Management of occlusal cant in skeletal Class II and Class III patients: a systematic review

Facial asymmetry complicated by occlusal cants presents significant diagnostic and treatment planning challenges, particularly in patients with Skeletal Class II and Class III malocclusions. This systematic review aimed to synthesize the literature regarding diagnostic criteria, dental compensation patterns, and treatment efficacy for correcting occlusal cants in this population. A protocol was registered in PROSPERO (CRD420251207015). Electronic databases (PubMed/MEDLINE, Scopus, Cochrane Library, Web of Science, Google Scholar) were searched for relevant published literature. References of relevant articles were cross-checked for additional articles. Observational studies evaluating patients with skeletal asymmetry and occlusal cants were selected. Quality assessment was performed using the AXIS tool and Newcastle-Ottawa Scale (NOS). Twenty-three articles were included (8 good, 10 moderate, 5 poor quality). Three-dimensional (3D) imaging was identified as essential for differentiating transverse asymmetry from vertical asymmetry. Dental compensation patterns revealed significant buccal tipping of maxillary molars on the deviated side, necessitating specific presurgical decompensation to prevent relapse. Regarding efficacy, isolated mandibular surgery was found to be effective for correcting moderate lip line cants (1.5 to 6 degrees), offering soft tissue outcomes comparable to bimaxillary surgery, whereas severe vertical discrepancies required differential maxillary impaction. The use of 3D imaging has redefined the etiology of the occlusal cant as a primary manifestation of vertical ramal asymmetry. A visual threshold of 4 degrees serves as a robust clinical guideline for determining the necessity of surgical intervention. While severe cants require 2-jaw surgery, 1-jaw surgery remains a viable treatment alternative for moderate lip line asymmetry. Three-dimensional imaging is an essential requisite in diagnosing facial asymmetry Vertical discrepancies require bimaxillary surgery Moderate lip line cants are treatable with isolated mandibular surgery Pre-surgical uprighting of molars on deviated side prevents relapse Dental compensation should be accurately identified prior to surgical planning.