Development of Asymmetries

Jan E. Kronmiller

One of the goals of the management of the developing occlusion and the
correction of malocclusion is the establishment of symmetry within the
individual arches (arch form) and the occlusal relationships between the
maxillary and mandibular arches. The symmetry in arch form is related to the
axial inclinations and rotations of the individual teeth. The occlusion is
affected not only by the positions of the teeth, but also by the patterns of
skeletal growth. Although these two components are interrelated, this
discussion attempts to address them independently. (Semin Orthod 1998;4:
134-137.) Copyright 1998 by W.B. Saunders Company

symmetric occlusal relationships can result from
A asymmetry within an individual arch or from
asymmetric skeletal relationships between the maxilla
and the mandible. A careful observation will reveal
some degree of asymmetry in all faces. Although some
of this asymmetry is found primarily in the soft tissue,
skeletal contributions can be significant. Many meth-
ods have been used to identify and quantify the
magnitude of asymmetry, including evaluations of the
vertical and horizontal proportions of the face by
using facial photographs, radiographic analyses, or
direct clinical observations.
Some of the most severe asymmetries are observed
in individuals with craniofacial syndromes. These
include hemifacial microsomia, retinoic acid and
thalidomide teratology, clefling syndromes, and cranio-
synostoses. It is beyond the scope of this text to
consider the cause of asymmetries related to craniofa-
cial syndromes in detail. However, it is interesting to
note that many of these asymmetries appear to be
related to abnormalities occurring early during embry-
onic development that affect either the number or
migration pathway of neural crest cells. Premature
fusion of craniofacial sutures can also result in facial
asymmetry. Although the underlying causes of these
abnormalities are not fully understood, the molecular
and genetic mechanisms are the focus of much in-
tense research. Specific mutations have been identi-
fied in muscle segment h o m e o b o x (Msx) and fibro-
blast growth factor-receptor genes that lead not only
From the Department of Orthodontics, School of Dentistry,
Oregon Health Sciences University, Portland, OR.
Address correspondence toJan E. K:ronmille~;DDS, PhD, Profes-
sor and Chairman, Department of Orthodontics, ,Schoolof Dentistry,
Oregon Health Sciences University, Portland, OR 97201.
Copyrigt*t 1998 by W.B. Saunders Company
1073-8746/98/0403-000258. 00/0
to facial clefling and craniosynostposes, but also to
congenitally missing teeth. 1,2 A mutation in the sonic
hedgehog gene has been linked to holoprosencephaly
that is characterized by the loss of midline structures.
In some mildly affected individuals, this mutation is
expressed as an absence of one maxillary central
incisor. ~ These mutations can obviously lead not only
to asymmetric skeletal development, but also to asym-
metries within the individual dental arches, particu-
larly when congenitally missing teeth occur unilater-
ally.
Although some skeletal asymmetries cannot be
linked to characterized craniofacial syndromes with
known genetic mutations, their effects on occlusal
symmetry can be significant. The cause of these
asymmetric relationships can be considered to be
related to asymmetric skeletal development of indi-
vidual craniofacial structures. As described later in this
issue in the article titled "Diagnosis and Treatment
Planning of Patients With Asymmetries," by Dr Charles
Burstone, asymmetric development within the cranial
base can lead to asymmetries in the positions of the
glenoid fossae. A fossa that is in a more anterior
position relative to the contralateral fossa may pro-
duce a rotation of the mandible relative to the maxilla
and an asymmetric occlusion, even if the maxilla and
the mandible are not significantly asymmetric in form.
This could lead to a Class III relationship on the side
of the more forward positioned fossa and condyle and
a Class II relationship on the contralateral side. These
asymmetries also produce midline discrepancies if not
masked by other dentoalveolar compensations. Rota-
tions of the maxilla relative to the cranial base can also
produce an asymmetric occlusal relationship, even
when the glenoid fossae are symmetrically positioned.
These asymmetries probably begin early in fetal life
and continue throughout development. Formation of

134 Seminars in Orthodontics, Vol 4, No 3 (September), 1998: pp 134-137

 Developmentof Asymmetries 135

bone begins as early as 12 weeks in utero. Differences

in the n u m b e r or differentiation of precursor cells3
within a primordial facial structure would become
more obvious with continued growth and develop-
ment.
Mandibular asymmetries may be related not only to
asymmetric positioning, but also to asymmetric mor-
phology of the mandible. Differences in the length of
the body of the mandible, as well as differences in the
height of the developing ramus, can lead to asymme-
tries. As previously mentioned, these developing asym-
metries may begin early in fetal life but may also be the
result of disturbances in postnatal development, includ-
ing trauma to the mandibular condyle.
Asymmetries within the maxillary or mandibular
arch can produce asymmetric occlusal relationships.
Ankylosis of primary molars occurs in 4.1% of Cauca-
sians.4 Whereas ankylosed teeth appear to be "sub-
merging" below the line of occlusion of the adjacent
teeth, dentoalveolar development with the continuing
eruption of the adjacent teeth into the intermaxillary
growth space allows these teeth to appear to "tip" over
the crown of the ankylosed tooth (Fig l). The net
result is a loss of space and asymmetric axial inclina-
tions of the adjacent teeth compared with those on the
contralateral (unaffected) side of the arch, producing
an asymmetric molar occlusion (Fig 2). This space loss
involves the distal eruption of the tooth anterior to the
Figure 2. Ankylosis of the maxillary and mandibular
ankylosed primary molar, as well as the mesial erup-
left primary first molars (A). These teeth have been
tion of the tooth posterior to the affected molar. The removed and the space is maintained with band and
distal eruption of the teeth anterior to the ankylosed loop space maintainers (B).
tooth can result in a shift of the dental midline toward
the affected side of the arch, compounding the
developing arch asymmetry and producing asymmet-
ric canine relationships. Space maintenance is a key ture loss of the primary second molar tooth and
feature of the management of ankylosed primary subsequent loss of arch length on the affected side.
teeth (Figs 2B, 3A, and B). The result is not only an asymmetric molar relation-
Ectopic eruptions of the maxillary p e r m a n e n t first ship, but also an arch length tooth size discrepancy
molars are reported to occur in 4.3% of tile popula- and possible impaction of the second premolar tooth.
tion. 5 Although some ectopically erupting p e r m a n e n t Primary molars are usually larger than the perma-
first molars are self-correcting, the majority require n e n t teeth that replace them (leeway space). This
intervention to direct them in a more distal path (Figs additional space may be needed to accommodate
4-6). Untreated ectopic eruptions often lead to prema- transitional crowding (incisor liability) or adjustment
of the molar occlusion. Frequently, the permanent
molars erupt into an end-to-end occlusion during the
mixed dentition when the primary molars occlude
with a flush terminal plane. Because tile leeway space
is usually larger in the mandibular arch than in the
maxillary arch, the shift of the p e r m a n e n t molars into
the leeway space and the differential growth of the
mandible relative to the maxilla will provide for some
spontaneous correction of the end-to-end relation-
ship, resulting in a Class I molar relationship. How-
Figure 1. Ankylosis of the mandibular left primary ever, unilateral loss of some of the leeway space will
second molar. Note the loss of the "E space" from result in a developing asymmetry in the molar occlu-
distal "tipping" of the primary first molar and mesial sion.
"tipping" of the p e r m a n e n t first molar. Approximately 5% of the population has congeni-
136 Jan E. Kronmiller
Figure 3. Ankylosis of the mandibular right second
primary molar (A). Space for the unerupted perma-
n e n t first molar is maintained with a distal shoe space
maintainer (B).
tally missing teeth. 6 The most commonly missing teeth
in children are the mandibular second premolars,
maxillary lateral incisors, and maxillary second premo-
lars. Congenitally missing mandibular premolars can
contribute to asymmetric molar relationships when
the primary molar is retained by preventing the mesial
Figure 4. Ectopic eruption of the maxillary left perma-
nent first molar. Note the developing Class II molar
relationship.
Figure 5. Corrected ectopic eruption of the maxillary
left permanent first molar and uncorrected ectopic
eruption on the right side. Note the molar asymmetry
that has developed.
movement of the p e r m a n e n t molar into the leeway
space. The result is a Class II relationship on the
affected side of the arch. Loss of the primary molar
can result in a shift of the adjacent teeth into the space
normally occupied by the missing premolar. This can
also occur when permanent teeth are impacted and
the space is not properly managed.
Although the prevalence of caries in the primary
dentition has declined from 5.32 decayed or filled
surfaces in 1979 to 1980 to 3.91 decayed or filled
surfaces in 1986 to 1987, children develop an average
of two new lesions every 3 years. 7 Space loss as a result
of interproximal caries or premature loss of a primary
or p e r m a n e n t tooth can result in asymmetric occlusal
relationships, as described above. Proper preventive
and restorative care during the primary and mixed
dentitions are key components of the management of
the developing occlusion.
Asymmetries in arch form can also be character-
ized by ntidline discrepancies. The ectopic eruption of
mandibular lateral incisors frequently causes the pre-
mature exfoliation of the primary canines (Fig 7).
When this ectopic eruption occurs unilaterally, the
result is a shift in the dental midline to the affected
side. This midline shift is often coincident with a
lingual uprighting of the mandibular incisors and
space loss. Continued facial growth and eruption of
the permanent teeth into these ectopic positions can
lead to a worsening of the discrepancy and asymmetry.
Correction of the midline discrepancy and active
management of the space is indicated to restore arch
symmetry.
Supernumerary teeth occur in approximately 1%
of children. These supernumerary teeth can cause
impaction or ectopic eruption of adjacent permanent
teeth and asymmetric arch forms. Supernumerary
maxillary incisors can produce a midline discrepancy
and must be considered in the differential diagnosis of
midline shifts in children. Maxillary anterior occlnsal
films are indicated in children in the early mixed
dentition for evaluation of eruption of the anterior
teeth. ~
 DevelopmentofAsymmetries
Figure 6. Ectopic e r u p t i o n of a maxillary r i g h t p e r m a -
n e n t first m o l a r (A). C o r r e c t i o n with a brass ligature
wire (B,C).
M t h o u g h ectopic e r u p t i o n s , c o n g e n i t a l l y missing
teeth, s u p e r n u m e r a r y teeth, impactions, a n d inter-
p r o x i m a l caries are c o m m o n causes for d e v e l o p i n g
occlusal asymmetries, habits can also cause asymmet-
ric a r c h forms. T h e key to m a n a g e m e n t of t h e s e
137
Figure 7. Ectopic e r u p t i o n o f t h e m a n d i b u l a r r i g h t
lateral incisor has c a u s e d p r e m a t u r e exfoliation o f the
p r i m a r y c a n i n e . T h e result is a shift o f t h e m a n d i b u l a r
m i d l i n e toward t h e right.
d e v e l o p i n g a r c h f o r m asymmetries is early diagnosis
a n d r e c o g n i t i o n followed by a p p r o p r i a t e m a n a g e -
ment.
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