes
a) Genetic or congenital malformations e.g.
hemifacial microsomia and unilateral clefts of
the lip and palate; multiple neurofibromatosis
b) Environmental factors, e.g. habits and
trauma;
c) Functional deviations, e.g. mandibular shifts
as a result of tooth interferences.

d. Epigenetic factors; and acquired
factors, for example, infections or
pathology
Facial asymmetries can be
classified based on the time of
onset, as outlined by Picuiniemi.
Anomalies may originate during the
prenatal period and be embryonic in
nature or may have developed during
the fetal term.

Mandibulofacial asymmetries have
a postnatal expression.
The causes are -
Tumors in the TMJ region
Condylar hyperplasia or hypoplasia,
Hemifacial atrophy (Romberg
syndrome),
Scleroderma

Inflammatory arthritic disease
Ankylosis
Intra-articular disorders with an
associated arthrosis
Condylar fracture
Damage to a nerve may indirectly lead
to asymmetry from the loss of muscle
function and tone.

Other factors -
Intra-uterine pressure during
pregnancy and significant pressure in
the birth canal during parturition can
have observable effects on the bones of
the fetal skull. Molding of the parietal
and facial bones from these pressures
can result in facial asymmetry.
Osteochondroma of the mandibular
condyle results in facial asymmetry,
open bite on the involved side, and
mandibular deviation

Localized factors
Early loss of a deciduous tooth
Rotation of the entire dental arch and its
supporting skeletal base.
Asymmetric crowding in anterior section
Prolonged retention of primary tooth
Periodontal trauma and migration.
Juvenile rheumatoidarthritis
Dental caries
Mandibular fractures
Drifting and tipping of teeth.
Congenitally missing teeth

Lundstrom stated that asymmetry can
be genetic or nongenetic in origin
and is usually a combination of both.
Some right-left asymmetries in the oral
cavity could be the result of
environmental factors, eg,
sucking habits or asymmetric
chewing habits caused by dental
caries, extractions, and trauma.
Hemifacial microsomia
Facial photographs of a patient with hemifacial
microsomia. The discrepancies involve one side of the
face only and include asymmetries in the mandibular
body, ramus and condyle as well as the external and
internal structures of the ear.
Asymmetry of Face due to
fracture of TMJ
Intrauterine moulding resulting in
midface deficiency
Deformation of second branchial arch
with corresponding malformations
Facial asymmetry due to
missing masseter muscle
Hemimandibular
hypertrophy
According to Lundstrom, asymmetry can
also be described as qualitative (all or
none) or quantitative.
Examples of Quantitative asymmetries
differences in the number of teeth on
each side
The presence of a cleft lip and palate.
Qualitative asymmetries could be
differences in the size and shape of
teeth, their location in the arches
Skeletal asymmetries-classification
Obwegeser classification as described in the
Journal of Maxillofacial Surgery in 1986.
Hemimandibular elongation
Hemimandibular hyperplasia.
It is important to differentiate between the two
types because:
(1) The timing of growth cessation is different
(2) The dentoalveolar compensations are different
(3) The likelihood of successful interception is
different.

Hemimandibular elongation
Can occur as elongation either of the
condyle or ramus in the vertical
plane or the mandibular body in the
horizontal plane.
Combinations are also possible.

Features
Mandible deviates to the opposite side of the
deformity
Exhibits flattening of the gonial angle on the
affected side
The mandibular borders and occlusal planes
will superimpose on a centric relation
cephalometric radiograph because there is no
vertical component to the asymmetry

Mandibular elongation tends to stop
when body or facial growth stops as it
follows more of a somatic growth
curve.
Presence of a unilateral posterior
crossbite on the opposite side from the
elongation.
Excessive growth occurs along
normal growth axes.

Hemimandibular hyperplasia
Recognized by entire half of the
mandible being enlarged.
Features
Mandibular lower border midline
notching on the panoramic film
Increased distances from the tooth
apices to the lower border of the
mandible when compared to the normal
contralateral side.

Hyperplasia, tends to grow longer
exhibiting latent growth.
The midline usually deviates to the
same side as the deformity.
Hyperplasia shows a normal or more
acute gonial angle due to excessive
vertical development.
Vertical differences in both planes can
be observed in mandibular hyperplasia.
Hemimandibular hyperplasia, however,
is just about always overgrowth as in
Angle Class III malocclusion that
results from mandibular prognathism.

Most hemimandibular elongations
are, in fact, Angle Class II or
hypoplasias. This is why they are
thought of as a variation of normal
growth and not pathoses.

Structural classification of
dentofacial asymmetries
a. Dental asymmetries: These can be
due to: local factors such as early loss of
deciduous teeth , congenitally missing
tooth, and habits such as thumb sucking.
asymmetries in mesiodistal crown
diameters.
Garn et al. found that tooth size
asymmetry generally does not
involve an entire side of the arch.
Teeth in the same morphological
class tend to have the same
direction of asymmetry.
Asymmetry tends to be greater for
the more distal teeth in each
morphological class i.e. the lateral
incisors, second premolars and third
molars.
Asymmetry may also be confined to
the shape of the dental arches.

b. Skeletal asymmetries: The deviation may
involve one bone such as the maxilla or
mandible , or it may involve a number of
skeletal and muscular structures on one side
of the face, e.g.hemifacial microsomia
c. Muscular asymmetries- hemifacial atrophy
or cerebral palsy.
Abnormal muscle function often results
in skeletal and dental deviations

Patient with a skeletal mandibular asymmetry. The mandibular
dental midline was shifted 7.0 mm to the left of the maxillary
midline. The right side had a severe Class III relationship while
the left side was closer to a Class I relationship
Post treatment photographs. Despite correction of the
skeletal asymmetry some soft tissue facial asymmetry
remained. Note that the mandibular midline was slightly
over-corrected
d. Functional asymmetries: These can
result from the mandible being deflected
laterally or antero-posteriorly, if occlusal
interferences prevent proper
intercuspation
May be caused by a constricted
maxillary arch or a malposed tooth,
TMJ derangements and in-
coordination

Intraoral view of a patient in centric relation. Note the shift in
the lower midline. Posterior occlusion was cusp on cusp bucco-
lingually.
CLASSIFICATION -According to
Steenbergen and Nanda
Dental asymmetries can be divided into four
groups:
1. Diverging occlusal planes
2. Asymmetric left to right buccal
occlusion, with or without midline
deviation
3. Unilateral crossbite
4. Asymmetric arch form

DIAGNOSIS
A: Clincial examination
1. Evaluation of the dental midlines:
includes an evaluation of the dental
midlines in the following positions:
mouth open; in centric relation; at
initial contact; and in centric occlusion

Location of midline
Various points (landmarks) can be identified from the
frontal head film, the frontal photographs, or by
clinical examination

Additional landmarks, such as crista galli, the
intermaxillary suture, and hard tissue pogonion,can
be seen on the headfilm.

These points happen to fall along the same line,.
Unfortunately, this does not always happen. Because of a
genuine asymmetry or by
(1) an inability to visualize the structures,
(2) head rotation in the cephalostat,
(3) soft tissue flexibility,
(4) an inexact technique.

A symmetrical head can produce an
asymmetrical posteroanterior film if the head
is improperly oriented
Any rotation of the head distorts the
constructed midpoints, with the greatest
discrepancy noted at landmarks farthest from
the film

Connecting the points-soft tissue nasion,
subnasale and soft tissue pogonion- also
locates midline
Can give variable results when repeated by
the same orthodontist.
Some authors have proposed constructing
additional landmarks by identifying bilateral
structures and determining the midpoint
between them.

Bisecting a line that connects
corresponding bilateral landmarks may
be invalid since absolute symmetry
between right and left does not exist.
The closer bilateral structures are
to the center of the face, the
smaller the variation is in the
midpoints as determined by a
bisector


Another method for determining the
facial midline is to establish a
horizontal plane from skeletal
structures and to construct a
perpendicular line from a midpoint
landmark
Two problems with this method.
Difficulty of determining which landmark or
constructed point to use,
Any small variation in the horizontal plane
can produce a large deviation in the facial
midline.

A commonly used guide in the X-
Z(occlusal) plane, in establishing a
treatment midpoint, is the median
palatal raphe.
Its limitations include
Errors in the construction of a single line
since curvature may be present
Correlation to other soft tissue facial
structures is lacking.

In some patients, the facial midline is
not a straight line but rather a curve;
hence, the facial midline could be
referred to as the facial mid-arc.
Philtrum of upper lip can also be
used to establish maxillary midline.

Mandibular midline
It is more precise to mark the
anteriorpoint of the mandibular midline
using the mental spine film or by using
the lingualfrenum (Korkbaus1939).
The posterior point for construction of
the mandibular midline is determined by
a perpendicular, which runs from the
posterior edge of the midpalatal raphe
from the maxillary to the mandibular
cast.
One more method is making lines
connecting the corners of the mouth
(chelion to chelion), the transverse
occlusal plane, and the upper and lower
lip horizontals
Soft tissue midpoints (cupid's bow, center of
the philtrum, and subnasale) are projected
onto the horizontal planes and are visually
compared to the incisor midpoints. (TOP =
treatment occlusal plane.)

Patient determination of midline
Found on apical bases of maxilla and
mandible.
It is necessary to construct the apical
base midpoints by placing a point at
approximately the midpoint of each of the
incisor roots occlusogingivally and then
finding their average mediolaterally
These two midpoints, one in the maxilla
and one in the mandible, are known as
the upper and lower apical base
midpoints

Incisor-Apical Base Midpoints
Incisor-Apical Base Midpoints
Used to evaluate skeletal asymmetry
In the sagittal view (Y-Z plane),
measuring the apical base points, A and B,
relative to the occlusal plane, is helpful in
determining the anteroposterior denture
base discrepancy.
The farther apart they are, the more
difficult it is to correct the Class II or
Class III malocclusion.
In the frontal view (Y-Xplane),
measuring the apical base midpoints
relative to the transverse occlusal plane
allows one to determine the
transverse denture base
discrepancy.

Rationale for selecting
Biological :
Forces exerted by muscles, transseptal
fibers and orthodontic appliances tend to
tip teeth about a point, generally near the
root center as measured from the
cementoenamel junction to the root apex.
Apical base midpoints serve as useful
functional landmarks in planning the
position of the treatment midpoint and
midline

MEASUREMENT
A perpendicular line from the upper and
lower apical base midpoints is extended to
the respective treatment occlusal plane.
Ideally, the upper and lower perpendicular
lines coincide at their intersection with the
occlusal plane, a sign of no transverse
apical base discrepancy
A transverse apical base discrepancy
exists when the upper and lower apical
base midpoints do not coincide

In some patients, orthognathic surgery is required to
achieve coincidence of the apical base midpoints.
For less severe apical base midpoint discrepancies
or for patients who wish to avoid surgery,the choice
of treatment midpoints is
Asymmetric mechanics
Minimal lateral translation
Anchorage control

The posterior midpoint
It is the geometric center of the arch
circumference.
Starting from the desired position of the
first molars (red line), equal radii are
marked off on the right and left sides
(blue lines). Where the right and !eft
radii cross anteriorly, the posterior
midpoint is located.
Determines the mesiodistal location
of the posterior teeth.

Intramaxillary asymmetry

-Transverse symmetry
-Anteroposterior symmetry

These symmetry analyses estimate the right-left
differences in transverse and anteroposterior
tooth positions (Korbitz1909).
The midpalatal raphe defined by two anatomical
points on the palatine raphe is the reference plane
for the transverse symmetry analysis.
The tuberosity plane is the
reference plane for comparing
anteroposterior symmetry.
This plane is perpendicular to the
midpalatal raphe and runs through
the distal-most tuberosity.

Maxillary midline
The following findings are derived
from this type of intramaxillary
assessment of the study casts.
Symmetric/asymmetric width
development between right and left
sides of the arch
Congruence/incongruence between
dental midline and skeletal midline
of the arches (dental midline shift)

Reveals the following:
Asymmetric mesiodistal tooth position of
corresponding teeth in the right and left sides
of the dental arches
This analysis serves to diagnose any mesial
tooth drift.
This involves drawing a line parallel to
the tuberosity plane, which runs through
the posterior surface of the distal-most
first molar, and comparing the sagittal
distances of the individual posterior
teeth

Analysis of Anteroposterior
Symmetry
2. Vertical occlusal evaluation: The
presence of a canted occlusal plane
The cant in the occlusal plane can be
readily observed by asking the patient
to bite on a tongue blade to determine
how it relates to the inter-pupillary
plane.
3. Transverse and antero-
posterior occlusal evaluations
Asymmetry in the bucco-lingual
relationship e.g. a unilateral posterior
crossbite

4. Transverse skeletal and soft tissue
evaluation: In addition to the
bilateral structural comparisons,
deviations in the dorsum and tip of
the nose as well as the philtrum and
chin point need to be determined
The clinical examination should include an
intraoral examination with an evaluation of
the dental and facial midlines and detection of
TMJ derangements.
Operator-assisted natural head position,
mandibular centric relation, and soft
tissue in repose are used to accurately
assess the frontal and profile views.

Facial and intraoral photographs are
indispensable.
A thorough facial examination must be conducted
to evaluate asymmetries in facial morphology
Examination of each dental arch and
quadrant should be evaluated by using-
Oriented dental casts
Occlusograms
Symmetroscopes

The diagnosis of a rotary displacement
of the maxilla may require further
evaluation by mounting the dental
casts by face-bow transfer on to
semiadjustable articulator
Finally, mounted dental casts and
model surgery are essential in planning
treatment for patients requiring
surgical orthodontic
B: Radiographic examination
1.The lateral cephalogram:, provides
useful information in ramal height,
mandibular length and gonial angle.
It is limited by the fact that the right and
left structures are superimposed on
each other and are at different
distances from the film and x-ray
source resulting in significant
differences in magnifications.

2.The panoramic radiograph: The
presence of gross pathology, missing
,supernumerary teeth can be
determined.
The shape of the mandibular ramus
and condyles on both sides can be
grossly compared
Geometric distortions are significant

3. Postero-anterior projection: It is a
valuable tool in the study of the right and left
structures since they are located at relatively
equal distances from the film and x-ray
source
Comparison between sides is therefore more
accurate
PA cephalograms can be obtained in centric
occlusion as well as with the mouth open.
The latter position might help determine the
extent of the functional deviation

Refined diagnostic tools, such as
computerized tomographic images
and stereo photogrammetry, allow
three-dimensional analyses of the
craniofacial complex. These methods
can generate, with the aid of a
computer, a three-dimensional image
of the patient's face. With a coordinate
system, the asymmetries can be
quantified.

TREATMENT
Dental asymmetries and a variety of
functional deviations can be treated
orthodontically.
Significant structural facial asymmetries are
not easily amenable to orthodontic treatment.
These problems may require orthopedic
correction during the growth period and/or
surgical management at a later point.
Patient complaints and desires need to be
addressed since they may vary from
unrealistic expectations to a lack of concern
even in the presence of large deviations.


Treatment Strategies
Breakspear advocates adapting the
occlusion by "stoning" (occlusal
equilibration).
This method of treatment allows the
occlusion to function more properly but
may not correct the dental or facial
asymmetry.

Lewis advocates a sliding yoke and intermaxillary
elastics.
He states midline deviation exists mostly in Class II
cases.
The more frequent causes are
Mandibular shift resulting from a posterior crossbite
Tipping or drifting of the teeth
Lateral mandibular rotation resulting from occlusal
interferences, arch asymmetries, tooth size
discrepancies
Overretraction of the canines on one side

Angle used a Class III elastic with a
anterior diagonal elastic in
conjunction with arch expansion for
the correction of midline discrepancies


Proffit admits that minor discrepancies
in midline coordination can be handled
in the finishing stages with
asymmetric Class II and Class III
elastics
Or by using unilateral Class II or
Class III intermaxillary elastics in
tandem with an anterior diagonal
elastic ,after extraction spaces
have been closed.

If one side of the arch is corrected and
other side is not, then heavy unilateral
class II or class III elastics can be
used on the affected side.
If there is abnormal transverse
relationship (cross bite) posteriorly leading
to mandibular shift ,POSTERIOR CROSS
-ELASTICS can be given
Parallel cross-elastics can also be given
when entire maxilla is displaced
transversely in relation to mandible.
In finishing stages rectangular wire
must be changed to round wire(.016
or .018) if asymmetric or unilateral
elastics are used to facilitate midline
correction.
Elastics along with coil springs can also
be used.
Open coil springs on the side of
deviation
Close coil springs on the side opposite
of deviation
Activation should be controlled.

Alexander advocates use of a heavy
anterior diagonal elastic supported by
a Class II or Class III elastic,
depending on whether the original
malocclusion was a Class II or Class
III during the finishing stages,
In an extraction case it may be
performed during space closure ,anterior
diagonal elastic is then attached to
the closing loops

Begg and Kesling state that the
proper balancing of space-closing classI
elastics coupled with appropriate Class
II traction during stage II keeps the
midlines coordinated

Augmenting a unilateral Class II
elastic, an anterior diagonal elastic, and
a Class III elastic with uprighting
springs to "walk the teeth" can effect
midline changes

Begg also advocated use of
asymmetric arch wire form for
correcting asymmetric arches
He advocated use of round wire as it
leads to efficient tipping facilitating
midline correction.

Hazards of Asymmetric elastic
wear
May cause undesirable side effects if
skeletal balance already exists.
The force vectors created by the
elastics impart a moment to the
mandible, ie, a tendency for rotation
that may lead to a transient alteration
in mandibular position.
If mandibular shift or rotation is not the
causative factor but rather the midline
deviation was a result of a dental shifting or
drifting of teeth, with the face being
symmetric, then use of such mechanics would
effect a change in mandibular position ,
potential for TMJ dysfunction.
Canting of occlusal plane can occur as a
result of vertical force vector of elastics.

Gianelly and Paul advocated a
biomechanical system for midline
correction with second-order bends
used to move teeth on one side distally
and create a space for shifting the
midline.
Lewis proposes the use of distal
spring mechanics as opposed to
second-order bends, bolstered by a
sliding yoke off Class II traction to
distalize upper posterior teeth in
cases exhibiting arch asymmetry

Strang and Thompson introduced a
double vertical spring loop assembly
to move the four incisors "en masse"
A modification of this arch wire
(rectangular) configuration using round
wire has come

A 0.020-inch arch wire is divided into three
parts: two posterior and one anterior. The arch
wire thus is segmented.
The two vertical loops allow for stabilization of
the posterior segments as long as molar stops
are used; hence only anterior movement takes
place. The incorporation of a helix in each loop
provides greater flexibility and longer activation.
To activate, a ligature is passed through the
circle on the closing loop side and tied to the
contralateral lateral incisor bracket. Each tooth
has been individually ligated to the anterior
section of the arch, each posterior section having
been ligated together as a unit.
The closing loop is constructed as close
as possible to the canine, with the
section to be activated lying anterior to
the helix.
When the closing loop is activated, the
opening loop is condensed and a push-
pull reaction occurs whereby all four
anterior teeth shift "en masse" toward
the desired side

In cases in which the midline
discrepancy is very slight (1 to 2 mm),
it is tempting to tip the anterior teeth
into a position that coordinates
with the facial midline with the
help of removable appliances such
as finger spring.

Discrepancies due to bodily rotation
as a result of crowding especially in mixed
dentition are corrected -by using fixed
appliance in the anterior section
-relieving the crowding
-teeth are then pushed to attain a
proper midline, by using coil springs
on side of deviation
Other appliances
Unilateral molar distalization
appliances:
-power arm face bow
-spring attachment face bow
-soldered arm face bow

Asymetric head gear
Pendulum appliance

Power arm facebow:
In this design the side to receive more
distalizing force is longer and wider than the
other
Soldered offset facebow:
Here the outer bow is attached to the side
favored to receive the distalizing force
Spring attachment face bow
bilateral face bow but with a open coil spring
placed distal to the stop on the side to be
distalized
Asymmetric Extractions Used in the
Treatment of Patients With
Asymmetries
Creative approach for managing
dental asymmetries is to extract a
combination of teeth that will simplify
intra-arch and interarch mechanics.
This reduces the dependency on
patient compliance for elastic wear
and may even shorten treatment
time.

A case presenting a number of dental arch asymmetries
including: retained mandibular left second deciduous
molar; congenitally missing mandibular left second
premolar; and unilateral anterior crossbite between the
maxillary lateral incisor and mandibular canine.
Post treatment intraoral, facial and model photographs
of the same patient. Treatment included extraction of
the deciduous tooth and three premolars
Mandibular Dental Midline Deviation with
Skeletal Symmetry
In 50% of all Class II malocclusions, majority
have distally positioned mandibular molars on the
Class II side with mandibular canine on that side
also positioned distally.
If such a patient presented with the maxillary
dental midline coincident with the facial midline,,
a three- premolar extraction plan may be
done
The extraction of a mandibular premolar on
the Class I side relocates the canine in a more
distal position to match the contralateral canine.
The extraction of two upper premolars would
maintain the maxillary midline symmetry to the
facial midline.

If the molar on the Class II side is in an
end-on relationship, Class I closure
mechanics can be used in all three
extraction buccal segments.

Differential extraction pattern on the Class II
side, such as the removal of a maxillary first
premolar and mandibular second premolar
to help lose lower molar anchorage can also be
used
The extraction of a mandibular premolar on the
Class II side may minimize the flaring of incisors
from Class II elastics by providing arch space for
the mandibular molar to advance

Unilateral Class III malocclusion
One premolar extraction on the Class III
side would allow for primarily Class I
closure mechanics
If the molar is in a full-step Class III
relationship, a lingual arch that is either
passive or unilaterally activated can be
used to maximize molar anchorage on
that side.
Maxillary Dental Midline Deviation
With Skeletal Symmetry
In the adult patient, non extraction correction
of the Class II buccal segment is less
predictable.
Removal of a maxillary premolar on the Class
II side would facilitate correction of the
canine to a Class I relationship with no
extraction in lower arch.
A passive or tightly activated transpalatal
arch could be used to control molar
anchorage, and space closure could be
accomplished primarily through Class I
mechanics

If extractions in the mandibular arch are
necessary because of excessive crowding,
and if a Bolton's tooth size discrepancy
exists, the extraction of a lower incisor
or lower incisor proximal reduction
may simplify the biomechanical
complexity of the case

Maxillary and Mandibular Dental
Midline Deviation With Skeletal
Symmetry
A) Both deviated to one side
Extraction of ipsilateral upper and
lower premolars may be the plan to
follow.
The decision to extract first or second
premolars or a combination of these is
dependent upon the amount of midline
correction that is desired, and molar
anchorage requirement

b) If the maxillary and mandibular midlines
are both off from the facial midline, but in
this instance on opposite sides from
each other, it is likely the result of
asymmetric arch crowding.
The appropriate plan in this situation may
be the extraction of an upper premolar
on the Class II side and a mandibular
premolar on the Class III side.

Jasper Jumper for mid line
correction
Significant midline discrepancies,
often due to anchorage loss, must
sometimes be corrected during the last
phase of orthodontic treatment.
The Jasper Jumper, a flexible sagittal
force module, was designed for the
correction of Class II high angle
malocclusions.


Flexible Jumper produces a range of
force from 1-16oz, depending on its
length when the teeth occlude.
Therefore used asymmetrically--one side with
conventional Class II mechanics, the other
with Class III mechanics--to correct a midline
discrepancy and a possible mandibular shift
resulting from maxillary deficiency.

Case example-
Diagnosis
A 10-year-old male showed a moderate facial asymmetry,.
A functional crossbite on the right side, resulting from a
narrow maxilla and the mandibular deviation to the right in
habitual occlusion.
The patient had a full-cusp Class II molar and cuspid
relationship on the right side, but a Class I relationship on
the left.
collapsed maxillary arch, upper and lower anterior crowding,
and a palatally positioned maxillary right lateral incisor.

Treatment Progress
Treatment was initiated with a bonded Minne-Expander, using
a spring force of about 450g, to correct the transverse
discrepancy
A unilateral medium-pull headgear was fitted later to the
molar tubes embedded in the buccal acrylic of the expander
to improve the skeletal relationship and to help correct the
maxillary asymmetry.
Leveling of the maxillary incisors and cuspids was initiated
with Straight-Edge brackets
After five months of unilateral headgear wear, similar
mechanics were continued with a transpalatal bar ,also
activated unilaterally

Despite the asymmetrical orthodontic mechanics
and good dental alignment, the midline discrepancy
remained
It was decided to use asymmetrical Jasper
Jumpers to obtain a more continuous and intensive
force system on the maxillary complex.
During the asymmetrical jumper application, the
stiffest possible rectangular stainless steel
archwires --.017" X .025" maxillary and .018" X
.025" mandibular--were placed
The transpalatal bar was kept in place to
counteract any side effects of the asymmetrical
mechanics on the maxillary arch.
After about four months of this
treatment, the intrusive effect of the
Class III jumper could be observed in the
maxillary left anterior region, so a 4.5oz
diagonal elastic (Zebra) was added from
the maxillary left lateral incisor to the
mandibular right lateral incisor.
By the end of sixth month, the midline was
overcorrected and the posterior occlusion
was satisfactory.

Asymmetrical intermaxillary elastics can correct midline discrepancy of more than
3mm,but extrusive vertical force vectors of Class III (F_1) and diagonal (F_2)
elastics will theoretically exceed force vector of Class II side (F_3). Maxillary
occlusal plane (MOP) may therefore be lower on left side, causing difficulties with
fixed appliance mechanics. B. With asymmetrical Jasper Jumpers, vertical force
vectors of Class III jumper (F_1) and diagonal elastic (F_2) are opposite.
Even if forces are unequal, adverse effects will be less likely.
Clinical results seem to indicate condyle -fossa
remodeling as a normal adaptation to the
maxillary skeletal and overall occlusal changes.
The dental effects of this force system are
reciprocal--the incisors moved bodily in opposite
directions, while the direction and amount of
movement were controlled by the sizes of the
jumpers.
The asymmetrical jumpers were well accepted by
the patients, and no breakage occurred.

Facilitation of Midline Correction
with a Premolar Extraction
Sequence
CASE EXAMPLE-
Diagnosis
A 16-year-old male presented with the chief
complaint of buccally erupting canines .The upper
and lower midlines were shifted to the right by 4mm
and 2mm, respectively.
The patient had a convex profile, an obtuse
nasolabial angle, a retrognathic mandible, and
excessive upper and lower facial heights. The molar
relationship was Class II on the right and Class I on
the left; the overjet was 7mm.

Camouflage comprehensive orthodontic treatment
was planned as follows:
1. Sequential extraction of the four first premolars,
with the maxillary left first premolar removed
before the contralateral first premolar to allow
correction of the upper midline and to conserve
anchorage.
2. Maximum anchorage from a mandibular lingual
holding arch and high-pull headgear.
3. Extraction of maxillary second molars as needed.

Treatment Progress
The maxillary left first premolar and
mandibular first premolars were extracted.
The maxillary right first premolar was left
in place to prevent distal drift of the right
canine.
Preadjusted .018" brackets were bonded
and an .016" nickel titanium archwire was
placed.

Functional asymmetries-
treatment
Mild deviations are corrected with minor
occlusal adjustments.
Severe deviations need orthodontic
treatment to align the teeth and to obtain
proper function.
Occlusal splints may be necessary to
properly evaluate the presence and extent
of the functional shift by eliminating
habitual posturing and deprogramming
the musculature.

Functional shifts can also be the result of
a skeletal asymmetry
Rapid maxillary expansion,
orthognathic surgery and orthodontic
treatment may be indicated in the
management of these cases
Treatment of asymmetrries
A) diverging occlusal planes
Canted anterior occlusal plane (in
transverse direction). The conventional
treatment for this problem is the use of
vertical interarch elastics to extrude
the side of the occlusal plane that is
farthest from the treatment occlusal
plane. The vertical elastic exerts an
extrusive force on both the maxillary and
mandibular arches.

B)Canted maxillary anterior
occlusal plane and a deep bite
One -piece intrusion arch of 0.017
0.025-inch titanium molybolenum
alloy (TMA) is tied to that side of
the anterior segment requiring
intrusion.
The intrusive force level should be
approximately 60 gm for four
maxillary incisors and
approximately 50 gm or less for
four mandibular incisors.

0.017 x 0.025-inch TMA intrusion arch comes from molar
auxiliary tube and is tied to one side of anterior segment (0.018
x 0.025-inch stainless steel) delivering intrusive force on that
side. B, Activated intrusion arch, before ligation on anterior
segment. C, Intrusion arch tied in on one side only.

If the canine also requires intrusion,
this is performed in a separate stage
after the incisor intrusion.
A simple cantilever (0.017 0.025-
inch TMA) exerting a force of 20 to 25
gm can be used

A. Anterior view of separate canine intrusion. 0.018 x 0.025-
inch stainless steel arch wire bypasses canine. 0.017 x 0.025-
inch TMA cantilever comes from molar auxiliary tube and is tied
underneath canine bracket (point force contact) delivering
intrusive force. B, Buccal view of separate canine intrusion.
Ideally wire should not be tied into bracket slot to deliver force
without moments. C, Buccal view of separate canine intrusion.
When only one side requires
extrusion,
A unilateral cantilever can be used
to correct the occlusal cant. The
cantilever, 0.017 0.025-inch TMA,
comes out of the auxiliary tube of the
first molar on the side where the
extrusion is to take place and is hooked
around the anterior segment. A force of
approximately 30 gm is sufficient

Diagrammatic representation of unilateral extrusion of
canted anterior segment. 0.017 x 0.025-inch TMA cantilever
coming from auxiliary tube of molar is tied to one side of
anterior segment. B, Patient with canted maxillary occlusal
plane. C, Correction of canted occlusal plane with cantilever
hook tied on affected side.
C)Canted posterior occlusal
plane (in anteroposterior
direction)
A variation of the intrusion arch can be
used to correct this along with a deep
overbite.
The magnitude of force is increased to
150 gm that causes a large tip-back
moment on the buccal segment, thereby,
flattening the occlusal plane. This
appliance delivers appropriate force to the
area of the arch in need of correction.


To upright buccal segment, cantilever with hook
can be used. Side effects are extrusion of buccal
segment and unilateral intrusion of anterior
segment.
D)Asymmetric arch form-
treatment
Orthodontists often use an asymmetrically shaped arch
wire or asymmetric interarch elastics to correct an
asymmetric arch form.
A more efficient way is to use a cantilever (0.017
0.025-inch TMA) from the first molar, with a hook that is
attached in the area where the arch needs to be
expanded or narrowed. The cantilever can be inserted on
top of a light arch wire, for example 0.016-inch TMA.
A transpalatal or lingual arch connecting the molars
should be in place to prevent rotation of the molar to
which the cantilever is attached.

E)Treatment of asymmetric left
and/or right buccal occlusion
Clinical example A: for example, Class
I on one side and Class II on the other.
This can be due to differences in axial
inclination of the molars
A lingual or palatal arch (0.032-inch
TMA or 0.032 x 0.032-inch TMA)
activation is made to deliver a tip
forward moment on the Class I side
and a tip-back moment on the Class II
side

Clinical example B: differences
in left and right molar rotation
Rotated molars are frequently seen in the
maxillary arch. A mesial-in rotation of one
molar often results in an asymmetric
molar occlusion.
To correct this problem, a transpalatal
arch is used with equal amounts of
antirotation activation. An 0.018 x
0.025-inch stainless steel wire is tied into
all teeth except the rotated molar

Clinical example C: no difference in
molar rotation and/or axial inclination
The right and left molar relationship can be
asymmetric without perverted axial inclinations
or rotations.
A conventional approach to correct this problem
is to use an asymmetric headgear.
This headgear has the potential to move one
molar further distally than the other molar

Unilateral dental crossbite
The treatment can be performed with a
lingual arch (0.032-inch TMA) in the
mandible and transpalatal arch (TPA) in the
maxilla

Treatment of skeletal
asymmetries- Surgical
The severity and nature of the skeletal
asymmetry will dictate whether the
discrepancy can be completely or partially
resolved solely through orthodontic
treatment.
In growing individuals, orthopedic appliances
in conjunction with orthodontic treatment are
used to help improve or correct the
developing skeletal imbalances.

Asymmetries of a skeletal nature treated with
orthodontics alone might dictate certain
compromises
Severe discrepancies may require a combination of
surgery and orthodontic treatment.
Abnormalities of the coronoid and condylar
processes as well as in the position and shape of
the articular discs should be considered whenever
limited opening, acute malocclusions, or mandibular
deviations are found.

The mandible is the dominant contributor to
dentofacial asymmetry in as much as it forms
the skeletal support for the soft tissues of the
lower face.
Conversely, the maxilla provides minimal
soft-tissue support and has small part in
asymmetry.
Most maxillary asymmetry is secondary to
asymetric mandibular growth and measured
simply by the location of the maxillary dental
midline and the cant of the frontal occlusal
plane.

The clinician should consider several
guidelines
Thoroughly evaluate the initial history and
diagnostic records.
Always check for a functional component to the
malocclusion and take the appropriate records in
centric relation.
Recognize the early signs of a progressive
asymmetry.
Understand the dentoalveolar compensations
associated.
Take progress records and reevaluate if there is
progressive asymmetry.

Treatment objectives should be to
coordinate arches
Minimize compensations such as axial
inclinations of the maxillary and
mandibular dentition and transverse
occlusal plane canting
keeping the maxillary transverse occlusal
plane as level as possible during growth by
using splints and other types of passive
appliances to prevent compensatory
supraeruption.

Unilateral condylar hyperplasia
(hemimandibular hyperplasia,
hemimandibular elongation)
Because the surgical treatment strategy
depends on condylar growth activity,
skeletal scintigraphy growth analysis
or
A technetium-99m methylene
diphosphonate (Tc99m) bone scan
can also be performed.
Unilateral condylectomy in a growing
child with condylar hyperplasia can
provide satisfactory resolution of facial
asymmetry
Secondary deformities, such as canting of
the maxillary frontal occlusal plane and
chin deformities should also be corrected.
A Le Fort I osteotomy to superiorly
reposition the affected side and bilateral
mandibular ramus osteotomies will
correct the cant of the frontal occlusal
plane.
Osteotomies can be simultaneously used to
correct any accompanying anteroposterior,
vertical, or transverse discrepancies.
Condylar shave procedure can be done to
correct minor deformities.

Genioplasty (augmentation or
redeuction) to further correct the chin
asymmetry
Inferior border mandibular
osteotomy to correct the bowing on the
affected side and/or augmentation of
the inferior border on the
contralateral side, may also be indicated
Orthodontic therapy is directed at ideally
positioning the teeth over basal bone.
Segmented arch mechanics are often
indicated, particularly when the surgical
plan calls for segmental osteotomies, but
also when precision in leveling by
intrusion, maximum anchorage retraction,
segmental torque and tip, and/or control
of the transverse dimension is required.

Bony ankylosis of the TMJ-
Gap arthroplasty
Interpositional arthroplasty The
ankylosis should be surgically released,
biocompatible interpositional material should
be placed eg. sialistic implants or bone
grafts
High condylar shave with disc
stabilisation
Condylectomy
Distraction osteogenesis etc are some
procedures to relieve ankylosis

Unilateral internal derangenents
are corrected by articular disc
repositioning procedures,
stabilisation or replacement
followed by pharmacotherapy ,
occlusotherapy , physiotherapy,
ultrasound etc
Rapid maxillary expansion can be
used to correct transverse asymmetries
Hemifacial microsomia-
Severity of this condition can be extremely
varied and treatment should be initiated early
to help prevent greater expression of the
asymmetry.
Distraction osteogenesis is an excellent
treatment modality in the growing patient in
an attempt to stimulate development of soft
tissue as well as hard tissue.
In more severe cases, reconstruction of
the TMJ with costochondral grafting will
usually be required
Surgery for Hemifacial
Microsomia
There are three stages of surgical intervention
described by Converse.
The initial surgery is at age 5 to 8 years. The goal is
to replace missing skeletal elements and augment
severely deficient areas to create a more favourable
environment for subsequent growth of unaffected areas.
At age 12 to 15, after the adolescent growth spurt,
orthognathic concerns are addressed, with
repositioning of both jaws as necessary.
The third stage, in the late teens, is designed to
enhance the contour of the skeleton and the soft
tissues.
Initial Surgical Phase:
Augmentation of Deficiencies.
Augmentation of mandible can be
accomplished by an inverted L
osteotomy via an extra oral approach,
with the placement of grafts as
appropriate.
If the zygomatic arch is missing or
severely deficient,one may be
constructed at the initial stage.
Second Surgical Phase: Jaw
Relationships.
Depending on growth, additional
mandibular advancement, usually
with vertical elongation of the
affected ramus and the placement of
a graft on that side, if necessary.
If sagittal correction is necessary,
sagittal split osteotomies may be
employed bilaterally.

Asymmetric inferior border
osteotomy to bring the chin to the
midline, which improves both lip function
and esthetics.
Additional onlay bone grafting to the
mandible or maxilla for contour purposes
also is performed
If occlusal cant persists beyond age
15, a LeFort I osteotomy to correct it
may be required.

When the bilateral osteotomies have been
completed, the mandible is repositioned and
bone grafts harvested from the cranium or the
ilium are inserted into the vertical and
horizontal defects and secured with wires, bone
plates, or screws.
Maxillomandibular fixation including an
occlusal wafer splint is applied and continued
for 4 weeks while healing takes place.
Overcontouring the affected side with
bone grafts helps camouflage some of the
missing soft tissues.

Third Surgical Phase:
Contour Modification.
If severe problems persist, major
reconstructive surgery with placement of
grafts in the zygomatic and/or mandibular
ramus areas may be required
Orthognathic surgery to reposition the
jaws may be needed
Occasionally, mandibular inferior border
osteotomy or onlay bone grafts to augment
deficient areas are planned to enhance the
final result.

Many asymmetric surgical orthodontic
cases are variations of other hypoplastic
or hyperplastic mandibular deformiities
and accordingly can be addressed by-
asymmetric movement of the
mandibular distal segment using
bilateral ramal osteotomies.
Sagittal split ramus osteotomy and
the intraoral vertical ramus
osteotomy are also commonly indicated
in these cases
Genioplasty
Mandibuloplasty
Soft -tissue augmentation/ reduction,
and inferior-border
augmentation/reduction provide
additional flexibility in correcting
asymmetries.
Not infrequently, maxilllary form and position
must be corrected, necessitating
simultaneous maxillary and mandibular
osteotomies.
Condylar Fractures: Asymmetry
due to Trauma
In most cases, the fractured condyle resorbs
and a new ramus articulation forms.
When growth restriction occurs, the ramus
grows more on the normal side, the chin
deviates toward the affected side.
Less tooth eruption takes place there
Restricted movements of mandible occur,
termed as functional ankylosis because jaw
movement and function occur but are
impaired.

The recommended management for a
child with a recent condylar fracture is
immobilization of the jaw for a few
days, until initial soft-tissue healing can
occur
Followed by physiotherapy to
maximize jaw movement
Functional appliance to guide
mandible to the proper position is
indicated.

When condylar segment is displaced
laterally or wedged between the ramus
and temporal bone, preventing motion
on the injured side.
Closed manipulation to free the
segment should be attempted first.
If mandibular motion is still
restricted, an open approach is
done , removing the condylar head
or repositioning it.
Management of Posttraumatic Asymmetry
occurs because there is more growth on the
normal than on the affected side.
If possible bring the mandible to a normal
symmetric position in the midline without
undue strain, so that the construction bite for
a functional appliance can be taken,
treatment of this type should be attempted
before any surgery
Or ramus osteotomy to bring the mandible
to its approximately normal position
Surgical intervention in the TM joint is
decided when previous therapy hasnt
worked.
Release of the ankylosis to provide free
movement involves removing soft tissue and
bone and excessive scar tissue
The coronoid process must also be released
or removed
Physical therapy follows surgery to
maintain the degree of jaw motion attained

REFERENCES
Shroff B, Siegel SM., Treatment of patients with asymmetries using
Semin Orthod. 1998 Sep;4(3):165-79. Review asymmetric
mechanics
Nanda R, Margolis MJ., Treatment strategies for midline
discrepancies.
Semin Orthod. 1996 Jun;2(2):84-9. .
: Jerrold L, Lowenstein LJ. The midline: diagnosis and treatment.
Am J Orthod Dentofacial Orthop. 1990 Jun;97(6):453-62.
: Rebellato J., Asymmetric extractions used in the treatment of
patients with asymmetries.
Semin Orthod. 1998 Sep;4(3):180-8.
: van Steenbergen E, Nanda R, Biomechanics of orthodontic
correction of dental asymmetries.
Am J Orthod Dentofacial Orthop. 1995 Jun;107(6):618-24.
Burstone CJ., Diagnosis and treatment planning of patients with
asymmetries.
Semin Orthod. 1998 Sep;4(3):153-64.
: Erdogan E, Erdogan E., Asymmetric application of the Jasper
Jumper in the correction of midline discrepancies.
J Clin Orthod. 1998 Mar;32(3):170-80..
Wong AM, Rabie AB ., Facilitation of midline correction
with a premolar extraction sequence.
J Clin Orthod. 2001 Jan;35(1):13-7
Joondeph DR. Mysteries of asymmetries.Am J Orthod
Dentofacial Orthop. 2000 May;117(5):577-9.
Bishara SE, Burkey PS, Kharouf JG ., Dental and facial
asymmetries: a review. Angle Orthod. 1994;64(2):89-
98.
Contemporary orthodontics-proffit
Surgical orthodontics-proffit and white
Kusnoto J, Evans CA, BeGole EA, Obrez A . Orthodontic
correction of transverse arch asymmetries. Am J Orthod
Dentofacial Orthop. 2002 Jan;121(1):38-45
Problem solving in orthodontics- Burstone

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