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Revista Española de Cirugía Oral y Maxilofacial

On-line version ISSN 2173-9161Print version ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.31 n.1 Madrid Jan./Feb. 2009

 

ARTÍCULO CLÍNICO

 

Craniofacial asymmetry: radiographic analysis in the frontal and transverse planes in subjects aged 18 to 22 years of both sexes

Asimetrías craneofaciales: análisis radiográfico en los planos frontal y basal en individuos de ambos sexos de 18 a 22 años

 

 

 

M.C. Fucini1, J.E. Baudo1, A.C. Bencini2, L.A. Sosa3, L.M. Etchegoyen1, C.G. Fornés3, L. Solari3, E.I. Milat4

1 Profesora Adjunta de Radiología y Fisioterapia de la Facultad de Odontología de la Universidad Nacional de La Plata. Buenos Aires, República Argentina.
2 Presidente de la Sociedad Argentina de Cirugía y Traumatología Bucmaxilofacial; Jefe del servicio de Odontología y Cirugía Bucomaxilofacial del Hospital San Juan de Dios de La Plata; Profesor Titular de la Cátedra Cirugía Ortognática de la Facultad de Odontología de la Universidad Nacional de La Plata. Buenos Aires, República Argentina.
3 Ayudante Diplomado de Radiología y Fisioterapia de la Facultad de Odontología de la Universidad Nacional de La Plata. Buenos Aires, República Argentina.
4 Profesora Titular de Radiología y Fisioterapia de la Facultad de Odontología de la Universidad Nacional de La Plata. Buenos Aires, República Argentina.

Correspondence

 

 

 


ABSTRACT

The aim of this study was to determine the type and magnitude of craniofacial asymmetry by multiplanar cephalometric analysis. The sample comprised 207 subjects of both sexes aged 18 to 22 years, who were radiographed in the frontal plane at posteroanterior incidence. Three separate acetate tracings were made on the same radiograph based on three planar structures: A (superficial), B (intermediate), C (deep). A virtual midline was traced. Real midlines were overlapped and compared with the virtual midline to determine the type and magnitude of the deviation on each plane.
The subjects were radiographed on the transverse plane. Three separate acetate tracings were made on the same radiograph based on three planar structures: A (orbital), B (maxillary superior), C (maxillary inferior). A virtual midline was traced and compared with the real midline.
Frontal plane: Results indicated a greater frequency of right deviation in the three planes, B being the plane with the largest percentage of deviation (type and magnitude) compared to C and A.
Transverse plane: Results indicated a greater frequency of left deviation in the three planes, C being the plane with the largest percentage of deviation (type and magnitude) compared to B and A.
These results show that craniofacial asymmetry was widespread and emphasize the importance of its study in the detection of craniofacial growth pathology.

Key words: Asymmetry; Craniofacial; Deviation.


RESUMEN

El objetivo de este trabajo fue determinar el tipo y magnitud de asimetrías craneofaciales a partir del análisis cefalométrico de planos múltiples. Se trabajó con una muestra de 207 individuos de ambos sexos de 18 a 22 años, que fueron radiografiados en plano frontal con incidencia posteroanterior. Sobre cada radiografía se realizaron tres calcos tomando como referencia estructuras en tres planos: A (superficial), B (medio) y C (profundo). Se trazó una línea media virtual. Las líneas medias reales fueron superpuestas comparadas con la línea media virtual, determinándose así la dirección y la magnitud de la desviación en cada plano. Estos individuos fueron radiografiados en plano basal. Sobre cada radiografía se realizaron tres calcos tomando como referencia estructuras en tres planos diferentes: A (orbital), B (maxilar) y C (mandibular). Se trazó una línea media virtual que se comparó con la línea media real. Plano frontal: Los resultados indicaron una mayor frecuencia de desviación hacia la derecha en los tres planos, siendo estas desviaciones mayores en el plano B, respecto de los planos C y A tanto en dirección como en magnitud. Plano basal: Los resultados indicaron una mayor frecuencia de desviación hacia la izquierda en los tres planos, siendo estas desviaciones mayores en el plano C, respecto de los planos B y A tanto en dirección como en magnitud. Estos resultados muestran la generalidad de las asimetrías craneofaciales y resaltan la importancia de su estudio para la detección de patologías de crecimiento craneofacial.

Palabras clave: Asimetría; Craneofacial; Desviación.


 

Introduction

The correspondence between the shape of the head, face, and dental arches has been demonstrated. It is due to the influence of genetic factors that determine not only this relation but many other relations typical of human beings, such as the length of the upper and lower limbs, and the form of the dental arches and teeth, among others. However, during growth, unfavorable influences can appear that may alter growth, causing notable variations in the form and size of the different tissues and organs involved.1

The dynamics of craniofacial development and normal variations in the growth of the jaws with the consequent dentoalveolar development need to be understood before planning or performing any treatment, particularly if we consider that most treatments begin in very active stages of general and specifically craniofacial growth.2 The mandible and the maxilla both frequently exhibit significant deviations with respect to the normal configuration and position.3-6 Development factors act reciprocally in conjunction with neuromuscular habits that cause alterations in the harmony of craniofacial structures.7,8

The diagnosis of the origin of craniofacial asymmetries is of fundamental importance in planning their treatment because these asymmetries may arise from dental or skeletal problems. Skeletal asymmetries can be masked by natural compensation in the form of the development of dental asymmetries.9

 

Objectives

To analyze the craniofacial morphology of subjects aged 18 to 22 years of both sexes in order to determine the existence of anteroposterior and transverse craniofacial asymmetries and, if present, the plane and side where they occur using multiplanar cephalometric analysis.

 

Material and Method

The study sample consisted of 207 subjects of both sexes, aged 18 to 22 years (Table 1), who underwent radiography:

A. Frontal plane at posteroanterior incidence. Three tracings were made from each radiograph, taking as reference structures in three different planes: A (superficial), B (intermediate), and C (deep). A virtual midline was drawn on each radiograph that passed through the midpoint of the biparietal distance and the intersection between the crista galli and cribiform plate of the ethmoid. Cephalograms were made on each tracing, marking the distances between bilateral structures and using the midpoint between them to determine the true midpoint for each plane. The real midlines were superimposed and compared with the virtual midline to determine the direction of the deviation in each plane.

B. Transverse plane. Three tracings were made from each radiograph, taking as reference structures in three different planes: A (orbital), B (maxillary), and C (mandibular). In the first tracing, a triangle was constructed by joining two points on the lower retromolar trigone with the midpoint of the lower central incisors. In the second tracing, a triangle similar to the one described in the first tracing was constructed in the upper maxilla by joining two points in the tuberosities with the midpoint of the upper central incisors. In the third tracing, a triangle similar to the previous ones was constructed with the vertices set in the center of the orbits and the crista galli ridge. A virtual midline was drawn on each radiograph that extended from the vertex of the triangle of the third tracing and coincided with the middle part of the foramen magnum and the midpoint of the internal occipital protuberance.

 

Results

A. Frontal planes: The frequency of asymmetry in the total sample was 76.33,%, of which 7.6% was only on the right side, 1.26% only on the left side, and 91.14% bilateral (Table 2). Analysis by age and sex indicated a uniform tendency in the age at which the asymmetry occurred and a slightly higher frequency in men than in women (Table 3).

 

 

In men the asymmetry was: 47% in plane B, 35% in plane C, and 18% in plane A (Fig. 1A). In women: 44% in plane B, 35% in plane C, and 21% in plane A (Fig. 1B). When the frequency by plane and side was analyzed, a larger number of male subjects had asymmetries in the right plane B, followed by the right plane C, and, finally, the right plane A. In contrast, in women the most frequent asymmetries were in the right C plane, right B plane, left B plane, and finally the right plane A (Fig. 2 A and B).

Some men and women subjects presented asymmetry in more than one plane. Of a total of 100 men, 14% did not present asymmetry, 38% had asymmetry in only one plane, 35% in two planes, and 13% in all three planes. Of the 107 women, there was no asymmetry in 35 (32.7%) and 39 (36.4%) had asymmetry in one plane, 23 (21.5%) in two planes, and 10 (9.4%) in three planes (Fig. 3 A and B).

B. Transverse planes: The percentage of subjects with asymmetry in the total sample was 54.10%, 60 men and 52 women. Analysis by age and sex indicated a uniform tendency in the age at which the asymmetry appears and a slightly higher frequency in men than in women (Table 4). In men, 45% of asymmetry was in plane C, 41% in plane B, and 14% in plane A (Fig. 4A). In women, 51% of asymmetry was in plane C, 46% in plane B, and 3% in plane A (Fig. 4B). When the frequency was analyzed by plane and side, the largest number of asymmetries in men was in left plane C, followed by left plane B. In women, the highest frequency of asymmetries was in left plane B, followed by plane C (Fig. 5 A and B). Asymmetry was found most frequently on the left side, with 107 subjects (77.53%), versus the right ride, with 65 (47.10%).

 

Of a total of 100 men, 40% did not present asymmetry, 34% had asymmetry in only one plane, 20% in two planes, and 6% in all three planes. Of the 107 women, there was no asymmetry in 55 (51.4%) and 30 (28%) had asymmetry in one plane, 21 (19.7%) in two planes, and 3 (0.9%) in three planes (Fig. 6 A and B).

 

Discussion

Most studies on growth involve measurements of bones. This is comprehensible because bone is solid and radiopaque and, therefore, easier to measure. The longitudinal cephalometric studies of Broadbent (1937) and Brodie (1941) lead them to think that the normal pattern of facial and cranial growth was as a unit and in a stable way. Skeletal bone growth patterns were considered to be predetermined and it was thought that the changes that accompanied the correction of bad bite were restricted to the alveolar processes (Graver, 1972). Later, the cephalometric and anatomic studies of Björk and Palling (1955), Björk (1955), Ricketts (1961), Moss and Salentjie (1971), Farkas and Munro (1987), and Enlow (1968, 1975), among others, showed that the idea that proportions remain constant during facial growth was erroneous. The pattern of facial growth is subject to changes. Whereas genetics plays a fundamental role in determining the extension and direction of growth, there is evidence that environmental influences also can profoundly alter growth patterns. The general use of cephalometric planes of the head in growth studies usually involves superimposing tracings on radiographic films using relatively stable anatomic reference points and less stable points or planes for measuring the direction and amount of growth of the reference points of the skeleton and teeth. Moyers et al. (1979) discussed how inappropriate conventional cephalometry is and proposed the use of a grid method. In order to overcome this difficulty, Buschang et al. (1968) recommended the use of polynomial regression techniques.

The basilar norm was described later by Schuller (1905) and then by Merril (1949). Berger (1964) proposed a method for aligning the basilar plane with the lateral and posteroanterior planes based on the Frankfurt plane as a common factor. This author informed of a method for the determination of the basilar plane by drawing a line through the vomer, the posterior part of the nasal septum, and the crista galli ridge. Nahoum et al. (1964) described a technique for orienting the structures in the lateral, posteroanterior, and basilar planes using tracings of three-dimensional projections on a plane. Marmary et al. (1979) proposed that the midline could be derived from the study of the neural foramina in the skull base, which are considered to have little environmental influence. These studies emphasize the value of constructing the midline in the basilar plane to evaluate asymmetries in the craniofacial skeleton.

Our knowledge and understanding of growth have increased in recent years, but science has not yet progressed to such a point in biology that growth processes can be anticipated. We think that radiographic analysis in the transverse plane and frontal plane at posteroanterior incidence help the observer to visualize the different regions of the craniofacial complex in order to understand the deformation of structures from symmetry.

 

Conclusions

The results obtained allow us to conclude that:

• Some type of asymmetry on the frontal plane was present in 76% of the subjects aged 18 to 22 years; bilateral asymmetries were the most frequent.

• Some type of asymmetry in the transverse plane was present in 54.10%.

• Men showed a greater percentage of asymmetry than women.

• There was no consistent relation between the frequency of asymmetry and age.

• In the frontal plane, the frequencies of asymmetry were higher in the intermediate plane, followed by the deep plane and then the superficial plane.

• In the transverse plane, the frequencies of asymmetry were higher in the mandibular plane, followed by the maxillary and then the orbital plane.

• In the frontal plane, 28% of the subjects presented asymmetry in two planes, 36.6% in the transverse plane.

• The right side was predominant in the frontal plane and the left side was predominant in the transverse plane.

 

 

Correspondence:
Prof. Dr. Adrián Carlos Bencini
C/ Diagonal, 74 nº 2571 - 1900 Plata (Buenos Aires, República Argentina)
e-mail: adrianbencini@speedy.com.ar

Received: 24.04.05
Accepted: 17.12.08

 

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