Background <p>This study aimed to evaluate mandibular ramus asymmetry in individuals with unilateral congenital tooth agenesis using panoramic radiography. The results were compared with individuals without agenesis and with bilateral agenesis.</p> Methods <p>The study included 150 individuals in three groups [no agenesis, bilateral, unilateral]. Condylar height, ramus height, and mandibular length were measured on panoramic radiographs using Viewbox-4, and asymmetry indices were calculated with the Habets formula. Statistical analyses were performed in SPSS 27.0 with significance set at <i>p</i> &lt; 0.05.</p> Results <p>No significant differences were observed among groups in linear measurements [<i>p</i> &gt; 0.05]. However, the unilateral agenesis group showed higher ramus and mandibular asymmetry indices [RAI: 2.05 ± 1.97; MAI: 2.15 ± 1.79] compared to the bilateral agenesis [RAI: 1.50 ± 1.23; MAI: 1.40 ± 1.03] and control groups [RAI: 0.89 ± 0.87; MAI: 0.82 ± 0.74] [<i>p</i> &lt; 0.001]. Ramus asymmetry was strongly correlated with overall mandibular asymmetry. In posterior unilateral agenesis cases, condylar and mandibular asymmetries were significantly greater [CAI: 7.67 ± 5.43 vs. 3.98 ± 3.11, <i>p</i> = 0.019; MAI: 2.70 ± 2.14 vs. 1.40 ± 1.11, <i>p</i> = 0.023]. Condylar asymmetry was also higher in individuals with mandibular agenesis than those with maxillary agenesis [<i>p</i> = 0.022].</p> Conclusion <p>Unilateral congenital tooth agenesis, particularly in posterior or mandibular cases, was associated with increased mandibular asymmetry. Ramus height was significantly associated with overall mandibular asymmetry. Panoramic radiography can be considered a practical first-line tool, while CBCT may be reserved for more detailed evaluation when necessary.</p>