Growth & Facial Asymmetry: When to Worry

Only a few dentists can notice it and realize the asymmetry can signal an underlying skeletal imbalance, a growth issue, or a functional shift that will later cause orthodontic complexity.

Here’s a detailed guide on how to catch it early and when to act so that more dentists can spot the red flag.

Why Asymmetry Deserves Attention?

Facial asymmetry is common, but significant asymmetry can have big implications.

Recent studies show that up to one third orthodontic patients show measurable skeletal asymmetry, often associated to mandibular deviation, functional crossbites, or TMJ loading differences¹.

Ignoring early skeletal imbalance can lead to:

• Distorted occlusal development
• Compensatory dental tipping
• Increased TMJ dysfunction risk
• Complicated orthodontic or surgical correction later on

Clinical refernce: if detected before the growth spurt, most asymmetries can be intercepted with simpler orthodontic guidance. After growth happens, the same problem may need orthognathic intervention.

Chairside Clues You Should Never Miss

Below are a few signs you should note² -

Alhammadi MS, Halboub E, Fayed MS, Labib A, El-Saaidi C. Global distribution of malocclusion traits: a systematic review. Dental Press J Orthod. 2018 Nov-Dec;23(6):40.e1-40.e10.

 Facial and Extraoral Signs

• Chin point deviating approximately 4 mm from the midline.
• Uneven ear heights or cheekbone prominence.
• Head tilt or a habitual face-turn in photos.

 Intraoral and Occlusal Signs

• Deviation in upper and lower dental midlines.
• Unilateral posterior crossbite or scissor bite.
• Smile line not parallel to interpupillary line.
• Functional shift - patient slides the jaw to achieve intercuspation.

If you suspect asymmetry, take a PA ceph or CBCT to differentiate skeletal vs dento-alveolar origin³.

You can evaluate condylar height, mandibular length, and dental arch coordination.

When to Worry?

These can be a few red flags you should look out for⁴ -

• Any visible facial deviation increasing over 6–12 months
• Crossbite or occlusal cant developing on one side
• Chin or dental midline shift of more than 4–5 mm
• Asymmetry in a growing child from ages 8–13

If this is the case, document the current status and refer to the specialist. Early collaborative planning can often redirect growth patterns and prevent surgical outcomes. 

Chairside Implementation Tips

Here are a few tips you should keep in mind -

Document everything
Include chin-to-midline notes, facial photos, and occlusal cants in your chart.

Educate parents/patients
Use simple language to explain to the patients. Put it in understandable language, like “Her chin is growing slightly to one side, and this could affect how her jaws align if we don’t monitor it.”

Schedule structured reviews
6-month growth checks during mixed dentition can help notice progression well on time.

Have a referral protocol
Collaborate with orthodontic dentists. Have clarity on situations that could lead to referral. 

Why This Matters?

Many dentists miss asymmetry because it’s subtle and patients rarely complain. Yet, it needs to be understood that these are exactly the cases that turn complex later⁵.
 By building a simple 2-minute “symmetry check” into every mixed-dentition exam, you:
 ✅ Catch skeletal issues early
 ✅ Reduce treatment invasiveness​​
 ✅ Strengthen interdisciplinary trust

Final Takeaway

Facial asymmetry isn’t just aesthetic. It’s an orthodontic red flag  and your early eye can change the patient’s entire treatment trajectory.

References (Vancouver style):

1. Zhu Y, Zhao Y, Wang Y. A review of three-dimensional facial asymmetry analysis methods. Symmetry (Basel). 2022;14(7):1414.
2. Alhammadi MS, Halboub E, Fayed MS, Labib A, El-Saaidi C. Global distribution of malocclusion traits: a systematic review. Dental Press J Orthod. 2018 Nov-Dec;23(6):40.e1-40.e10.
3. Pedersoli L, Dalessandri D, Tonni I, Bindi M, Isola G, Oliva B, Visconti L, Bonetti S. Facial asymmetry detected with 3D methods in orthodontics: A systematic review. Open Dent J. 2022 Apr 25;16:e2111251. 
4. American Academy of Pediatric Dentistry. Management of the developing dentition and occlusion in pediatric dentistry. In: The Reference Manual of Pediatric Dentistry. Chicago (IL): American Academy of Pediatric Dentistry; 2024. p. 475–93.
5. Adel M, Hunt KJ, Lau D, Hartsfield JK, et al. Precision assessment of facial asymmetry using 3D imaging and artificial intelligence. J Clin Med. 2025;14(20):7172