Stedman TL Stedman's Medical Dictionary for the Dental Professions. Lippincott Williams and Wilkins. 2011;
Jackson TH, Mitroff SR, Clark K, Proffit WR, Lee JY, Nguyen TT Face symmetry assessment abilities: Clinical implications for diagnosing asymmetry. Am J Orthod Dentofacial Orthop. 2013; 144:663-671
Peck S, Peck L, Kataja M Skeletal asymmetry in esthetically pleasing faces. Angle Orthod. 1991; 61:43-48
Kusayama M, Motohashi N, Kuroda T Relationship between transverse dental anomalies and skeletal asymmetry. Am J Orthod Dentofacial Orthop. 2003; 123:329-337
Bishara SE, Burkey PS, Kharouf JG Dental and facial asymmetries: a review. Angle Orthod. 1994; 64:89-98
Cheong YW, Lo LJ Facial asymmetry: etiology, evaluation, and management. Chang Gung Med J. 2011; 34:341-51
Choi YK, Park SB, Kim YI, Son WS Three-dimensional evaluation of midfacial asymmetry in patients with nonsyndromic unilateral cleft lip and palate by cone-beam computed tomography. Korean J Orthod. 2013; 43:113-119
Pruzansky S Not all dwarfed mandibles are alike. Birth Defects. 1969; 5:120-129
Vento AR, Labrie RA, Mulliken JB The OMENS classification of hemifacial microsomia. Cleft Palate Craniofac J. 1991; 28:68-77
Gabrick KS, Wu RT, Singh A, Bartlett SP, Taylor JA, Persing JA, Alperovich M Assessing facial asymmetry in postoperative patients with unilateral coronal craniosynostosis. J Craniofac Surg. 2020; 31:1000-1005
Obwegeser HL, Makek MS Hemimandibular hyperplasia—hemimandibular elongation. J Maxillofac Surg. 1986; 14:183-208
Obwegeser HL, Makek MS Hemimandibular hyperplasia— hemimandibular elongation. J Maxillofac Surg. 1986; 14:183-208
Ishizaki K, Suzuki K, Mito T, Tanaka EM, Sato S Morphologic, functional, and occlusal characterization of mandibular lateral displacement malocclusion. Am J Orthod Dentofacial Orthop. 2010; 137:454-455
Chia MS, Naini FB, Gill DS The aetiology, diagnosis and management of mandibular asymmetry. Orthod Update. 2008; 1:44-52
Cook JT Asymmetry of the craniofacial skeleton. Br J Orthod. 1980; 7:33-38
Djordjevic J, Toma AM, Zhurov AI, Richmond S Three-dimensional quantification of facial symmetry in adolescents using laser surface scanning. Eur J Orthod. 2014; 36:125-32
Nur RB, Çakan DG, Arun T Evaluation of facial hard and soft tissue asymmetry using cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2016; 149:225-237
Plooij JM, Maal TJ, Haers P, Borstlap WA, Kuijpers-Jagtman AM, Bergé SJ Digital three-dimensional image fusion processes for planning and evaluating orthodontics and orthognathic surgery. A systematic review. Int J Oral Maxillofac Surg. 2011; 40:341-352
Gill D, Naini F, McNally M, Jones A The management of transverse maxillary deficiency. Dent Update. 2004; 31:516-518
Ugolini A, Agostino P, Silvestrini-Biavati A, Harrison JE, Batista KBSL Orthodontic treatment for posterior crossbites. Cochrane Database Syst Rev. 2021; 12
Suppapinyaroj C, Lin CH, Lo LJ, Ko EW Outcome of surgical-orthodontic treatment in hemifacialmicrosomia with and without early mandibular distraction osteogenesis. Int J Oral Maxillofac Surg. 2021; 50:763-773
Ferguson J Definitive surgical correction of the deformity resulting from hemimandibular hyperplasia. J Craniomaxillofac Surg. 2005; 33:150-157
Ramanathan M, Kiruba GA, Christabel A, Parameswaran A, Kapoor S, Sailer HF Distraction osteogenesis versus orthognathic surgery: demystifying differences in concepts, techniques and outcomes. J Maxillofac Oral Surg. 2020; 19:477-489
Olivieri P, Uribe FA, Quereshy FA Aesthetic Facial surgery and orthodontics: common goals. Oral Maxillofac Surg Clin North Am. 2020; 32:153-165
Haas Junior OL, Guijarro-Martínez R, de Sousa Gil AP, da Silva Meirelles L, Scolari N, Muñoz-Pereira ME, Hernández-Alfaro F
Al-Moraissi EA, Wolford LM Is Counterclockwise rotation of the maxillomandibular complex stable compared with clockwise rotation in the correction of dentofacial deformities? A systematic review and meta-analysis. J Oral Maxillofac Surg. 2016; 74:2066. E1-2066.E12
Al-Daghreer S, Flores-Mir C, El-Bialy T Long-term stability after craniofacial distraction osteogenesis. J Oral Maxillofac Surg. 2008; 66:1812-1819

Skeletal discrepancies Part 3: assessment, aetiology and management of facial asymmetry

From Volume 16, Issue 3, July 2023 | Pages 137-144


Melisa Padashi-Fard


Specialist Registrar, Bristol Dental Hospital

Articles by Melisa Padashi-Fard

Michelle Wong Yin Mun


Specialist Registrar, Bristol Dental Hospital

Articles by Michelle Wong Yin Mun

Jennifer Haworth


Academic post-CCST trainee in Orthodontics, Royal United Hospitals, Bath and University of Bristol

Articles by Jennifer Haworth

Email Jennifer Haworth

Peter Fowler

BDS, MSc, PhD, MOrth RCS, FRACDS(Orth)

Consultant, Senior Lecturer, Graduate Program Director, Bristol Dental Hospital

Articles by Peter Fowler


This is the third article in a three-part series considering skeletal discrepancies in the vertical and transverse dimensions. Significant discrepancies in the transverse dimension are relatively rare but present challenges for the orthodontist, in terms of treatment planning, management and relapse.

CPD/Clinical Relevance: This article aims to increase awareness of the assessment, aetiology and management of patients presenting with facial asymmetry.


Assessment of facial attractiveness is subjective and is influenced by social, personal and cultural factors. Facial symmetry is the equilibrium of contralateral facial landmarks in dimension and form around the mid-sagittal plane.1 Asymmetry occurs when there is a difference in the size and relationship of the two sides of the face and can include either the soft tissues alone, or a combination of the craniofacial skeletal complex and the soft tissues. No individual face is truly symmetrical, but imbalance beyond a threshold becomes clinically significant, although this threshold is subjective.2 There is an increasing gradient of asymmetry along the vertical axis, with mandibular disproportion observed more frequently than maxillary disproportion.3 This article provides an overview of the assessment of the transverse dimension and discusses the aetiology and management of patients presenting with transverse skeletal asymmetry.

The face can be divided into equal fifths, using intercanthal distance to define a fifth (Figure 1). This intercanthal distance represents the central fifth, while the width of an eye (inner to outer canthus) on each side are the medial fifths, and the lateral fifth on each side is the distance from the outer canthus of the eye to the ear. While the alar base width often approximates the central fifth, the distance between the mesial margins of the irises often correspond to the distance between the commissures of the lips.

Register now to continue reading

Thank you for visiting Orthodontic Update and reading some of our resources. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Up to 2 free articles per month
  • New content available