Quantitative Evaluation of Lip Symmetry in Functional Asymmetry
Quantitative Evaluation of Lip Symmetry in Functional Asymmetry
Quantitative Evaluation of Lip Symmetry in Functional Asymmetry
5
European Orthodontic Society 2003; all rights reserved.
SUMMARY The objectives of this study were to quantitate lip symmetry/asymmetry from clinical
photographs; to demonstrate that asymmetry due to functional side shifts (functional asymmetry)
leading to unilateral crossbites including the canines, results from measurable thinning of the upper lip
and thickening of the lower lip on the side of the crossbite when viewed in the intercuspal contact
position; and to show that orthodontic treatment aimed at eliminating the functional shift and crossbite
would achieve lip symmetry, both visually and quantitatively.
The study consisted of 26 patients, who were divided into two groups: a study group of 13 patients
(eight females, five males, aged 8–17 years) with a functional asymmetry, and a control group of
13 age- and gender-matched subjects with other forms of malocclusion without functional asymmetry.
All patients in the study group exhibited unilateral crossbites including the canines in intercuspal
Introduction
with a functional side shift is quite common in the
Dentofacial asymmetry is a facial deformity which primary, mixed and transitional dentitions (Pirttiniemi,
is usually associated with a skeletal component. 1994). Changes in the arch width dimension can result in
Although the development of an asymmetry is not fully dental malalignment due to sucking habits and impaired
understood, several aetiological factors are recognized: nasal breathing (Linder-Aronson, 1970). Thus, the
(1) genetic or congenital malformations, such as hemi- created occlusal interferences could guide the mandible
facial microsomia, cleft lip and palate, hemimandibular into an acquired asymmetric maximal closure, which
hypertrophy or elongation (Severt and Proffit, 1997); causes a transverse component of asymmetry. In these
(2) environmental, such as mouth breathing (Pirttiniemi, cases, interarch tooth relationships often exhibit uni-
1994); and (3) functional, due to occlusal interferences lateral crossbites extending to the canines or to the
in the path of mandibular closure, resulting in a side anterior teeth. The contralateral side may exhibit a
shift (Bishara et al., 1994; Mossey, 1999). An asymmetry crossbite or a normal buccolingual relationship. The
may be present in the vertical, sagittal, or transverse antero-posterior jaw relationships are also affected,
plane, or a combination in all three planes of space. exhibiting more of a Class II relationship on the side of
Asymmetry in the transverse plane is the most the shift and crossbite (Bishara et al., 1994). In these
perceptive to the eyes of the patient and the observer situations, it is important to determine the retruded
(Proffit et al., 1990). Transverse asymmetry associated contact position (RCP) and the degree and direction of
444 T. G A Z I T- R A P PA P O RT E T A L .
the functional slide to the intercuspal contact position demonstrate that asymmetry due to functional side
(ICP). The prevalence of this functional asymmetry varies shifts (functional asymmetry) leading to unilateral
between 8 and 16 per cent (Thilander et al., 1984). crossbites including the canines, results in measurable
The long-standing presence of functional asymmetry thinning of the upper lip and thickening of the lower lip
in a dynamic growing and continuously changing on the side of the crossbite when viewed in the ICP; and
stomatognathic system may produce clinical situations, to show that orthodontic treatment aimed at eliminating
such as canting of the occlusal planes, vertical growth of the functional shift and crossbite would achieve lip
unsupported dentoalveolar units, temporomandibular symmetry, both visually and quantitatively.
joint adaptational changes and increasing skeletal
asymmetry (Mongini, 1984; O’Byrn et al., 1995). Muscle Subjects and methods
activity and function adapt to the malocclusion making
the RCP difficult to determine (Ingervall and Thilander, Patient selection
1975; Brin et al., 1996). In these cases it is necessary to Twenty-six patients were recruited from an orthodontic
‘de-programme’ the muscle memory with a bite splint practice prior to treatment. The study group consisted of
prior to RCP registration (Mongini, 1982; Mongini 13 patients (eight females and five males), aged 8–17 years
and Schmid, 1987). It is obvious that reversing these (mean 10.3 years), with the following inclusion criteria:
dynamic processes becomes extremely difficult and a functional side shift leading to transverse asymmetry
Figure 1 Frontal view of three patients from the study group with various degrees of asymmetry.
(a) Pre-treatment asymmetry 20.6 per cent, (b) post-treatment 0.6 per cent, (c) pre-treatment
asymmetry 7.4 per cent, (d) post-treatment 2.6 per cent; (e) pre-treatment asymmetry 17.8 per cent,
(f) post-treatment 1.4 per cent.
446 T. G A Z I T- R A P PA P O RT E T A L .
The lip outline and the transverse line at the merging was calculated as the absolute value of the difference in
of the two lips were carefully drawn to create (together percentage of area or length between the two quadrants
with the vertical line) four quadrants (Figure 2e,f), two of each lip, according to the formula: asymmetry = (right
making up the upper lip and two the lower lip. The segment value – left segment value) × 100/(right
surface area and length (along the lip border) of each segment value + left segment value). This calculation
quadrant was measured with the Bioquant Nova uses the sum of right + left values (which varied
Software (R&M Biometrics, Nashville, TN, USA). Data between patients). Thus, perfect symmetry would result
from each of the upper or lower lip quadrants were in a zero value. The absolute value was used as patients
expressed as a percentage of the total surface area/ in the control group had slight lip asymmetry to either
length of the relevant lip. Additionally, lip asymmetry the right or left side.
Figure 2 Frontal view of a symmetrical patient: (a) pre-treatment, (b) post-treatment. Frontal
view of an asymmetrical patient: (c) pre-treatment, (d) post-treatment. Frontal view of an
asymmetrical patient (e) with the measuring system (f).
QUA N T I TAT I V E E VA L UAT I O N O F L I P S Y M M E T RY 447
observation that the changes in area in the lower lip of 52.0 per cent was measured, indicating that the upper lip
the study group were much larger than those in the quadrant on the side of the shift was reduced in length
upper lip. Asymmetry values in the study group were (P < 0.05). The post-treatment ratio was 49.9 to 50.1 per
reduced post-treatment to approximately 3 per cent. cent. Figure 9 shows the absolute values of asymmetry
The mean percentage length of each of the two in length of all patients. In the control group, patients
quadrants of the lower lip outline pre- and post- had up to 2 per cent asymmetry in length regardless of
treatment in both groups is shown in Figure 7. In the treatment. In contrast, those in the study group
controls, the mean ratio of lower lip quadrants length exhibited mean asymmetry of 6.3 per cent in the upper
pre- and post-treatment ranged between 49.9 and lip and 8.6 per cent in the lower lip. This finding
50.4 per cent. In the study group, a mean ratio of 53.0 to corroborates the clinical observation that the changes in
47.0 per cent was measured between the lower lip area in the lower lip of the study group were much
quadrants, indicating that the lower lip quadrant on the larger than those in the upper lip. Asymmetry values in
side of the shift was significantly enlarged in length the study group were reduced post-treatment to
(P < 0.05). The post-treatment ratio was only 50.1 to approximately 2 per cent.
49.9 per cent. Figure 8 shows the mean percentage
length of the two quadrants of the upper lip. In the
Discussion
controls, the mean ratio of the upper lip quadrants
length pre- and post-treatment ranged between 49.5 and Dentoskeletal asymmetries in general, and functional
50.4 per cent. In the study group, a mean ratio of 48.0 to asymmetries in particular, have been the focus of
QUA N T I TAT I V E E VA L UAT I O N O F L I P S Y M M E T RY 449