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Dental Tribune Middle East & African Edition

14 Dental Tribune Middle East & Africa Edition | March-April 2015Paediatric Tribune > Page 15 Face asymmetries in children and adolescents – Classification and clinical characteristics By Athanasios E. Athanasiou, D.D.S., M.S.D., Dr. Dent. I ntroduction Perfect bilateral body sym- metry is more of a theoretic concept that seldom exists in living organisms. However, pro- nounced and recognizable face asymmetries do exist and can have serious esthetic, functional and psychological implications. Asymmetry in the craniofacial areas may be the result of dis- crepancies either in the form and/or size of individual bones as well as malposition of one or more bones in the craniofacial complex. The asymmetry may also be limited to the overlying soft tissues (1). Early detection of face asymmetry may be criti- cal with regard to the diagnosis, prognosis, and therapeutic man- agement. The aim of this article is to briefly present the major categories of face asymmetries in children and adolescents and to provide information on their clinical characteristics. Etiology Genetics have been implicated in certain conditions such as multiple neurofibromatosis (Figure 1), hemifacial microso- mia, cleft lip and palate. Intrauterine pressure during pregnancy and significant pres- sure at the birth canal during parturition can have observable effects on the bone of the fetal skull. Environmental factors can cause face asymmetry and may include pathological changes that are not congenital in nature (e.g., osteochondroma of the mandibular condyle), trauma, infection and inflammation within the temporomandibu- lar joint (TMJ), ankylosis of the mandibular condyle to the tem- poral bone, damage to a nerve, which may indirectly lead to asymmetry from the loss of muscle function and tone, and sucking or chewing habits with influence on tooth position equi- librium (1,2). Classification Skeletal Asymmetries The skeletal asymmetries may involve one bone (e.g., max- illa or mandible) or a number of skeletal and muscular struc- tures on one side of the face. Hemifacial microsomia Hemifacial microsomia results from the malformation of the 1st and 2nd branchial arches. In- volves mostly unilateral condy- lar underdevelopment, it may be associated with variable abnor- malities of the external and mid- dle ear, has similar manifesta- tions with Goldenhar syndrome, and its etiology is heterogene- ous. The extent of TMJ involve- ment primarily determines severity, prognosis, timing and type of treatment. Face asymme- try in hemifacial microsomia is characterized by chin deviation. Occlusal manifestations include lower dental midline deviation, unilateral cross bite, tilting of the occlusal plane, all of them towards the affected side (Figure 2). Apart from ear abnormalities, soft tissue defects may include skin tags, facial clefts, cranial nerve function, soft palate func- tion, bulk of subcutaneous soft tissue, muscles of mastication and facial expression, macrosto- mia, and skin tags (3). Hemimandibular hyperplasia Hemimandibular hyperplasia is an uncommon maxillofacial deformity characterized by in- creased ramus height, rotated facial appearance, and kinking at the mandibular symphysis. Usually it is associated with prominence of the lower bor- der of the mandible, maxillary and mandibular alveolar bone overgrowth, compensatory canting of occlusal plane, and serious functional malocclusion (4) (Figure 3). Heminandibu- lar hyperplasia presents diffuse enlargement of the condyle, the condylar neck, the ramus, and the body of the mandible, it usually begins before puberty, is clearly due to hyperactivity in the condyle, whose cartilage ac- tively proliferates. Condylar fracture Condylar fractures in grow- ing individuals are usually the results of accidents and sports (Figure 4). In children they are often overlooked by parents and physicians since short time af- ter the injury symptoms of pain usually disappear. The majority of condylar fractures in children, if properly diagnosed and man- Figure 1. Facial photograph of an 11-year-old girl with neurofibroma- tosis (a). The lesion is also apparent in lateral cephalometric (b) and pan- oramic (c) radiographs. Figure 4. Panoramic radiograph of a 15-year-old girl showing fracture of the left condyle. Figure 5. Facial photograph of a 16-year-old boy with osseous ankylo- sis of the left TMJ. The discrepancies include severe asymmetries in the mandibular body and ramus (a). Malocclusion is characterized by left anterior and posterior crossbite, tilt- ing of the occlusal plane, and lower dental midline deviation to the af- fected side (b). Figure 3. Facial photograph of a 16-year-old girl with heminandibu- lar hyperplasia (right side). The dis- crepancies include asymmetries in the mandibular body, ramus, and condyle (a). Malocclusion is charac- terized by left anterior crossbite and lower dental midline deviation to the non-affected side (b). Figure 2. Facial photograph of a 13-year-old girl with hemifacial mi- crosomia (right side) (a). The dis- crepancies include asymmetries in the mandibular body, ramus, and condyle, as well as involvement of the ear. Malocclusion is characterized by right posterior crossbite, tilting of the occlusal plane and lower dental mid- line deviation to the affected side (b). a a b b a a b b c

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