Facial Asymmetry, Class II subdivision, TMJ Clicking
Dear Dr Chamberland,
First off, thank you in advance for taking the time to look over my email. I hope you don’t mind my correspondence in English.
I am sincerely hoping you might be able to help me with my case as you seem to be an expert in TMJ and facial asymmetry and I’m very lost on what treatment options I should pursue.
Essentially, I am trying to determine what my situation is, as I have been told different opinions by different doctors. As you can see from my attached CT images,
I have an asymmetric jaw (right border lower than left, as you can see from lateral ceph) with a skeletal midline deviation to the right, creating a Class I relationship on left with a Class II on right.
Because of this, I have very noticeable TMJ symptoms on the right, specifically very loud clicking when I open my jaw about half way. However, there is no pain and no locking to make note of. I also have noticeable facial asymmetry where the right side of my face is higher than the left.
The doctors I have met with have suggested bite splints, neuromuscular dentistry to rearrange teeth and a sliding genioplasty as ways to fix my issues. None have suggested jaw surgery as they say my jaw is not recessed enough to warrant it. None have made note of anything significant regarding my condyles other than slight flattening which they say is within normal limits.
My question to you is, based on my images, is there anything to specifically make note of that needs attention? If my facial asymmetry is the result of normal skeletal growth and won’t worsen over time, I’m more inclined to leave things alone and perhaps use a bite splint as one oral surgeon suggested at night to help with TMJ symptoms.
However, if there’s anything you see on my scans that leads you to believe my facial asymmetry and TMJ might worsen without surgical intervention, I would really appreciate your insight on how it should be treated. BSSO? Condyle surgery? Braces only? Your insight on my case would be greatly appreciated.
Thank you for having chosen my website to ask your question. You sent me your picture and gave me the authorization to publish it.
Your frontal photo confirms mandibular asymmetry to the right. The chin is to the right of the facial midline. The profile view shows a fairly normal relationship of your lips to the esthetic plane (tangent nose-chin).
The 3D reconstruction confirm asymmetric molar relationship (Class II on the right, Class I on the left and lower midline deviated to the right). The ceph shows a moderate prominence of the dentition as one can see the tip of the lower incisors is in front of the plane A-Pg.
The panogram that you sent me, as well as the condylar view, suggest a left elongated condylar neck which explains why your left mandibular border is lower than the right mandibular border in frontal view.
Chances are that you have this kind of asymmetry since a while because it is unlikely that full cusp Class II would have developed because of a recent condylar hyperplasia. However, I would recommend a bone scan to confirm that there is no condylar growth activity.
The right condylar clicking can be explained by some torsion of the condyle in the glenoid fossa. You may have some slight medial disk displacement. As you open, the disk returns over the condylar head and you hear the click.
The important thing is that you have no pain and no limitation of jaw movements.
Your occlusion seems fairly good despite the asymmetric molar relationship and midline deviation.
My recommendation would be to do a bone scan to assess condylar growth.
If it is negative, you may consider an orthodontic treatment plan. The treatment plan would involve extraction of 2 maxillary premolars (1 left, 1 right) and one mandibular premolar (1 left). This would help to camouflage the skeletal asymmetry and obtain a symmetric Class I canine relationship.
A sliding genioplasty to the left would help to achieve frontal facial symmetry, assuming that there is no growth activity.
I would not recommend any neuromuscular dentistry. You may consider an occlusal splint for 3-4 months prior to treatment, but I am not sure this would be that much important.
I hope that helps.