The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
Condylar Hyperplasia: Correlation Between Clinical, Radiological, Scintigraphic, and Histologic Features Jonathan Elbaz, MD, PhD,* Axel Wiss, MD, PhD,* Gwenael Raoul, MD, PhD,* Xavier Leroy, MD, PhD,Þ Claude Hossein-Foucher, MD, PhD,þ Joel Ferri, MD, PhD* Purpose: The objectives of this study were to compare demographic, clinical, radiographic, scintigraphic, and histologic differences between the 2 main types of condylar hyperplasia (CH) and to suggest a new therapeutic management based on such findings. Methods: This was a retrospective study based on 28 patients who presented either vertical (group 1) or horizontal (group 2) forms of CH and underwent surgical treatment. Every patient had a complete preoperative clinical and radiological examination as well as a single-photon emission computed tomography scan. A histologic analysis of each resected condyle was performed. These various parameters were then compared in the 2 patient groups. Results: The mean age at time of the diagnosis was 25.8 years (range, 12Y50 years), and there were 22 females and 6 males. Nineteen patients had the vertical form of CH, and 9 had the horizontal form. Scintigraphic analysis showed moderate to extensive radionucleotide uptake in cases with rapid growth. Four cases had negative single-photon emission computed tomography scan uptake, and all were vertical forms, but there was no statistically significant difference between the 2 groups. The histologic analysis showed both a global thickening of the cartilage cap and of the prechondroblastic cells layer with no statistically significant difference between the 2 groups. Conclusions: Condylar hyperplasia is a pathologic condition affecting mainly young females and whose origin remains unknown. Single-photon emission computed tomography scans as an indicator of the rapidity of the disease progress are essential in assessing the condylar hyperplasia and to guide the therapeutic approach. Key Words: Condylar hyperplasia, condylectomy, facial asymmetry
C
ondylar hyperplasia (CH) is an uncommon mandibular benign pathology. Since its first description by Adams in 1836, there have been several reports in the literature about this entity,1Y4 but nosologic, anatomic, etiopathogenic, and therapeutic issues are still debated. This condition is characterized by a progressive development of a typical facial asymmetry, a direct consequence of an From the *Department of Oral and Maxillofacial Surgery, Roger Salengro Hospital, †Department of Pathology, and ‡Department of Nuclear Medicine, Roger Salengro Hospital, University Medical Center, Lille, France. Received June 12, 2013. Accepted for publication November 13, 2013. Address correspondence and reprint requests to Dr. Jonathan Elbaz, 47 Boulevard de la Liberte´, 59000 Lille, France; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000555
Brief Clinical Studies
excessive unilateral growth of the condylar cartilage. This asymmetry results in aesthetic, occlusal, and functional abnormalities. Obwegeser and Makek5 have classified CH into 3 categories: hemimandibular hyperplasia, type 1; hemimandibular elongation, type 2; and a combination of type 1 and 2. Gordeeff et al6 also described 3 categories: a vertical form corresponding to type 1, a horizontal form corresponding to type 2, and the same combination of both entities. Diagnosis of CH is based on the medical history and clinical examination and radiological and histologic features. Planar scintigraphy and, more recently, single-photon emission computed tomography (SPECT) scans have become essential for visualization of the hyperactivity of the condyle.7,8 Hemimandibular hyperplasia is characterized by a unilateral asymmetrical increase in height of the affected side of the face. There is a downward projection of the ascending ramus and the angle. The maxilla follows the downward growth of the mandible, and the teeth on the affected side remain in occlusion at a lower level than the teeth on the nonpathologic side. This results in a tilted occlusal plane. When the overgrowth is very rapid, the maxilla is not able to follow, and an open bite appears on the affected side. In hemimandibular elongation, the chin deviates toward the unaffected side, and the horizontal rami on both sides are located on the same level. There is a contralateral displacement of the midline of the lower dental arch, resulting in a crossbite on the nonpathologic side. In the combination of both entities (type 1 and 2), there is an increase in height of the face on the affected side. The occlusal plane is tilted with a lateral open bite if the maxilla is not able to follow the rapid overgrowth. There is an extreme displacement of the chin and the midline of the lower dental arch toward the unaffected side with a cross bite. The expression of the predominant form of the anomaly also dominates the clinical and radiographic features. The treatment of CH is based on a multidisciplinary approach. Surgical solutions are represented by condylectomy and orthognathic surgery. They can be used as a single method or be associated. The time to perform the surgery is still controversial.9 The aim of this retrospective study was to compare the clinical findings and various diagnostic procedures available in the 2 major types of CH. We then used the results as a basis for suggesting a new therapeutic management.
PATIENTS AND METHODS This study included 28 patients who were referred in the Department of Oral and Maxillofacial Surgery at the University Medical Center of Lille, France, for CH management. All patients underwent condylectomy between September 1999 and November 2011. Every patient had a complete clinical and radiological examination and underwent bone scintigraphy. The histologic features of the surgical specimens were also examined. The sex and the age at time of the diagnosis for each patient were recorded. Other clinical data included the main reason for consultation, a functional analysis, and the medical history. The side involved was recorded. The type of CH was classified as vertical (group 1) or horizontal (group 2), and the results of each group were then compared. Extraoral and intraoral examinations were also performed in search of etiologic signs and degree of deformity (Fig. 1A). The radiological assessment included orthopantographs and posteroanterior, lateral, and axial cephalograms. The latter threedirectional radiographic views allowed an appreciation of the degree of bony facial asymmetry (Fig. 1B). Each patient also underwent SPECT scanning in the Department of Nuclear Medicine using technetium Tc 99m dihydroxyl diphosphonate. Images centered on skull and facial bones were performed 3 minutes (early) and 3 hours (late) after intravenous administration of the radionucleotide. The
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1085
The Journal of Craniofacial Surgery
Brief Clinical Studies
& Volume 25, Number 3, May 2014
FIGURE 3. Thickening of the PCs layer (
& Volume 25, Number 3, May 2014
Condylar Hyperplasia: Correlation Between Clinical, Radiological, Scintigraphic, and Histologic Features Jonathan Elbaz, MD, PhD,* Axel Wiss, MD, PhD,* Gwenael Raoul, MD, PhD,* Xavier Leroy, MD, PhD,Þ Claude Hossein-Foucher, MD, PhD,þ Joel Ferri, MD, PhD* Purpose: The objectives of this study were to compare demographic, clinical, radiographic, scintigraphic, and histologic differences between the 2 main types of condylar hyperplasia (CH) and to suggest a new therapeutic management based on such findings. Methods: This was a retrospective study based on 28 patients who presented either vertical (group 1) or horizontal (group 2) forms of CH and underwent surgical treatment. Every patient had a complete preoperative clinical and radiological examination as well as a single-photon emission computed tomography scan. A histologic analysis of each resected condyle was performed. These various parameters were then compared in the 2 patient groups. Results: The mean age at time of the diagnosis was 25.8 years (range, 12Y50 years), and there were 22 females and 6 males. Nineteen patients had the vertical form of CH, and 9 had the horizontal form. Scintigraphic analysis showed moderate to extensive radionucleotide uptake in cases with rapid growth. Four cases had negative single-photon emission computed tomography scan uptake, and all were vertical forms, but there was no statistically significant difference between the 2 groups. The histologic analysis showed both a global thickening of the cartilage cap and of the prechondroblastic cells layer with no statistically significant difference between the 2 groups. Conclusions: Condylar hyperplasia is a pathologic condition affecting mainly young females and whose origin remains unknown. Single-photon emission computed tomography scans as an indicator of the rapidity of the disease progress are essential in assessing the condylar hyperplasia and to guide the therapeutic approach. Key Words: Condylar hyperplasia, condylectomy, facial asymmetry
C
ondylar hyperplasia (CH) is an uncommon mandibular benign pathology. Since its first description by Adams in 1836, there have been several reports in the literature about this entity,1Y4 but nosologic, anatomic, etiopathogenic, and therapeutic issues are still debated. This condition is characterized by a progressive development of a typical facial asymmetry, a direct consequence of an From the *Department of Oral and Maxillofacial Surgery, Roger Salengro Hospital, †Department of Pathology, and ‡Department of Nuclear Medicine, Roger Salengro Hospital, University Medical Center, Lille, France. Received June 12, 2013. Accepted for publication November 13, 2013. Address correspondence and reprint requests to Dr. Jonathan Elbaz, 47 Boulevard de la Liberte´, 59000 Lille, France; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000555
Brief Clinical Studies
excessive unilateral growth of the condylar cartilage. This asymmetry results in aesthetic, occlusal, and functional abnormalities. Obwegeser and Makek5 have classified CH into 3 categories: hemimandibular hyperplasia, type 1; hemimandibular elongation, type 2; and a combination of type 1 and 2. Gordeeff et al6 also described 3 categories: a vertical form corresponding to type 1, a horizontal form corresponding to type 2, and the same combination of both entities. Diagnosis of CH is based on the medical history and clinical examination and radiological and histologic features. Planar scintigraphy and, more recently, single-photon emission computed tomography (SPECT) scans have become essential for visualization of the hyperactivity of the condyle.7,8 Hemimandibular hyperplasia is characterized by a unilateral asymmetrical increase in height of the affected side of the face. There is a downward projection of the ascending ramus and the angle. The maxilla follows the downward growth of the mandible, and the teeth on the affected side remain in occlusion at a lower level than the teeth on the nonpathologic side. This results in a tilted occlusal plane. When the overgrowth is very rapid, the maxilla is not able to follow, and an open bite appears on the affected side. In hemimandibular elongation, the chin deviates toward the unaffected side, and the horizontal rami on both sides are located on the same level. There is a contralateral displacement of the midline of the lower dental arch, resulting in a crossbite on the nonpathologic side. In the combination of both entities (type 1 and 2), there is an increase in height of the face on the affected side. The occlusal plane is tilted with a lateral open bite if the maxilla is not able to follow the rapid overgrowth. There is an extreme displacement of the chin and the midline of the lower dental arch toward the unaffected side with a cross bite. The expression of the predominant form of the anomaly also dominates the clinical and radiographic features. The treatment of CH is based on a multidisciplinary approach. Surgical solutions are represented by condylectomy and orthognathic surgery. They can be used as a single method or be associated. The time to perform the surgery is still controversial.9 The aim of this retrospective study was to compare the clinical findings and various diagnostic procedures available in the 2 major types of CH. We then used the results as a basis for suggesting a new therapeutic management.
PATIENTS AND METHODS This study included 28 patients who were referred in the Department of Oral and Maxillofacial Surgery at the University Medical Center of Lille, France, for CH management. All patients underwent condylectomy between September 1999 and November 2011. Every patient had a complete clinical and radiological examination and underwent bone scintigraphy. The histologic features of the surgical specimens were also examined. The sex and the age at time of the diagnosis for each patient were recorded. Other clinical data included the main reason for consultation, a functional analysis, and the medical history. The side involved was recorded. The type of CH was classified as vertical (group 1) or horizontal (group 2), and the results of each group were then compared. Extraoral and intraoral examinations were also performed in search of etiologic signs and degree of deformity (Fig. 1A). The radiological assessment included orthopantographs and posteroanterior, lateral, and axial cephalograms. The latter threedirectional radiographic views allowed an appreciation of the degree of bony facial asymmetry (Fig. 1B). Each patient also underwent SPECT scanning in the Department of Nuclear Medicine using technetium Tc 99m dihydroxyl diphosphonate. Images centered on skull and facial bones were performed 3 minutes (early) and 3 hours (late) after intravenous administration of the radionucleotide. The
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1085
The Journal of Craniofacial Surgery
Brief Clinical Studies
& Volume 25, Number 3, May 2014
FIGURE 3. Thickening of the PCs layer (
