Systematic Review Article

Prevalence of mandibular asymmetry in different skeletal sagittal patterns:

A systematic review
Karine Evangelistaa; Ana Beatriz Teodorob; Jonas Bianchic; Lucia Helena Soares Cevidanesd;
Antônio Carlos de Oliveira Ruellase; Maria Alves Garcia Silvaf; José Valladares-Netog

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ABSTRACT
Objectives: To analyze the prevalence of mandibular asymmetry in skeletal sagittal malocclusions.
Materials and Methods: PubMed/MEDLINE, EMBASE, LILACS, Web of Science, Scopus, LIVIVO
and gray literature (OpenGrey, ProQuest, and Google Scholar) were electronically searched. Two
independent investigators selected the eligible studies, and assessed risk of bias and certainty of
evidence (GRADE). One reviewer independently extracted the data and the second reviewer
checked this information. Any disagreement between the reviewers in each phase was resolved by
discussion between them and/or involved a third reviewer for final decision.
Results: Electronic search identified 5,132 studies, and 5 observational studies were included.
Risk of bias was low in two studies, moderate in one, and high in two. The studies showed high
heterogeneity. Mandibular asymmetry ranged from 17.43% to 72.95% in overall samples.
Horizontal chin deviation showed a prevalence of 17.66% to 55.6% asymmetry in Class I
malocclusions, and 68.98% in vertical asymmetry index. In Class II patients, prevalence of
mandibular asymmetry varied from 10% to 25.5% in horizontal chin deviation, and 71.7% in vertical
asymmetry index. The Class III sample showed a prevalence of mandibular asymmetry ranging
from 22.93% to 78% in horizontal chin deviation and 80.4% in vertical asymmetry index. Patients
seeking orthodontic or orthognathic surgery treatment showed greater prevalence of mandibular
asymmetry.
Conclusions: Skeletal Class III malocclusion showed the greatest prevalence of mandibular
asymmetry. Mandibular vertical asymmetry showed a marked prevalence in all malocclusions.
However, conclusions should be interpreted with caution due to use of convenience samples and
low-quality study outcomes. (Angle Orthod. 2022;92:118–126.)
KEY WORDS: Asymmetry; Mandible; Angle’s malocclusion classification; Prevalence; Systematic
review

INTRODUCTION opposite sides of the median sagittal plane (MSP).1

Mandibular asymmetry has a major impact because of
Facial asymmetry refers to unbalanced proportions its effects on facial appearance, as it can have
in size, shape, and position of bilateral structures on permanent and marked effects on facial harmony and

a
Temporary Professor, Division of Orthodontics, School of Dentistry, Federal University of Goiás, Goiânia, Brazil.
b
Graduate Student, Graduate Program, School of Dentistry, Federal University of Goiás, Goiânia, Brazil.
c
Assistant Professor, Department of Orthodontics, University of the Pacific, San Francisco, CA, USA.
d
Associate Professor, Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI,
USA.
e
Full Professor, Department of Orthodontics, Federal University of Rio de Janeiro, Brazil.
f
Full Professor, Department of Stomatology, School of Dentistry, Federal University of Goiás, Goiânia, Brazil.
g
Associate Professor, Division of Orthodontics, School of Dentistry, Federal University of Goiás, Goiânia, Brazil.
Corresponding author: Dr Karine Evangelista, School of Dentistry, Federal University of Goiás, Avenida Universitária esquina com 1a
Avenida, S/N. Zip Code: 74605-220, Goiânia, Goiás, Brazil
(e-mail: kemar_7@hotmail.com)
Accepted: July 2021. Submitted: April 2022.
Published Online: September 21, 2021
Ó 2022 by The EH Angle Education and Research Foundation, Inc.

Angle Orthodontist, Vol 92, No 1, 2022 118 DOI: 10.2319/040921-292.1

PREVALENCE OF MANDIBULAR ASYMMETRY 119

the smile,2,3 and can affect social and psychological mandibular asymmetry, mandibular asymmetry related
aspects3–5 of quality of life.4,5 to syndromes and/or congenital disorders, mandibular
A skeletal diagnosis of mandibular asymmetry is asymmetry not confirmed by tomographic analysis or
established mainly by the location of central points of PA, or studies based on soft tissue analysis, case
the mandible, such as Pogonion (Pog), Gnathion (Gn), reports, reviews, letters, personal opinions, book
and Menton (Me). Traditionally, the distance from these chapters, and conference abstracts.
central landmarks to the facial MSP is calculated to
quantify and classify mandibular skeletal asymmetry as Information Sources and Search Strategy
mild (,2 mm), moderate (2–4 mm), or severe (.4
Detailed individual search strategies for each of the
mm),1,6–8 using cone-beam computed tomography
following were designed: PubMed/MEDLINE, EM-

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(CBCT)9,10 or posterior anterior cephalometric radiog-
BASE, LILACS, Web of Science, Scopus, and LIVIVO
raphy (PA cephalogram).9 In 1988, Habets et al.,11
(Table 1). Grey literature searches through Open Grey,
introduced the asymmetry index using orthopantomo-
Google Scholar, and ProQuest were also undertaken.
grams to analyze vertical asymmetries in the mandible,
Google Scholar search was limited to the first 100 most
in cases of ramus and/or condylar height asymmetries.
relevant articles published over the last 10 years.
Index values over 3% were considered to have vertical
References were stored and managed, and duplica-
asymmetry. This method had been applied with better
tions removed, using EndNote X7 (Thomson Reuters,
accuracy through three-dimensional exams, such as
Philadelphia, PA, USA). The search strategy was
CBCT.12
performed in August of 2020 and was updated in
Studies on facial asymmetries in orthodontic and
March of 2021.
orthognathic surgery patients clinically found a preva-
lence of 12%–37% of mandibular asymmetries in
Selection Process
different populations and with different anterior poste-
rior skeletal relationships.13–18 Some authors6,8,19,20 Study selection was completed in two phases. In
showed higher prevalence of mandibular asymmetry phase 1, two reviewers (KE, ABT) independently
in Class III malocclusion patients than in Class II or reviewed titles and abstracts of all identified electronic
Class I. It was postulated that excessive growth of the database citations. In phase 2, these reviewers
mandible in Class III patients could be a risk factor for independently applied inclusion and exclusion criteria
unbalanced development on both sides of the mandi- to the full article texts. The selected article written in
ble.21 French was translated by a speaker certificated in
Knowledge of the most prevalent malocclusion with French. This blind process was ensured and regis-
mandibular asymmetry is crucial in following up tered using Rayyan (https://rayyan.qcri.org).22 Refer-
orthodontic patients to prevent deterioration and ence lists of selected studies were then critically
minimize risk of developing facial asymmetry. Under- assessed.
standing the prevalence of mandibular asymmetry
could also guide researchers analyzing the etiology Data Items Extracted
and morphologic features within each malocclusion.
Therefore, this systematic review aimed to provide a The first reviewer independently collected the
synthesis of available evidence to answer the following information required from the articles. The second
focused question: ‘‘What is the prevalence of mandib- checked this information. In cases of disagreement, a
ular asymmetry in each skeletal sagittal malocclu- third reviewer participated for consensus decision.
sion?’’ The following data were collected from each article:
study characteristics, population characteristics, im-
MATERIAL AND METHODS aging diagnosis methods, criteria for Angle maloc-
clusion classification, mandibular asymmetry
Eligibility Criteria diagnosis criteria, and outcome characteristics (Table
2).
Inclusion criteria were observational studies without
restrictions of year and language, which presented a
Risk of Bias in Individual Studies
CoCoPop framework: Condition (Co): mandibular
asymmetry diagnosed using computed tomography or The risk of bias for the selected studies was
PA radiographs, Context (Co): sample with skeletal assessed using Joanna Briggs Institute Critical Ap-
Class I, II, or III malocclusion classification, Population praisal Checklist for Studies Reporting Prevalence
(P): children, adolescent, and adults. Data (2014).23 The two reviewers independently scored
The following exclusion criteria were applied: studies the risk of bias as ‘low’, ‘moderate’, or ‘high’,
with animals, studies not investigating prevalence of categorizing it as high when up to 49% of the items

Angle Orthodontist, Vol 92, No 1, 2022

120 EVANGELISTA, TEODORO, BIANCHI, CEVIDANES, DE OLIVEIRA RUELLAS, SILVA, VALLADARES-NETO

Table 1. Databases and Search Strategiesa

Database Search Strategy
PubMed (‘‘Malocclusion"[Mesh] OR ‘‘Malocclusion’’ OR ‘‘Malocclusions’’ OR ‘‘Tooth Crowding’’ OR ‘‘Crossbite’’ OR ‘‘Crossbites’’
OR ‘‘Cross Bite’’ OR ‘‘Cross Bites’’ OR ‘‘Angle Classification’’ OR ‘‘Angles Classification’’ OR ‘‘Malocclusion, Angle
Class I"[Mesh] OR ‘‘Angle Class I Malocclusion’’ OR ‘‘Angle Class I’’ OR ‘‘class I"[Title/Abstract] OR ‘‘Malocclusion,
Angle Class II"[Mesh] OR ‘‘Angle Class II Malocclusion’’ OR ‘‘Angle Class II’’ OR ‘‘class II"[Title/Abstract] OR
‘‘Malocclusion, Angle Class III"[Mesh] OR ‘‘Angle Class III Malocclusion’’ OR ‘‘Habsburg Jaw’’ OR ‘‘Hapsburg Jaw’’
OR ‘‘Angle Class III’’ OR ‘‘Underbite’’ OR ‘‘class III"[Title/Abstract] OR ‘‘Overbite"[Mesh] OR ‘‘Overbite’’ OR
‘‘Overbites’’ OR ‘‘Deep Bite’’ OR ‘‘Deep Bites’’ OR ‘‘Over Bite’’ OR ‘‘Over Bites’’ OR ‘‘Dental Overjet’’ OR ‘‘Incisor
Protrusion’’ OR ‘‘Incisor Protrusions’’) AND (‘‘Facial Asymmetry"[Mesh] OR ‘‘Facial Asymmetry’’ OR ‘‘Facial
Asymmetries’’ OR ‘‘Asymmetry’’ OR ‘‘mandibular asymmetry’’ OR ‘‘mandibular Asymmetries’’ OR ‘‘chin deviation’’)
Embase (’malocclusion’/exp OR malocclusion OR malocclusions OR ’tooth crowding’/exp OR ’tooth crowding’ OR ’crossbite’/

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exp OR crossbite OR crossbites OR ’cross bite’/exp OR ’cross bite’ OR ’cross bites’ OR ’angle classification’ OR
’angles classification’ OR ’angle class i malocclusion’ OR ’angle class i’ OR ’class i’ OR ’angle class ii
malocclusion’/exp OR ’angle class ii malocclusion’ OR ’angle class ii’ OR ’class ii’ OR ’angle class iii malocclusion’
OR ’habsburg jaw’ OR ’hapsburg jaw’ OR ’angle class iii’ OR underbite OR ’class iii’ OR ’overbite’/exp OR overbite
OR overbites OR ’deep bite’ OR ’deep bites’ OR ’over bite’ OR ’over bites’ OR ’dental overjet’ OR ’dental overjets’
OR ’incisor protrusion’ OR ’incisor protrusions’) AND (’facial asymmetry’/exp OR ’facial asymmetry’ OR ’facial
asymmetries’ OR ’mandibular asymmetry’/exp OR ’mandibular asymmetry’ OR ’mandibular asymmetries’ OR ’chin
deviation’)
Scopus TITLE-ABS-KEY(Malocclusion OR Malocclusions OR ‘‘Tooth Crowding’’ OR Crossbite OR Crossbites OR ‘‘Cross Bite’’
OR ‘‘Cross Bites’’ OR ‘‘Angle Classification’’ OR ‘‘Angles Classification’’ OR ‘‘Angle Class I Malocclusion’’ OR
‘‘Angle Class I’’ OR ‘‘class I’’ OR ‘‘Angle Class II Malocclusion’’ OR ‘‘Angle Class II’’ OR ‘‘class II’’ OR ‘‘Angle Class
III Malocclusion’’ OR ‘‘Habsburg Jaw’’ OR ‘‘Hapsburg Jaw’’ OR ‘‘Angle Class III’’ OR Underbite OR ‘‘class III’’ OR
Overbite OR Overbites OR ‘‘Deep Bite’’ OR ‘‘Deep Bites’’ OR ‘‘Over Bite’’ OR ‘‘Over Bites’’ OR ‘‘Dental Overjet’’ OR
‘‘Dental Overjets’’ OR ‘‘Incisor Protrusion’’ OR ‘‘Incisor Protrusions’’) AND TITLE-ABS-KEY(‘‘Facial Asymmetry’’ OR
‘‘Facial Asymmetries’’ OR ‘‘mandibular asymmetry’’ OR ‘‘mandibular Asymmetries’’ OR ‘‘chin deviation’’)
Web of Science TS¼(Malocclusion OR Malocclusions OR ‘‘Tooth Crowding’’ OR Crossbite OR Crossbites OR ‘‘Cross Bite’’ OR ‘‘Cross
Bites’’ OR ‘‘Angle Classification’’ OR ‘‘Angles Classification’’ OR ‘‘Angle Class I Malocclusion’’ OR ‘‘Angle Class I’’
OR ‘‘class I’’ OR ‘‘Angle Class II Malocclusion’’ OR ‘‘Angle Class II’’ OR ‘‘class II’’ OR ‘‘Angle Class III Malocclusion’’
OR ‘‘Habsburg Jaw’’ OR ‘‘Hapsburg Jaw’’ OR ‘‘Angle Class III’’ OR Underbite OR ‘‘class III’’ OR Overbite OR
Overbites OR ‘‘Deep Bite’’ OR ‘‘Deep Bites’’ OR ‘‘Over Bite’’ OR ‘‘Over Bites’’ OR ‘‘Dental Overjet’’ OR ‘‘Dental
Overjets’’ OR ‘‘Incisor Protrusion’’ OR ‘‘Incisor Protrusions’’) AND TS¼(‘‘Facial Asymmetry’’ OR ‘‘Facial
Asymmetries’’ OR ‘‘mandibular asymmetry’’ OR ‘‘mandibular Asymmetries’’ OR ‘‘chin deviation’’)
LILACS tw:((tw:(malocclusion OR malocclusions OR ‘‘Tooth Crowding’’ OR crossbite OR crossbites OR ‘‘Cross Bite’’ OR
‘‘Cross Bites’’ OR ‘‘Angle Classification’’ OR ‘‘Angles Classification’’ OR ‘‘Angle Class I Malocclusion’’ OR ‘‘Angle
Class I’’ OR ‘‘class I’’ OR ‘‘Angle Class II Malocclusion’’ OR ‘‘Angle Class II’’ OR ‘‘class II’’ OR ‘‘Angle Class III
Malocclusion’’ OR ‘‘Habsburg Jaw’’ OR ‘‘Hapsburg Jaw’’ OR ‘‘Angle Class III’’ OR underbite OR ‘‘class III’’ OR
overbite OR overbites OR ‘‘Deep Bite’’ OR ‘‘Deep Bites’’ OR ‘‘Over Bite’’ OR ‘‘Over Bites’’ OR ‘‘Dental Overjet’’ OR
‘‘Dental Overjets’’ OR ‘‘Incisor Protrusion’’ OR ‘‘Incisor Protrusions’’ OR ‘‘Má Oclusão’’ OR ‘‘Apinhamento de Dente’’
OR ‘‘Classificação de Angle’’ OR ‘‘Má Oclusão dos Dentes’’ OR maloclusão OR ‘‘Mordida Cruzada’’ OR
maloclusión OR ‘‘Clasificación de Angle’’ OR ‘‘Dientes Apinados’’ OR ‘‘Mala Oclusión’’ OR maloclusiones OR
‘‘Malposición de los Dientes’’ OR ‘‘Mordida Cruzada’’ OR ‘‘Má Oclusão de Angle Classe I’’ OR ‘‘Classe I de Angle’’
OR ‘‘Maloclusão de Angle Classe I’’ OR ‘‘Maloclusión de Angle Clase I’’ OR ‘‘Clase I de Angle’’ OR ‘‘Classe I’’ OR
‘‘Má Oclusão de Angle Classe II’’ OR ‘‘Classe II de Angle’’ OR ‘‘Maloclusão de Angle Classe II’’ OR ‘‘Angle Classe
II’’ OR ‘‘Maloclusión de Angle Clase II’’ OR ‘‘Clase II de Angle’’ OR ‘‘Angle Clase II’’ OR ‘‘Clase II’’ OR ‘‘Má Oclusão
de Angle Classe III’’ OR ‘‘Classe III de Angle’’ OR ‘‘Maloclusão de Angle Classe III’’ OR ‘‘Classe III’’ OR
‘‘Maloclusión de Angle Clase III’’ OR ‘‘Clase III de Angle’’ OR ‘‘Clase III’’ OR sobremordida)) AND (tw:(‘‘Facial
Asymmetry’’ OR ‘‘Facial Asymmetries’’ OR ‘‘mandibular asymmetry’’ OR ‘‘mandibular Asymmetries’’ OR ‘‘chin
deviation’’ OR ‘‘Assimetria Facial’’ OR ‘‘Assimetrias faciais’’ OR ‘‘assimetria mandibular’’ OR ‘‘assimetrias
mandibulares’’ OR ‘‘desvio do queixo’’ OR ‘‘Asimetrı́a Facial’’ OR ‘‘Asimetrı́as faciales’’ OR ‘‘asimetrı́a mandibular’’
OR ‘‘asimetrı́as mandibulares’’ OR ‘‘desviación del mentón’’))) AND ( db:(‘‘LILACS’’))
LIVIVO (Malocclusion OR Malocclusions OR ‘‘Tooth Crowding’’ OR Crossbite OR Crossbites OR ‘‘Cross Bite’’ OR ‘‘Cross
Bites’’ OR ‘‘Angle Classification’’ OR ‘‘Angles Classification’’ OR ‘‘Angle Class I Malocclusion’’ OR ‘‘Angle Class I’’
OR ‘‘class I’’ OR ‘‘Angle Class II Malocclusion’’ OR ‘‘Angle Class II’’ OR ‘‘class II’’ OR ‘‘Angle Class III Malocclusion’’
OR ‘‘Habsburg Jaw’’ OR ‘‘Hapsburg Jaw’’ OR ‘‘Angle Class III’’ OR Underbite OR ‘‘class III’’ OR Overbite OR
Overbites OR ‘‘Deep Bite’’ OR ‘‘Deep Bites’’ OR ‘‘Over Bite’’ OR ‘‘Over Bites’’ OR ‘‘Dental Overjet’’ OR ‘‘Dental
Overjets’’ OR ‘‘Incisor Protrusion’’ OR ‘‘Incisor Protrusions’’) AND (‘‘Facial Asymmetry’’ OR ‘‘Facial Asymmetries’’ OR
‘‘mandibular asymmetry’’ OR ‘‘mandibular Asymmetries’’ OR ‘‘chin deviation’’)
OpenGrey Malocclusion

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PREVALENCE OF MANDIBULAR ASYMMETRY 121

Table 1. Continued
Database Search Strategy
ProQuest Dissertation (‘‘Facial Asymmetry’’ OR ‘‘Facial Asymmetries’’ OR ‘‘mandibular asymmetry’’ OR ‘‘mandibular Asymmetries’’ OR ‘‘chin
and Thesis deviation’’) AND (Malocclusion OR Malocclusions OR ‘‘Tooth Crowding’’ OR Crossbite OR Crossbites OR ‘‘Cross
Bite’’ OR ‘‘Cross Bites’’ OR ‘‘Angle Classification’’ OR ‘‘Angles Classification’’ OR ‘‘Angle Class I Malocclusion’’ OR
‘‘Angle Class I’’ OR ‘‘class I’’ OR ‘‘Angle Class II Malocclusion’’ OR ‘‘Angle Class II’’ OR ‘‘class II’’ OR ‘‘Angle Class
III Malocclusion’’ OR ‘‘Habsburg Jaw’’ OR ‘‘Hapsburg Jaw’’ OR ‘‘Angle Class III’’ OR Underbite OR ‘‘class III’’ OR
Overbite OR Overbites OR ‘‘Deep Bite’’ OR ‘‘Deep Bites’’ OR ‘‘Over Bite’’ OR ‘‘Over Bites’’ OR ‘‘Dental Overjet’’ OR
‘‘Dental Overjets’’ OR ‘‘Incisor Protrusion’’ OR ‘‘Incisor Protrusions’’)
Google Scholar (Malocclusion OR Crossbite OR Overbite ‘‘Deep Bite’’ OR ‘‘Dental Overjet’’ OR ‘‘class I’’ OR ‘‘class II’’ OR ‘‘class III’’)
AND (‘‘Facial Asymmetry’’ OR ‘‘mandibular asymmetry’’ OR ‘‘chin deviation’’)

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a
Search strategies were drafted for all databases included in this study by using specific word combinations and truncations with the support of
a librarian.

scored ‘yes’, moderate when 50%–69% scored ‘yes’, ness of evidence, consistency of results, precision of
and low when over 70% scored ‘yes’. Any disagree- estimates, risk of publication bias, and magnitude of
ment between the reviewers in each phase was the effect.
resolved by discussion and agreement between them.
The consensus involved a third reviewer (JV-N) for RESULTS
final decision.
Study Selection
Summary Measurements Through seven databases, 5,132 citations were
Predictor variables were patients with sagittal skel- identified and 748 found in grey literature were added
etal malocclusions, described as Class I, II, and/or III. in phase 1. After removing duplicates, 2275 articles
The only outcome variable was the prevalence of remained for screening based on title and abstract.
mandibular asymmetry described using frequency After comprehensive evaluation of abstracts, a final
rates. sample of 18 articles was read in full text, of which five
met the inclusion criteria.6,25–28 The agreement between
Synthesis of Results both reviewers was almost perfect (kappa ¼ 0.98).
Mandibular asymmetry prevalence was evaluated Figure 1 illustrates the study selection and identifica-
through qualitative analysis. Heterogeneity of the tion process.
studies was calculated using the Cochran’s Q method
and the value of I 2, where a P value ,.05 by the Q and Study Characteristics
I 2 value greater than 50% was considered substantial Table 2 summarizes the extracted data of all studies.
heterogeneity. Meta-analysis of mandibular asymme- The five selected studies were all published between
try prevalence pooling random effects with arcsine 2009 and 2018 from the following countries: Brazil,6
transformation (quality effects) was planned to mini-
France,27 Iran,25 Spain,26 and Turkey.24 The total
mize the effect of extreme prevalence on overall
sample size was 1389 patients (491 females and 785
estimates. However, the high heterogeneity of the
males), and no sex was reported for 114 cases
studies precluded the quantitative data synthesis. The
extracted in one study.27 Sample sizes ranged from
agreement between both reviewers in phases 1 and 2
61 to 952 in different groups of malocclusion, with ages
was tested by Cohen’s kappa test. The significance
level (null hypothesis) was rejected at a 5% level (P , between 18 and 75 years. Settings of the whole
.05). sample included oral radiology clinic databases (n ¼
952),6 orthognathic surgery clinical records (n ¼
Risk of Bias Across Studies and Certainty of 278)26,28 and orthodontic clinical records (n ¼ 159).27
Evidence
Sample Classification
Analyses for small-study effects, publication bias,
and exploratory subgroup analyses were planned if an All selected studies used ANB angle for sagittal
adequate number of studies were identified. The malocclusion diagnosis.6,25–28 Four studies considered
Grading of Recommendation Assessment, Develop- mandibular asymmetry using the horizontal position
ment and Evaluation (GRADE) system of rating quality of the chin 6,25,26,28 and, another 27 reported the
of evidence was performed to show certainty of asymmetry index to identify vertical asymmetry in
outcome in this review.24 GRADE considered direct- the mandible.

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122 EVANGELISTA, TEODORO, BIANCHI, CEVIDANES, DE OLIVEIRA RUELLAS, SILVA, VALLADARES-NETO

Mandibular Asymmetry Prevalence Risk of Bias within the Studies

Mandibular asymmetry ranged from 17.43% to Figure 2 and Table 3 present the complete list of
72.95% in the overall sample. According to mandibular quality assessment items. No study satisfied all risk of
asymmetry direction, horizontal chin deviation showed bias criteria. However, most of the studies were
a prevalence of asymmetry in the Class I sample of considered methodologically acceptable. Of the five
17.66% to 55.6%,6,26 and 68.98% in vertical asymmetry studies, two showed a low risk of bias,6,27 one showed
index.27 In Class II patients, prevalence of mandibular moderate risk26 and two showed high risk.25,28 The main
asymmetry varied from 10% to 25.5% in horizontal chin methodological limitations of the studies were related
deviation,6,26,28 and 71.7% in vertical asymmetry in- to representation of the target population (Question 1),
dex.27 Class III sample showed prevalence of mandib- since the samples were all from specific settings.

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ular asymmetry ranging from 22.93% to 78% in
horizontal chin deviation 6,25,26,28 and 80.4% in vertical Heterogeneity Analysis
asymmetry index.27
Considerable heterogeneity between studies was
Regarding methods of image diagnosis, the preva-
found in all malocclusion analyses, as seen by I 2 index
lence of mandibular asymmetry showed rates of
over 96% and Q (P , .001). Due to this result, a meta-
34.95% in overall malocclusion using PA cephalo-
analysis wasn’t performed.
gram26 and 17.43% to 72.95% using tomographic
images.6,27 According to patient settings, one study
Risk of Bias Across the Studies and Certainty of
showed a sample from the database of an oral
Evidence
radiology clinic6 and four studies presented patients
seeking for treatment for orthodontics27 or orthognathic Due to the limited number of studies included,
surgery.25,26,28 Prevalence of mandibular asymmetry publication bias analysis was not performed. Inconsis-
showed greater rates in patients seeking orthodontic or tency, indirectness, and imprecision were rated as
orthognathic surgical treatment, ranging from 34.95% serious issues. According to the GRADE criteria,
to 72.95%. confidence in cumulative evidence was considered

Table 2. Summary of Descriptive Characteristics of Articles Includeda

Sample Mean/ Data Collection

Author, Year, n Range of Imaging Examiner (n)
Country Study Design Female/Male Age (yr) Settings Analysis Calibration/ Reproducibility
Kilic et al., 200925 Observational 61 (31/30) 21.44 Orthognathic surgery PA ceph 1 examiner
Turkey 32,16/16) 19.20 patient records Paired t-test (values not
Control group informed)
29, 15/14
Class III
Queiss et al., Observational 114 NA Orthognathic surgery CT NA
201028 France patient records at
University Hospital
Thiesen et al., Observational 952 18-75 Database of oral CBCT 3 examiners Intraobserver
20176 Brazil 317/635 radiology clinic reliability ICC . 0.90

Eslamipour et al., Observational 103 23.47 Orthognathic surgery PA ceph Not informed
201726 Iran 58/45 patient records at
Dentistry University

Mendoza et al., Observational 159 32.32 Orthodontic patient CBCT 2 examiners

201827 Spain 85/74 records at University Intraobserver CV-0.70% –
Hospital 1.13%
Inter-observer CV- 1.21%-
1.49%
Intra and inter-observer error
measurement-, 0.16
mm
a
CBCT indicates cone-beam computed tomography; CT, computed tomography; CV, coefficient of variation; NA, not available; OR, odds ratio;
PA ceph, posteroanterior cephalogram.

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PREVALENCE OF MANDIBULAR ASYMMETRY 123

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Figure 1. PRISMA flow diagram of literature search and selection
criteria. Figure 2. Risk-of-bias and applicability concerns graph: (A) risk-of-
bias graph; (B) risk-of-bias summary.

Table 2. Extended
Prevalence of mandibular asymmetry
Criteria for Criteria for Overall
Angle’s Mandibular Malocclusions Class I Class II Class III Secondary Results
Malocclusion Asymmetry n/Total n/Total n/Total n/Total (Regions of
Classification Diagnosis % % % % Mandibular Asymmetry) Conclusions
ANB angle Chin deviation — —— —— 21/29 — Subjects with Class III dentofacial
(.2mm) 78% deformity could have frontal skeletal
facial asymmetries, predominantly in
the lower third of their face.

ANB angle Chin deviation — NA 4/40 10/34 — Skeletal Class III are related to
(.3 mm) 10% 29% accentuated asymmetries

ANB angle Chin (Gn) 166/952 71/402 45/332 50/218 — Mandibular asymmetry was 61%
deviation (. 17.43% 17.66% 13.55% 22.93% higher in skeletal Class III when
4mm) compared with skeletal Class II.
ANB angle Chin deviation 36/103 5/9 12/47 19/47 — The trend toward an increased
34.95% 55.6% 25.5% 40.4% incidence of facial asymmetry in the
Class III population was interesting
but was not statistically significant.
ANB angle Asymmetry index in 116/159 42/61 39/54 35/44 Asymmetry index of Linear and volumetric asymmetries
condylar height 72.95 % 68.9% 71.7% 80.4% condyle height . 10% were more prevalent among Class
.3% associated to Class III III patterns. Significant associations
(OR ¼2.882) were found between condylar height
asymmetries .10% and skeletal
class III.

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124 EVANGELISTA, TEODORO, BIANCHI, CEVIDANES, DE OLIVEIRA RUELLAS, SILVA, VALLADARES-NETO

Table 3. Risk of Bias in Individual Studies. JBS Critical Appraisal for. Studies Reporting Prevalence Dataa,23
Author, Year Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Total Risk of Bias
Kilic et al., 2009
25
N N N Y U Y U Y U U 40% High
Oueiss et al., 201028 N U Y U U U U Y Y U 30% High
Eslamipour et al., 201726 N N Y Y U Y U Y U Y 50% Mod
Thiesen et al., 20176 N Y Y Y U Y Y Y Y Y 70% Low
Mendoza et al., 201827 N N Y Y Y Y Y Y Y Y 80% Low
Q1 Was the sample representative of the target population?
Q2 Were study participants recruited in an appropriate way?
Q3 Was the sample size adequate?
Q4 Were the study subjects and the setting described in detail?

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Q5 Was the data analysis conducted with sufficient coverage of the identified sample?
Q6 Were objective, standard criteria used for the measurement of the condition?
Q7 Was the condition measured reliably?
Q8 Was the statistical analysis appropriate?
Q9 Are all important confounding factors/subgroups/differences identified and accounted for?
Q10 Were subpopulations identified using objective criteria?
Total 1/4 SY/applicable items (the not applicable (NA) items were excluded from the sum).
Risk of bias was categorized as high when the study reached a score of up to 49% ‘yes’, moderate when the study reached a score of 50%–
69% ‘yes’, and low when the study reached a score of more than 70% ‘yes’.
a
N indicates no; NA, not applicable; U, unclear; Y, yes.

‘‘very low’’ for the outcome evaluated (prevalence of According to patient settings, the results showed
mandibular asymmetry), due to the convenience new information about mandibular asymmetry in an
sampling of all studies. orthognathic surgery setting. Severt and Proffit 14
analyzed a large sample of orthognathic surgery
DISCUSSION patients with facial and/or mandibular asymmetries.
Asymmetric patients showed mandibular asymmetry
In this systematic review, prevalence of mandibular
with chin deviation, more commonly in Class III (78%)
asymmetry was assessed overall in sagittal skeletal
malocclusions and individually in Class I, II, and III and Class I (58%) malocclusions.14 This systematic
malocclusions. Although quantitative analyses regard- review also found a greater prevalence of mandibular
ing heterogeneity exposed meaningful rates, the asymmetry in Class III patients. A Class I sample in an
qualitative prevalence rates could be explored and orthognathic surgery setting was available in one
showed new perspectives for research and clinical report only,26 and found 56% of patients with mandib-
application in mandibular asymmetry. ular asymmetry, similar to findings in Severt and
Mandibular asymmetry is a craniofacial feature Proffit.14 Thiesen et al.21 compared mandibular asym-
occurring in all types of sagittal malocclusion.6,26,27 metry between cut-off values of chin deviation, using
Greater prevalence of mandibular asymmetry in Class values under and over 4 mm as orthodontic and
III patients found in this systematic review was already orthognathic surgery parameters, respectively. They
highlighted in many studies.6,8,16,19,20,26–28 However, with found prevalence rates of 27.2% for orthodontic and
regard to Class I and Class II malocclusions, prior 17.6% for orthognathic surgery patients. In light of
studies showed inconclusive results. In Class II these rates, it should be noted that this asymmetric
samples, some studies reported lesser prevalence of condition was a common craniofacial deformity in
mandibular asymmetry among all malocclusions,6,26 patients seeking orthognathic treatment, except for
while another showed similar rates with Class I those with Class II malocclusion, which occurred in
malocclusion. 27 Likewise, Class I malocclusions 10%–20.5% of patients in this systematic review.
showed varied prevalence rates, sometimes smaller These results suggest that mandibular asymmetry in
than Class III,6 sometimes greater.26,27 This review surgical patients was more common in malocclusion
brings focus to the prevalence rates among all types with potential excessive mandibular growth and/
malocclusions. Although there was strong evidence or normal growth, such as Class III and Class I
for the predominance of mandibular asymmetry in malocclusions, than in patients with lower potential for
Class III patients, Class I samples also showed mandibular growth, such as Class II patients.
considerable frequency of mandibular asymmetry. Other valuable information in the current study
The results also indicated that Class II malocclusion involved the diagnosis of mandibular asymmetry using
had the smallest prevalence of mandibular asymmetry, different imaging methods. Computed tomography
9%–19% smaller than Class III patients and 4%–30% incorporated different measurements into image anal-
smaller than Class I patients, in agreement with ysis to enhance diagnostic methods and identify
Thiesen et al.6 different bone regions related to asymmetry.10,12,29,30 In

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PREVALENCE OF MANDIBULAR ASYMMETRY 125

terms of imaging method, the results showed that CONCLUSIONS

prevalence of mandibular asymmetry could be under-
According to this review, the following conclusions
estimated, as prevalence rates for all malocclusions
may be considered:
increased at least 2.5 times using the asymmetry index
in tomographic images.27 Greater prevalence of man-  Skeletal Class III malocclusion shows the greatest
dibular asymmetry using CT or CBCT imaging must be prevalence of mandibular asymmetry.
viewed with caution when considering the clinical  Skeletal Class II malocclusion has the lowest
manifestation of facial asymmetry. This approach can prevalence of mandibular asymmetry.
show a patient’s vertical asymmetry, as seen in ramus  Vertical asymmetry shows a marked prevalence in all
and condylar height, with different vertical positions in malocclusions.

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the gonion region and not necessarily due to chin  However, conclusions should be interpreted with
deviation. Craniofacial bones located in upper facial caution due to convenience sampling and low-quality
regions, such as the maxilla, zygoma, and temporal study outcomes.
bone (glenoid fossae), can have an important function
in masking asymmetric mandibular conditions.30 ACKNOWLEDGMENTS
Previous studies using the asymmetry index found a
difference in ramus height between sides in asymmet- Support
ric Class III31 and Class II patients.32 Mendoza et al.27 This study received partial support from Capes (Financial
also found considerable rates of condylar height code 001) and NIH grant NIDCR R01 DE024450.
asymmetry in all sagittal malocclusions. In this sys-
tematic review, chin deviation was the parameter Competing Interests
mainly used to consider mandibular asymmetry.6,25,26,28 The authors declare no competing interests.
The asymmetry index was considered only in one
study in all sagittal malocclusions.27 Thus, a clinical Data Availability Statement
question arose after this systematic review: Are vertical
Data are available on request to the corresponding author by
asymmetries a common feature in all malocclusions? e-mail.
Future studies with different designs and control
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