Int. J. Oral Maxillofac. Surg. 2015; 44: 771–773 http://dx.doi.org/10.1016/j.ijom.2014.11.015, available online at http://www.sciencedirect.com
Case Report TMJ Disorders
Condylar hyperplasia following unilateral temporomandibular joint replacement
V. Machon1,, J. Levorova1, D. Hirjak2, R. Foltan1 1
Department of Oral and Maxillofacial Surgery, Charles University and Faculty Hospital Prague, Czech Republic; 2 Department of Oral and Maxillofacial Surgery, Faculty Hospital Bratislava, Ruzinov, Slovakia
V. Machon, J. Levorova, D. Hirjak, R. Foltan: Condylar hyperplasia following unilateral temporomandibular joint replacement. Int. J. Oral Maxillofac. Surg. 2015; 44: 771–773. # 2015 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
Abstract. Total joint replacement of the temporomandibular joint (TJR) can be associated with intraoperative and postoperative complications. We report herein the occurrence of a postoperative open bite malocclusion, the result of condylar hyperplasia affecting the non-operated joint at 1 year after unilateral total joint replacement.
Enhanced growth resembling activity of the condyle, accompanied by facial asymmetry, can be found in hemimandibular or condylar hyperplasia, even in adulthood. Condylar hyperplasia is a postnatal growth abnormality, characterized by excessive unilateral growth resembling activity of the mandibular condyle, which results in facial asymmetry and bite defects. The disorder develops as a consequence of accelerated growth in adolescents, or due to its prolongation in adult patients. The disorder most commonly involves those aged between 10 and 30 years, with males and females equally affected (ratio 1:1). While the exact aetiology is unknown, genetic and hormone disorders contribute to its development, as well as trauma; it may develop in response to excessive stress on the condyle or an infection.1–6 Clinical symptoms include facial asymmetry, and depending on the growth dynamics, various bite defects. These bite 0901-5027/060771 + 03
defects can be divided into two groups. The first comprises an open bite with an angular shift of the mandible and elongation of the mandibular arm on the affected side, chin centre deviation towards the affected side, and the development of a unilateral open bite on the same side; this is seen with vertical growth. The second involves the centre of the mandible and biting point shifting towards the unaffected side, resulting in cross bite; this is seen with rotational growth. In condylar hyperplasia, the symptoms typical of temporomandibular joint (TMJ) involvement, i.e. sound phenomena, restricted mobility, and pain, are infrequent. In addition to clinical examination, the diagnosis of this condition also requires an X-ray image (which can confirm the skeletal abnormality) and a scintigraphy image; scintigraphy makes it possible to distinguish the active form of hyperplasia from the passive form. This then determines the type of treatment. For the active
Key words: total joint replacement; complication; condylar hyperplasia. Accepted for publication 21 November 2014 Available online 3 February 2015
form, i.e. with continued growth activity, the primary treatment includes a high condylectomy (condylar shaving) during which up to 5 mm of cartilage and bone are shaved off the top of the condyle; this inhibits condylar growth. For the passive form, the only option is orthognathic and orthodontic correction of the mandibular abnormality.1–9 Case report
We report the case of a 41-year-old male who was without systemic disease. At the age of 15 years he suffered a fracture of the left condyle. Following conservative treatment, ankylosis gradually developed in his left TMJ. At age 19 years he underwent open surgery for gap arthroplasty. In the course of the first postoperative year, the condition relapsed with restricted mandibular mobility. At the age of 41 years, the patient attended for examination due to mandibular mobility restricted to 11 mm
# 2015 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
772
Machon et al.
(inter-incisal). In view of the fibro-osseous ankylosis in the left TMJ, resection of the ankylotic block was planned with subsequent total joint replacement. The patient underwent the planned surgery, which involved resection of the ankylotic bone block, followed by joint replacement with a stock prosthesis (Biomet Inc., Jacksonville, FL, USA). The correct position of the jaws was secured by rigid intermaxillary fixation, which was removed on completion of the surgery. Following surgery, the patient confirmed a significantly improved condition; at 1 month postoperative he was able to open his mouth to 29 mm with deviation towards the left (the operated side). At a check-up 12 months postoperative (February 2011), the patient indicated a shift of the mandible towards the left operated side and a modified bite. Objectively, the mandibular centre was shifted towards the operated side (with the bite point shifted by 5 mm); facial asymmetry due to the chin shift was observed. The inter-incisal mouth opening was recorded at 44 mm. The patient was X-rayed for a suspected implant failure. Implant failure was not demonstrated, however there was a change in shape of the condyle on the right side compared to the postoperative image; hyperplasia of the condyle was noted. Skeletal scintigraphy confirmed heightened osseous alteration of the right TMJ, i.e. on the non-operated side (Fig. 1). Computed tomography (CT) images clearly showed advanced condylar hyperplasia on the right side (Figs 2 and 3). Over the course of the next 2 months, the growth continued to progress and the lower mandible shifted further to the left – the shift of the incisal point of the lower mandible was measured as 11 mm. For this reason, a high condylectomy was performed (condylar shaving), removing 5 mm of the right condyle and stopping the pathological growth (May 2011). Histopathological investigations showed a significant increase in hyperplastic cartilage, which had broadened the subchondral layer of bone. Osteochondroma and other tumours were excluded. At the present time, 35 months after this last operation, the patient’s condition is stable, without any signs of further growth progression (Fig. 4).
Fig. 1. Bone scan at 12 months after TMJ replacement.
structures) and poor adaptation of the prosthesis components. Postoperative complications may include infection, haematoma, heterotopic bone formation, implant failure, pain, salivary fistula, foreign body and allergic reactions, and malocclusion.7
A bite modification can occur as a postoperative complication of TMJ replacement. This may result from malpositioning of the mandible with the TMJ prosthesis due to inadequate intermaxillary fixation and from implant failure7;
Fig. 2. CT scan of the right condyle before TMJ replacement.
Discussion
Complications of total TMJ replacement can be divided into intraoperative and postoperative (late). Intraoperative complications include injuries to the anatomical structures (blood vessels, nerves, otological
Fig. 3. CT scan of right condyle at 12 months after TMJ replacement; note elongation of the condyle.
Condylar hyperplasia after TMJ replacement
773
Patient consent
Patient consent was obtained to publish clinical photographs. References
Fig. 4. CT scan of the right condyle at 30 months after condylar shaving.
however, this was ruled out in our patient. A bite modification due to condylar hyperplasia on the non-operated joint following a unilateral TMJ replacement has not been described to date. Causes of condylar hyperplasia that have been described include (1) acceleration of growth in adolescent patients,8,9 which was not a possibility in the case presented here; (2) hormonal disorders and reactions to infections,1,6,8,9 which were not found in our patient; and (3) excessive stress or trauma, which must be taken into account in the case presented. Due to TMJ replacement enables only rotational movement, the non-operated joint is then placed under excessive pressure and is effectively traumatized by the modified movement. This possibility is supported by the fact that the healthy joint was not under long-term stress in regard to the ankylosis on the opposite side; it was only after joint replacement that its function was changed. The condyle could then react in accordance with Wolff’s law10: exterior appearance, internal structure, and functional skeletal stress are in harmony; any change leads to skeletal alteration aiming to re-establish the original harmonious condition. Some authors state prolongation of growth as another possible cause of condylar hyperplasia.6,8,9 We can merely speculate as to whether such growthresembling activity occurred in this patient’s joint, the movement of which was restricted for 26 years by ankylosis on the opposite side. Another aetiological factor causing hyperplasia is mandibular protrusion, which results in a metabolic
adaptation connected to strengthening of cartilage and initiation of growth centres2,3,5; however, this did not occur during the TMJ replacement. The treatment of condylar hyperplasia consists of surgical correction of the mandibular asymmetry (if the process is passive) or in stopping the growth of the hyperplastic condyle in its active forms. Such growth inhibition is performed through a high condylectomy (where 4–5 mm is removed from the top of the condyle).6,8,9 A high condylectomy was performed on the patient in this case report, after which his condition stabilized and no further progression of mandibular growth-resembling activity was observed. In conclusion, condylar hyperplasia of the non-operated joint following unilateral TMJ replacement is a complication of TMJ replacement that has not been described to date. If a progressive bite defect occurs in a patient after surgery, this complication must be taken into account.
Funding
No sources of funding.
Competing interests
No competing interests.
Ethical approval
Ethical approval was obtained from the Ethics Committee of the General University Hospital Prague, No. 1248/14 S-IV.
1. Bruseti R, Pedrazzoli M, Colletti G. Functional results after condylectomy in active laterognathia. J Craniomaxillofac Surg 2010; 38:179–84. 2. Fuentes MA, Opperman LA, Buschang P, Bellinger LL, Carlson DS, Hinton RJ. Lateral functional shift of the mandible: Part I. Effects on condylar cartilage thickness and proliferation. Am J Orthod Dentofacial Orthop 2003;123:153–9. 3. Fuentes MA, Opperman LA, Buschang P, Bellinger LL, Carlson DS, Hinton RJ. Lateral functional shift of the mandible: Part II. Effects in gene expression in condylar cartilage. Am J Orthod Dentofacial Orthop 2003; 123:160–6. 4. Lippold C, Kruse-Loster B, Danesh G, Joos U, Meyer U. Treatment of hemimandibular hyperplasia: the biological basis of condylectomy. Br J Oral Maxillofac Surg 2007; 45:353–60. 5. McNamara JA, Carlson DS. Quantitative analysis of temporomandibular joint adaptations to protrusive function. Am J Orthod 1979;156:453–503. 6. Meng Q, Long X, Deng M, Cai H, Li J. The expressions of IGF-1, BMP-2 and TGF beta 1 in cartilage of condylar hyperplasia. J Oral Rehabil 2011;38:34–40. 7. Mercuri LG. Alloplastic temporomandibular joint reconstruction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85: 631–7. 8. Obwegeser HL. Mandibular growth anomalies Terminology aetiology diagnosis and Treatment, vol. XVII. Springer; 2001. 9. Sidebotton AJ, Crank ST, Gray S. A pathway for the treatment of condylar hyperplasia and assessment of treatment outcomes. Int J Maxillofac Surg 2010;21(Suppl 1):43–9. 10. Wolff J. Das Gesetz der Transformation der Knochen. Berlin – 1892. English translation. Springer; 1986.
Address: Vladimir Machon Department of Oral and Maxillofacial Surgery Charles University and Faculty Hospital Prague U nemocnice 2 str. 120 00 Prague 2 Czech Republic
Case Report TMJ Disorders
Condylar hyperplasia following unilateral temporomandibular joint replacement
V. Machon1,, J. Levorova1, D. Hirjak2, R. Foltan1 1
Department of Oral and Maxillofacial Surgery, Charles University and Faculty Hospital Prague, Czech Republic; 2 Department of Oral and Maxillofacial Surgery, Faculty Hospital Bratislava, Ruzinov, Slovakia
V. Machon, J. Levorova, D. Hirjak, R. Foltan: Condylar hyperplasia following unilateral temporomandibular joint replacement. Int. J. Oral Maxillofac. Surg. 2015; 44: 771–773. # 2015 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
Abstract. Total joint replacement of the temporomandibular joint (TJR) can be associated with intraoperative and postoperative complications. We report herein the occurrence of a postoperative open bite malocclusion, the result of condylar hyperplasia affecting the non-operated joint at 1 year after unilateral total joint replacement.
Enhanced growth resembling activity of the condyle, accompanied by facial asymmetry, can be found in hemimandibular or condylar hyperplasia, even in adulthood. Condylar hyperplasia is a postnatal growth abnormality, characterized by excessive unilateral growth resembling activity of the mandibular condyle, which results in facial asymmetry and bite defects. The disorder develops as a consequence of accelerated growth in adolescents, or due to its prolongation in adult patients. The disorder most commonly involves those aged between 10 and 30 years, with males and females equally affected (ratio 1:1). While the exact aetiology is unknown, genetic and hormone disorders contribute to its development, as well as trauma; it may develop in response to excessive stress on the condyle or an infection.1–6 Clinical symptoms include facial asymmetry, and depending on the growth dynamics, various bite defects. These bite 0901-5027/060771 + 03
defects can be divided into two groups. The first comprises an open bite with an angular shift of the mandible and elongation of the mandibular arm on the affected side, chin centre deviation towards the affected side, and the development of a unilateral open bite on the same side; this is seen with vertical growth. The second involves the centre of the mandible and biting point shifting towards the unaffected side, resulting in cross bite; this is seen with rotational growth. In condylar hyperplasia, the symptoms typical of temporomandibular joint (TMJ) involvement, i.e. sound phenomena, restricted mobility, and pain, are infrequent. In addition to clinical examination, the diagnosis of this condition also requires an X-ray image (which can confirm the skeletal abnormality) and a scintigraphy image; scintigraphy makes it possible to distinguish the active form of hyperplasia from the passive form. This then determines the type of treatment. For the active
Key words: total joint replacement; complication; condylar hyperplasia. Accepted for publication 21 November 2014 Available online 3 February 2015
form, i.e. with continued growth activity, the primary treatment includes a high condylectomy (condylar shaving) during which up to 5 mm of cartilage and bone are shaved off the top of the condyle; this inhibits condylar growth. For the passive form, the only option is orthognathic and orthodontic correction of the mandibular abnormality.1–9 Case report
We report the case of a 41-year-old male who was without systemic disease. At the age of 15 years he suffered a fracture of the left condyle. Following conservative treatment, ankylosis gradually developed in his left TMJ. At age 19 years he underwent open surgery for gap arthroplasty. In the course of the first postoperative year, the condition relapsed with restricted mandibular mobility. At the age of 41 years, the patient attended for examination due to mandibular mobility restricted to 11 mm
# 2015 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
772
Machon et al.
(inter-incisal). In view of the fibro-osseous ankylosis in the left TMJ, resection of the ankylotic block was planned with subsequent total joint replacement. The patient underwent the planned surgery, which involved resection of the ankylotic bone block, followed by joint replacement with a stock prosthesis (Biomet Inc., Jacksonville, FL, USA). The correct position of the jaws was secured by rigid intermaxillary fixation, which was removed on completion of the surgery. Following surgery, the patient confirmed a significantly improved condition; at 1 month postoperative he was able to open his mouth to 29 mm with deviation towards the left (the operated side). At a check-up 12 months postoperative (February 2011), the patient indicated a shift of the mandible towards the left operated side and a modified bite. Objectively, the mandibular centre was shifted towards the operated side (with the bite point shifted by 5 mm); facial asymmetry due to the chin shift was observed. The inter-incisal mouth opening was recorded at 44 mm. The patient was X-rayed for a suspected implant failure. Implant failure was not demonstrated, however there was a change in shape of the condyle on the right side compared to the postoperative image; hyperplasia of the condyle was noted. Skeletal scintigraphy confirmed heightened osseous alteration of the right TMJ, i.e. on the non-operated side (Fig. 1). Computed tomography (CT) images clearly showed advanced condylar hyperplasia on the right side (Figs 2 and 3). Over the course of the next 2 months, the growth continued to progress and the lower mandible shifted further to the left – the shift of the incisal point of the lower mandible was measured as 11 mm. For this reason, a high condylectomy was performed (condylar shaving), removing 5 mm of the right condyle and stopping the pathological growth (May 2011). Histopathological investigations showed a significant increase in hyperplastic cartilage, which had broadened the subchondral layer of bone. Osteochondroma and other tumours were excluded. At the present time, 35 months after this last operation, the patient’s condition is stable, without any signs of further growth progression (Fig. 4).
Fig. 1. Bone scan at 12 months after TMJ replacement.
structures) and poor adaptation of the prosthesis components. Postoperative complications may include infection, haematoma, heterotopic bone formation, implant failure, pain, salivary fistula, foreign body and allergic reactions, and malocclusion.7
A bite modification can occur as a postoperative complication of TMJ replacement. This may result from malpositioning of the mandible with the TMJ prosthesis due to inadequate intermaxillary fixation and from implant failure7;
Fig. 2. CT scan of the right condyle before TMJ replacement.
Discussion
Complications of total TMJ replacement can be divided into intraoperative and postoperative (late). Intraoperative complications include injuries to the anatomical structures (blood vessels, nerves, otological
Fig. 3. CT scan of right condyle at 12 months after TMJ replacement; note elongation of the condyle.
Condylar hyperplasia after TMJ replacement
773
Patient consent
Patient consent was obtained to publish clinical photographs. References
Fig. 4. CT scan of the right condyle at 30 months after condylar shaving.
however, this was ruled out in our patient. A bite modification due to condylar hyperplasia on the non-operated joint following a unilateral TMJ replacement has not been described to date. Causes of condylar hyperplasia that have been described include (1) acceleration of growth in adolescent patients,8,9 which was not a possibility in the case presented here; (2) hormonal disorders and reactions to infections,1,6,8,9 which were not found in our patient; and (3) excessive stress or trauma, which must be taken into account in the case presented. Due to TMJ replacement enables only rotational movement, the non-operated joint is then placed under excessive pressure and is effectively traumatized by the modified movement. This possibility is supported by the fact that the healthy joint was not under long-term stress in regard to the ankylosis on the opposite side; it was only after joint replacement that its function was changed. The condyle could then react in accordance with Wolff’s law10: exterior appearance, internal structure, and functional skeletal stress are in harmony; any change leads to skeletal alteration aiming to re-establish the original harmonious condition. Some authors state prolongation of growth as another possible cause of condylar hyperplasia.6,8,9 We can merely speculate as to whether such growthresembling activity occurred in this patient’s joint, the movement of which was restricted for 26 years by ankylosis on the opposite side. Another aetiological factor causing hyperplasia is mandibular protrusion, which results in a metabolic
adaptation connected to strengthening of cartilage and initiation of growth centres2,3,5; however, this did not occur during the TMJ replacement. The treatment of condylar hyperplasia consists of surgical correction of the mandibular asymmetry (if the process is passive) or in stopping the growth of the hyperplastic condyle in its active forms. Such growth inhibition is performed through a high condylectomy (where 4–5 mm is removed from the top of the condyle).6,8,9 A high condylectomy was performed on the patient in this case report, after which his condition stabilized and no further progression of mandibular growth-resembling activity was observed. In conclusion, condylar hyperplasia of the non-operated joint following unilateral TMJ replacement is a complication of TMJ replacement that has not been described to date. If a progressive bite defect occurs in a patient after surgery, this complication must be taken into account.
Funding
No sources of funding.
Competing interests
No competing interests.
Ethical approval
Ethical approval was obtained from the Ethics Committee of the General University Hospital Prague, No. 1248/14 S-IV.
1. Bruseti R, Pedrazzoli M, Colletti G. Functional results after condylectomy in active laterognathia. J Craniomaxillofac Surg 2010; 38:179–84. 2. Fuentes MA, Opperman LA, Buschang P, Bellinger LL, Carlson DS, Hinton RJ. Lateral functional shift of the mandible: Part I. Effects on condylar cartilage thickness and proliferation. Am J Orthod Dentofacial Orthop 2003;123:153–9. 3. Fuentes MA, Opperman LA, Buschang P, Bellinger LL, Carlson DS, Hinton RJ. Lateral functional shift of the mandible: Part II. Effects in gene expression in condylar cartilage. Am J Orthod Dentofacial Orthop 2003; 123:160–6. 4. Lippold C, Kruse-Loster B, Danesh G, Joos U, Meyer U. Treatment of hemimandibular hyperplasia: the biological basis of condylectomy. Br J Oral Maxillofac Surg 2007; 45:353–60. 5. McNamara JA, Carlson DS. Quantitative analysis of temporomandibular joint adaptations to protrusive function. Am J Orthod 1979;156:453–503. 6. Meng Q, Long X, Deng M, Cai H, Li J. The expressions of IGF-1, BMP-2 and TGF beta 1 in cartilage of condylar hyperplasia. J Oral Rehabil 2011;38:34–40. 7. Mercuri LG. Alloplastic temporomandibular joint reconstruction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85: 631–7. 8. Obwegeser HL. Mandibular growth anomalies Terminology aetiology diagnosis and Treatment, vol. XVII. Springer; 2001. 9. Sidebotton AJ, Crank ST, Gray S. A pathway for the treatment of condylar hyperplasia and assessment of treatment outcomes. Int J Maxillofac Surg 2010;21(Suppl 1):43–9. 10. Wolff J. Das Gesetz der Transformation der Knochen. Berlin – 1892. English translation. Springer; 1986.
Address: Vladimir Machon Department of Oral and Maxillofacial Surgery Charles University and Faculty Hospital Prague U nemocnice 2 str. 120 00 Prague 2 Czech Republic
