Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                

Quantitative Evaluation of Lip Symmetry in Functional Asymmetry

Download as pdf or txt
Download as pdf or txt
You are on page 1of 8

European Journal of Orthodontics 25 (2003) 443–450 European Journal of Orthodontics vol. 25 no.

5
 European Orthodontic Society 2003; all rights reserved.

Quantitative evaluation of lip symmetry in functional asymmetry


Talia Gazit-Rappaport*, Miron Weinreb** and Esther Gazit***
*Private Practice, Tel Aviv, **Departments of Oral Biology and ***Occlusion and Behavioral Sciences,
The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Israel

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

Downloaded from ejo.oxfordjournals.org by guest on November 2, 2010


contact position. Digitized images of frontal facial photographs were analysed for upper and lower lip
symmetry pre- and post-orthodontic treatment. The upper and lower lips were subdivided into four
quadrants and the surface area and length of each quadrant were measured and expressed as a
percentage of the total surface area/length of the relevant lip. The degree of asymmetry was obtained
by calculating the difference in percentage area or length between the two quadrants of each lip.
In the study group, the lower lip quadrant on the shift side was enlarged while the contralateral side
was reduced (mean area ratio 59.9 to 40.1 per cent, mean length ratio 53.0 to 47.0 per cent). The upper
lip demonstrated differences that were smaller and inverse. The controls showed a small difference
between the right and left sides (less than 1 per cent). After treatment, both groups displayed visual and
quantitative lower and upper lip symmetry, i.e. an area or length of approximately 50 per cent of each
quadrant. In absolute values, the control patients had up to 3 per cent asymmetry in area regardless of
treatment. The patients in the study group exhibited mean absolute asymmetry of 9.2 per cent in the
upper lip and 19.8 per cent in the lower lip. Asymmetry values in the study group were reduced to
approximately 3 per cent post-treatment. The absolute values of asymmetry in length of all patients
were up to 2 per cent in the control group regardless of treatment. The subjects in the study group
exhibited mean absolute asymmetry of 6.3 per cent in the upper lip and 8.6 per cent in the lower lip.
Asymmetry values in the study group were reduced post-treatment to approximately 2 per cent.
Although asymmetry in the study group could be quantitated using both parameters (lip surface area
and lip length), the surface area parameter proved to be a more sensitive tool for measuring lip
asymmetry.

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

Downloaded from ejo.oxfordjournals.org by guest on November 2, 2010


demands more complex treatment (Brin et al., 1996; of the lower face in the ICP; a unilateral crossbite extend-
Padwa et al., 1997; Pirttiniemi, 1998). ing to the primary or permanent canine and occasionally
Facial soft tissue architecture is the most important additional anterior tooth/teeth; and competent lips.
factor that highlights the presence of an asymmetry The control group comprised 13 age- and gender-
with or without a skeletal component. With regard to matched patients with other forms of malocclusion but
transverse asymmetries, most of the literature focuses without a functional shift and crossbite. A clinical and
on the hard tissue architecture of the lower jaw (Cook, panoramic radiograph examination to assess dental,
1980; Grayson et al., 1983; Forsberg et al., 1984; Rose facial, and major skeletal asymmetry was carried out for
et al., 1994). For the soft tissues, the focus is on the both groups. The assessment of skeletal asymmetry was
outline of the lower third of the face, mainly the location performed clinically while the mandible was in the RCP
of the midpoint of the chin (Bishara et al., 1994; Edler or at rest. When asymmetry was visually detected in
et al., 2001). To the best of our knowledge, there has these positions the patients were excluded from the
been no clinical study published on lip asymmetry. study group. Of the 13 patients, two were post-growth.
Clinically, in the present study, it was observed that All patients looked symmetrical in the RCP prior to the
asymmetry due to a functional side shift, associated with side shift leading to the ICP. A frontal face photograph
a unilateral buccal crossbite, including the canine and in the ICP was taken prior to orthodontic treatment.
occasionally an incisor, could supply differential support
to the left and right sides of the lips. This would result in
Orthodontic treatment
a mild upper lip thinning and substantial lower lip thicken-
ing on the crossbite side when compared with the contra- In the study group the crossbite was corrected as
lateral side. The lower face in general, and the lip follows: a symmetrical maxillary arch expansion device
architecture in particular, appear quite symmetrical in the was first used to treat patients in the mixed dentition.
RCP, or at rest with the lips apart. However, the mandibular When there was resolution of the crossbite, treatment
shift and lip asymmetry are noticeable with each mandibular continued with partial bonding of the maxillary anterior
closure, swallowing and occasionally with speech. For a teeth for aesthetic or functional demands. Before
crossbite to cause lip asymmetry, the canine and possibly debonding, care was taken to ensure occlusal stability
additional anterior teeth should be involved. Qualitative and selective grinding was performed when necessary
observations regarding lip symmetry have been briefly on primary teeth only. Patients in the permanent
reported (Mongini and Schmid, 1987). dentition received rapid palatal expansion treatment for
To support the present observations scientifically maxillary arch expansion followed by full bonding to
(i.e. quantitatively) a prospective investigation was achieve optimal anterior alignment with normal overjet
conducted in which patients with functional side shifts and overbite, buccolingual and mesiodistal relationships.
and unilateral crossbites involving the canine were Stable occlusal contacts were established at the end of
consecutively recruited upon arrival for orthodontic treatment. The control group had various treatments, all
treatment over a 1 year period. Because the patients carried out with fixed appliances to achieve optimal
ranged in age from 8 to 17 years, they exhibited cross- interarch relationships.
bite of the primary and permanent canines. A frontal face photograph of each patient was
The objectives of this study were to quantitate lip taken in the ICP when the orthodontic treatment was
symmetry/asymmetry from clinical photographs; to completed.
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 445

Photographic procedure Data collection


One person took all the facial photographs in the same All frontal photographs were scanned using a Hewlett-
room, using the same camera (Nikon FE2 with a Kiron Packard S20 scanner. The lower half of the face was
105 mm lens and a Holgon RF-50 macro-lite flash) and enlarged and saved as a digital image. Four photo-
colour print 100 ASA film. The patient was seated and graphs, three from the study group and one from the
requested to look straight at the camera and to keep control group, are shown pre- and post-orthodontic
their head perpendicular to the floor. Special care was treatment (Figures 1a–d, 2a–d). A vertical line from
taken to ensure frontal head posture with no side the midpoint of the base of the nose (the mid-distance
rotation around the vertical axis of the head. The between the inner outline of the nostrils) through the
distance from the patient to the camera was focused at midpoint of the philtrum towards the chin was super-
1.2 magnification. Glasses were removed and the patient imposed on the images (Figure 2f). The midpoint of the
was asked to close the back teeth and lightly close the lips. chin did not fall on this line in the study group.

Downloaded from ejo.oxfordjournals.org by guest on November 2, 2010

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.

Downloaded from ejo.oxfordjournals.org by guest on November 2, 2010

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

Reproducibility Thus, the study group showed a reduction in lip


thickness on the side where the shift and crossbite
Area and length were measured five times in eight
presented pre-treatment (from 59.9 to 50.6 per cent). At
patients to determine the reproducibility of the measure-
the same time, all patients in the study group showed an
ments and the coefficient of variation (CV) for each
increase in lip thickness on the contralateral side from
parameter was calculated. The mean CVs of area and
40.1 to 49.4 per cent. These changes in lip quadrant area,
length measurements were 2.35 and 1.95 per cent,
associated with the orthodontic treatment, were highly
respectively, indicating that these measurements were
significant (P < 0.001).
highly reproducible.
Figure 4 demonstrates the percentage of the surface
area of the lower lip quadrants pre- and post-
Statistical analysis orthodontic treatment for each individual patient in
both groups. Note that prior to treatment, each patient
Differences between area and length values of the
in the study group showed remarkable differences
quadrants of each lip (one side versus the other, and
between the two lower quadrants. On completion of
pre- versus post-treatment) were evaluated with a
orthodontic treatment the lip surface area in the study
paired t-test.
group approached 50 per cent in each patient. In the
control group, changes were subtle pre- and post-

Downloaded from ejo.oxfordjournals.org by guest on November 2, 2010


treatment and varied slightly around 50 per cent. These
Results
data indicate that lower lip symmetry was achieved in all
All patients displayed visual lip asymmetry in the treated patients.
study group compared with the controls where no lip The mean percentage surface area of each of the two
asymmetry was observed. The mean percentage surface halves of the upper lip pre- and post-treatment in both
area of each of the two quadrants of the lower lip groups is shown in Figure 5. In the controls, the mean
pre- and post-treatment in both groups is shown in values of the upper lip surface area quadrants ranged
Figure 3. In patients with perfect symmetry, each half of between 49.4 and 50.6 per cent regardless of the
the lip occupied 50 per cent of the total lip area. orthodontic treatment. A mean ratio of 45.9 to 54.1 per
The mean values of the lower lip surface area cent of the study group pre-treatment was measured
quadrants ranged between 49.6 and 50.4 per cent between the upper lip quadrants, indicating that the
regardless of orthodontic treatment in the controls. In upper lip quadrant on the side of the shift was greatly
the study group, the difference in percentage area reduced in area. The post-treatment ratio was 50.1 to
between the lip quadrants pre-treatment was remark- 49.9 per cent. Figure 6 shows the absolute values of
able. A mean ratio of 59.9 to 40.1 per cent was measured asymmetry in lip area of all patients. In the control
between the lower lip quadrants, indicating that the group, patients had up to 3 per cent asymmetry in area
lower lip quadrant on the side of the shift was greatly regardless of treatment. In contrast, those in the study
enlarged. These pre-treatment differences were highly group exhibited mean asymmetry of 9.2 per cent in the
significant (P < 0.001). After orthodontic treatment upper lip and 19.8 per cent in the lower lip pre-
there was a mean residual difference of 1.2 per cent. treatment. This finding corroborates the clinical

Figure 3 Mean values of the percentage area of the lower lip


quadrants. Note the asymmetry in the lower lip in the study group
before treatment. $$$P < 0.001 (between pre-treatment values); Figure 4 Individual patient data from Figure 3. The surface area of
***P < 0.001 (before versus after treatment). each lower quadrant pre- and post-treatment is connected with a line.
448 T. G A Z I T- R A P PA P O RT E T A L .

Figure 7 Mean values of the percentage length of the lower lip


Figure 5 Mean values of the percentage area of the upper lip quadrants. Note the asymmetry in the lower lip in the study group
quadrants. Note the inverse asymmetry in the upper lip in the study pre-treatment. $P < 0.05 (between pre-treatment values); **P < 0.01
group pre-treatment. $$P < 0.01 (between pre-treatment values); (before versus after treatment).

Downloaded from ejo.oxfordjournals.org by guest on November 2, 2010


**P < 0.01 (before versus after treatment).

Figure 6 Absolute values of area asymmetry. Note that in the


control group asymmetry was up to 3 per cent regardless of treatment. Figure 8 Mean values of the percentage length of the upper lip
Note also the larger asymmetry of the lower lip compared with the quadrants. Note the inverse asymmetry in the upper lip in the study
upper lip in the study group and their reduction to control values group pre-treatment. $P < 0.05 (between pre-treatment values);
post-treatment. *P < 0.05, ***P < 0.001 (before versus after treatment). *P < 0.05 (before versus after treatment).

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

thickness. Whilst both lip surface and length demon-


strated significant differences between the two halves of
each relevant lip in the study group prior to treatment,
surface area proved to be a more sensitive tool for
measuring lip asymmetry, probably due to the expression
of two planes of space.
Lip symmetry should always be examined in the full
ICP. In the postural (rest) position, without any tooth
contact or in the RCP, the mandible is more centrally
located, and lip asymmetry may not be obvious. In this
study, a minor asymmetry of up to 3 per cent between
left and right surface area or length of the lower and
upper lips in the control group was not clinically
Figure 9 Absolute values of length asymmetry. Note that in the apparent at the time of examination. However, in the
control group asymmetry was up to 2 per cent regardless of treatment. study group the ratio was sufficiently large between
Also note the larger asymmetry of the lower lip compared with the the lower quadrants to be easily noted at the initial
upper lip in the study group and their reduction to control values
examination. Upper lip thinning was more difficult to

Downloaded from ejo.oxfordjournals.org by guest on November 2, 2010


post-treatment. **P < 0.01 (before versus after treatment).
determine due to its smaller volume. Lu (1965) stated
orthodontic interest (Pirttiniemi, 1994; Joondeph, 2000), that only facial asymmetries greater than 3 per cent
which encompasses the aetiology of the developing are clinically discernible, which is in agreement with the
problem and the structural, muscular, and joint adap- present study. This explains why all patients in the
tations when the asymmetry persists (Bishara et al., control group, pre- and post-treatment, and in the study
1994; Pirttiniemi, 1998). The muscular and skeletal group, post-treatment, appeared to have symmetrical lips.
changes after resolution of the malocclusion have also Lip asymmetry can be used as a diagnostic aid. Both
been reported (Brin et al., 1996). The general consensus professionals and lay-people will be able to recognize a
is that functional crossbites should be corrected as soon problem when lip asymmetry exists and thus be able to
as possible to eliminate the potential for musculo- refer young people to seek treatment. This will avoid
skeletal adaptive changes, or if already present, to the future complications mentioned above. Quantitative
reduce them in the future (Mongini and Schmid, 1987). analysis of the lip area/symmetry is a valuable aid in
Lips have varying configurations, shapes, and degrees diagnosis and the evaluation of treatment outcome.
of thickness. Generally, lip fullness is hereditary, but can
also be determined, to a large extent, by the position of
Conclusions
the dental arches. It is well known in orthodontics and
aesthetic dentistry that in the same patient, anteriorly 1. Lip surface area and length can be quantitated from
positioned teeth will create fuller lips compared with a clinical photographs and used to measure lip asymmetry.
more retruded position. Whatever their shape and 2. Functional side shifts accompanied by a unilateral
volume, they should exhibit bilateral symmetry. This is crossbite that includes the canine, result in thickening
examined by visually comparing the homologous parts of the lower lip and thinning of the upper lip on the
of the lips. In the presence of an anterior unilateral or same side. These changes result in measurable lip
buccal crossbite extending to the canine area or to the asymmetry.
lateral incisor, tooth support to the lips in the anterior 3. Elimination of the crossbite and the functional side shift
segment will not be symmetrical. When the canine restores lip symmetry both visually and quantitatively.
is involved the lower lip on the crossbite side will 4. Focus on lip asymmetry can encourage young patients
have more pronounced support by the mandibular to seek treatment as soon as possible, thus avoiding the
protruding tooth (or teeth) and will show increased dental, skeletal, muscular, and joint complications that
thickness contrary to the upper lip, which lacks that may accompany uncorrected side shifts into adulthood.
support. In the presence of a functional shift, it is easy
to assume that this asymmetry will be accentuated as
Address for correspondence
the displaced mandible pulls the lower lip sideways
and the merging of both lips at the commissure is not Esther Gazit
symmetrical (Figure 1c, e). Future studies are necessary Department of Occlusion and Behavioral Sciences
to show which of these two factors contributes more to The Maurice and Gabriela Goldschleger School of
lip asymmetry. The percentage expression of right and Dental Medicine
left relevant lip surface area or outline as performed in Tel Aviv University
this study allowed lip symmetry to be estimated object- Tel Aviv 69978
ively in spite of individual lip configuration and Israel
450 T. G A Z I T- R A P PA P O RT E T A L .

References Mongini F, Schmid W 1987 Treatment of mandibular asymmetries


during growth. A longitudinal study. European Journal of
Bishara S E, Burkey P S, Kharouf J G 1994 Dental and facial Orthodontics 9: 51–67
asymmetries: a review. Angle Orthodontist 2: 89–98
Mossey P A 1999 The heritability of malocclusion: Part 1 Genetics,
Brin I et al. 1996 Skeletal and functional effects of treatment for principles and terminology. British Journal of Orthodontics 26:
unilateral posterior crossbite. American Journal of Orthodontics 103–113
and Dentofacial Orthopedics 109: 173–179
O’Byrn L B, Sadowsky C, Schneider B, BeGole E 1995 An
Cook J T 1980 Asymmetry of the craniofacial skeleton. British evaluation of mandibular asymmetry in adults with unilateral
Journal of Orthodontics 7: 33–38 posterior crossbite. American Journal of Orthodontics and
Edler R, Wertheim D, Greenhill D 2001 Clinical and computerized Dentofacial Orthopedics 107: 394–400
assessment of mandibular asymmetry. European Journal of Padwa B L, Kaiser M O, Kaban L B 1997 Occlusal cant in the frontal
Orthodontics 23: 485–494 plane as a reflection of facial asymmetry. Journal of Oral and
Forsberg C T, Burstone C J, Hanley K J 1984 Diagnosis and treat- Maxillofacial Surgery 55: 811–816
ment planning of skeletal asymmetry with the submento-vertical Pirttiniemi P 1994 Associations of mandibular and facial asymmetries
radiograph. American Journal of Orthodontics 85: 224–237 —a review. American Journal of Orthodontics and Dentofacial
Grayson B H, McCarthy J G, Bookstein F 1983 Analysis of Orthopedics 106: 191–200
craniofacial asymmetry by multiplane cephalometry. American Pirttiniemi P 1998 Normal and increased functional asymmetries
Journal of Orthodontics 84: 217–224 in the craniofacial area. Acta Odontologica Scandinavica 56:
Ingervall B, Thilander B 1975 Activity of temporal and masseter 342–345
muscles in children with lateral forced bite. Angle Orthodontist Proffit W R, Phillips C, Dann C 1990 Who seeks surgical-orthodontic

Downloaded from ejo.oxfordjournals.org by guest on November 2, 2010


45: 249–258 treatment? International Journal of Adult Orthodontics and
Joondeph D R 2000 Mysteries of asymmetries. American Journal of Orthognathic Surgery 5: 153–160
Orthodontics and Dentofacial Orthopedics 117: 577–579 Rose J M, Sadowsky C, BeGole E A, Moles R 1994 Mandibular
Linder-Aronson S 1970 Adenoids: their effect on mode of breathing skeletal and dental asymmetry in Class II subdivision
and nasal airflow and their relationship to characteristics of the malocclusions. American Journal of Orthodontics and Dentofacial
facial skeleton and dentition. Acta Otolaryngologica Scandinavica Orthopedics 105: 489–495
Supplement 265
Severt T R, Proffit W R 1997 The prevalence of facial asymmetry in
Lu K H 1965 Harmonic analysis of the human face. Biometrics 21: the dentofacial deformities population at the University of North
491–505 Carolina. International Journal of Adult Orthodontics and
Mongini F 1982 Combined method to determine the therapeutic Orthognathic Surgery 12: 171–176
position for occlusal rehabilitation. Journal of Prosthetic Dentistry Thilander B, Wahlund S, Lennartsson B 1984 The effect of early
47: 434–439 interceptive treatment in children with posterior crossbite.
Mongini F 1984 The stomatognathic system. Function dysfunction European Journal of Orthodontics 6: 25–34
and rehabilitation. Quintessence, Chicago, pp. 21–25

You might also like