Article Type : Editorials
Authors : Rohit Kulshrestha
Keywords : Dental sciences
Symmetry may be defined as “equality or correspondence
in form of parts distributed around a centre or an axis, at the two extremes or
poles or on the two opposite sides of the body.” Clinically, symmetry can be
taken as balance and significant asymmetry means imbalance. Humans, like most
other animals, are considered to display bilateral symmetry. By strict
definition, this implies that mirror image mathematical identity exists between
right and left halves. Because of biological imperfection, some of which is
inherent in the developmental process and some of which is caused by
environmental disturbance, such symmetry is never encountered. Therefore,
asymmetry within reasonable bounds cannot be considered an abnormal condition.
However, what is considered to be within reasonable bounds is largely the
result of subjective opinion because accepted objective standards do not exist
by which a judgement of abnormality can be made.
Symmetry is both a conceptual and a perceptual notion
associated with beauty- related judgments, even as it implies different things
in a range of scholarly areas. In general, mammals have marked asymmetry as to
the placement of viscera in the oral cavity. Man frequently experiences
functional as well as morphologic asymmetry (e.g., right and left handedness as
well as a preference for one eye or one leg). According to Dorland’s medical
dictionary symmetry is defined as: - “the similar arrangement in form and
relationships of parts around a common axis or on each side of a plane of the
body.”
Facial asymmetries are imbalances that occur between
homologous parts of the face affecting the proportion of these parts to one
another with regards to size, form and position on opposite sides of the plane,
line or point. Asymmetries exist in orthodontics as well as non-orthodontic
individuals. Asymmetry is characterized by a shift of the midline, a difference
in facial height between sides, a difference in facial width between sides or a
combination of two or more of these features.
Facial asymmetry, being a common phenomenon, was
probably first observed by the artists of early Greek statuary who recorded
what they found in nature – normal facial asymmetry. This may be the result of
discrepancies either in the form of individual bones or a malposition of one or
more bones in the craniofacial complex. The symmetry may also be limited to the
overlying soft tissues. Macgregor defined disability as any condition which
prevents one from performing the normal activities of daily living. Yet the
inability of the facially disfigured to lead normal lives tends to be
overlooked because they are ostensibly able-bodied, can work, and can
physically accomplish the basic routines of daily living. Peck and Peck
evaluated bilateral facial symmetry in 52 “exceptionally well-balanced” white
adults and observed that there is less asymmetry and more dimensional stability
as the cranium is approached. Significant facial asymmetry causes both
functional as well as aesthetic problems. When patient complains of facial
asymmetry, the underlying cause should be investigated.
Woo evaluated ancient Egyptian skulls and found that
the bones of the cranium showed asymmetry with the right frontal, temporal and
parietal bones being larger. The contra lateral side of the facial complex
exhibited an asymmetry with the left zygoma and maxilla being larger. Along
with the clinical assessment, the radiographic techniques most used for
evaluation of facial asymmetries is frontal cephalograms, among other
radiographs. The frontal or postero-anterior cephalograms has advantage of positioning
the subject in a fixation device thereby allowing image reproduction of high
accuracy.
Some clefts of the lip or palate are genetically
influenced and result in a facial deformity with an associated collapse of the
maxillary dental arch. Intrauterine pressure during pregnancy and significant
pressure at the birth canal during parturition can have observable effects on
the bones of the fetal skull. The moulding of the parietal and facial bones
from these pressures can result in facial asymmetry. In a detailed study of the
asymmetry in the dental arches and face, Lundstrom explained that asymmetry can
be genetic or non-genetic in origin and that it is usually a combination of
both. According to Lundstrom asymmetry can also be described as either qualitative
(all or none) or quantitative.
As Leo Tolstoy said in Childhood, “I am convinced that
nothing has so marked influence on the direction of a man’s mind as his
appearance, and not his appearance itself so much as his conviction that it is
attractive or unattractive.” Till early 1900’s it was a fact that of all the
concerns within the field of physical disability & rehabilitation, the
large group of persons in the society with facial deviations, i.e.,
disfigurement or malformations, were seldom included. In this respect they were
the marginal or forgotten people. As facial asymmetry could be a social
handicap, there is even evidence of discrimination because of facial
appearance. When F. C. Macgregor began his research on the psychological &
sociological aspects of facial deformity, in searching the literature he was
surprised to discover that, in all the studies there was practically no mention
of the face.
In 1953 a compilation by Barker and others contained
but two references on facial deformities under the rubric “cosmetic”. In
campaigns for the handicapped either to raise funds or to encourage their
employment, the focus is on amputees, paraplegics, the blind, the deaf, those
with cerebral palsy, and so on. The victims of such disabilities may even be seen
or interviewed on television but never a person with a facial disfigurement.
Even at most national and international conferences on disability or
rehabilitation, facial disfigurement as a category is omitted. The more
Macgregor pursued his investigations of patients with marred faces, repulsive
to look at, or whose malformations, though less severe, were stimuli for jokes
or ridicule, the more this large group was omitted. As he interviewed and
followed patients in need of plastic surgery, prosthetic devices, and
orthodontic work, it became abundantly clear that defects of the face can be
one of the most tragic handicaps a person can have. It is quite true that
unless there is some functional problem, the physical ability of the facially
disfigured is not impaired. His handicap is social and psychological.
It is enough to say that the role of the face in our
interactions with others is the curse of the problem for anyone whose face
deviates from the norm coupled with our cultural emphasis on external appearance,
physical attractiveness and conformity, the problems of the facially
handicapped lie squarely in the area of mental health. One might suppose that
the psychic distress caused by disfigurement is in direct proportion to its
severity. But this is not the case. In an interdisciplinary study of facially
disfigured patients conducted at New York University College of Medicine
(1949-1952) it was found that for those whose deformities evoked ridicule,
stimulated jokes, and were sources of amusement, the psychological impact was
exceedingly great. In fact, it was found that many patients with such
deviations were in worse psychological shape, had more behavioural disorders,
and were more maladjusted than those with the kinds of deformities that were
distressing to look at or tended to elicit strong emotional reactions such as
pity or revulsion.
The impact of a physical defect on an individual also
will be strongly influenced by that person’s self-esteem. The result is that
the same degree of anatomic abnormality can be merely a condition of no great
consequence to one individual but a genuinely severe problem to another. It
seems to be easier to cope with a defect if other people’s responses to it are
consistent rather than if they are not. Unpredictable responses produce anxiety
and can have strong deleterious effects. It seems clear that the major reason
people seek treatment is to minimize psychosocial problems related to their
facial appearance. But we should remember that these problems are not “just cosmetic”
and can have a major effect on the quality of life. Facial asymmetry has a high
co-relation with attractiveness. Even a slight asymmetry is quickly noticed by
the human eye. Greater degrees of asymmetry are co-related with clinical
depression, neurosis, inferiority complex, poor self-esteem, and general
poor-quality-of-life health problems.