European Jotmurf ofOrthodontics 13(1991) 143-148
© 1991 European Orthodontic Society
Orthodontic and surgical treatment of unilateral condylar hyperplasia during growth—a case report Giinter Feldmann,* Sten Linder-Aronson," Arne Rindler,* and Ulf Soderstrom* * Public Dental Health Service, Orebro, and "Departments of Orthodontics, Karolinska Institutet, Sweden
Introduction
Hyperplasia of the mandibular condyle is an anomaly which usually occurs unilaterally and with equal frequency in both men and women. The term 'condylar hyperplasia' refers to hyperplasia of the condyle alone and should not be used to mean hemimandibular hyperplasia or hemimandibular elongation (Obwegeser and Makek, 1986). Condylar hyperplasia occurs between 10 and 25 years of age (Rushton, 1946), although the majority of cases have been recorded between 15 and 19 years of age. In all probability there is a certain delay before the anomaly is diagnosed. The extent and nature of the deformity is largely dependent on when the increase in growth takes place. Should this occur unilaterally during early childhood one half of the mandible will become enlarged. At the same time, in order to maintain the occlusion, the maxillary teeth and alveolar process tend to compensate for the change in jaw relationships. A growth increase during the teens usually leads to a lateral open bite since alveolar adaptive potential in both the maxilla and mandible is no longer capable of
achieving adequate compensation (Bruce and Hay ward, 1968). Aetiology The cause of unilateral condylar hyperplasia is unknown. Hereditary factors, inflammation, hormonal disturbances and trauma have all been suggested (Rushton, 1946). Oberg el al. (1962) carried out a histological, micro-radiographical, and auto-radiographical examination of one such case. They found an increase in the number of blood vessels penetrating the upper posterior part of the condyle and concluded that the enhanced blood supply could explain the increase in growth. Walker (1967) noted during surgery that the para-condylar soft tissues were more vascular in cases with hyperplasia. WangNorderud and Ragab (1977) believe that condylar hyperplasia is more likely to be due to an intra-uterine moulding rather than to genetic disturbances. Surgical intervention Early surgical intervention and removal of the enlarged mandibular condyle is recommended, in particular in those cases where continued
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SUMMARY A 9-year-old boy was diagnosed as having an unilateral cross-bite with mandibular deviation. This was later found to be due to unilateral hyperplasia of the right condyle. The increased growth activity subsequently led to an extreme facial asymmetry and a serious psychological condition began to develop. Consequently, surgery was performed at the age of 11 years 8 months when removal of the enlarged condyle and an oblique ramus osteotomy on the opposite side was performed. I n this way the facial asymmetry was eliminated. No effort during the surgery was made, however, to restore normal occlusion. The post-operative orthodontic treatment was successful in allowing growth to bring about a normalization of the occlusal relationships. Two years after surgery, complete aesthetic and function rehabilitation has been achieved. This has also led to an improvement in the patient's psychological condition. The result was still stable 11 years post-operatively. The case illustrates the value of early treatment and cooperation between orthodontists and oral surgeons.
144 excess condylar growth is suspected. Such i measure is also necessary if the pathology anc anatomical characteristics of the condyle are tc be satisfactorily diagnosed (Gruca and Meisels 1926; Rushton, 1946). In cases where growth ha: normalized and joint function is acceptable intervention in the ramus or mandibular corpus may instead be indicated. Surgical correction of jaw discrepancies is normally performed after termination of growth There are few reports in the literature (Smeets 1975; Promt, 1986) on such measures performec during the active growth period and observed until the end of the growth. Case report
1. Skeletal scintigraphy showed that the mandibular condyle was undergoing a period of increased growth activity. Consequently, further deformation of the mandible could be expected with the added risk of maxillary distortion resulting from compensatory growth. Should this be allowed to occur, surgical correction at a later date would probably have to include maxillary osteotomy also. 2. The present anomaly had led to serious psychological and social problems for the patient. It was feared that these would become irreversible if surgery were delayed until the end of the growth period (for about 10 years). 3. Early surgical intervention would allow maximum advantage to be taken of the remaining vertical growth potential of the alveolar process during post-operative orthodontics. A physically healthy 9-year-old boy (JJ) was referred to the orthodontic clinic in Orebro. He was psychologically withdrawn and unobstrusive. The orthodontic diagnosis was Angle Class I with a Class III tendency and unilateral dentoalveolar cross-bite with mandibular deviation. The initial occlusal relations are presented in Fig. 1 a. In maximum occlusion (IP) the mandible had a left-side deviation with a reverse overjet involving 21, 22, and 63. In the retruded position
Figure 1 (a) The initial occlusal relations in IP. (b) The initial occlusal relations in RP.
(RP) 21 made edge-to-edge contact with 31 and 32. In this position the midlines of both upper and lower dentitions coincided and lateral relationships were satisfactory (Fig. lb). An upper lingual arch was inserted for transverse expansion and for proclination of 21 and 22. Due to unsatisfactory co-operation and repeated distortion of the appliance this was replaced by a labial arch, but to no avail. During this period of 9 months, the facial morphology and dentition were noted to change considerably so that a distinct asymmetry could be seen (Fig. 2a,b). The patient was now fully aware of his abnormal appearance and serious psychological disturbances were beginning to make themselves manifest. The oral surgeons were consulted and a new analysis was performed. This included lateral skull and frontal radiographs, an orthopantomogram, and skeletal scintigraphy all of which were assessed by the entire team. The radiographic analysis revealed an asymmetric and deviated mandible together with a right-sided enlargement of the condylar process (Fig. 3). Tecnetium scintigraphy showed that increased growth activity also existed in this condyle (Fig. 4). It was decided that the above findings were sufficient to justify a combined surgical and orthodontic treatment plan. A tracing prediction and a plaster model reconstruction indicated that a satisfactory aesthetic and functional result could be achieved using the following measures. 1. Pre-surgical orthodontic correction of the reverse overjet involving 21 and 22. 2. Removal of the right condylar process.
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The case presented here is of special interest due to the fact that surgery was performed long before the end of growth. The reasons for such early intervention were as follows.
G. FELDMANN ET AL.
145
UNILATERAL CONDYKLAR HYPERPLASIA
Figure 2
(a, b) Distinct facial asymmetry to the left.
A left-sided oblique ramus osteotomy and osteotomy of the coronoid process. The latter was found to be necessary in order to avoid the adverse influence of the temporal muscle. Biopsy of the condyle. Post-operative orthodontic treatment using growth adaptive appliances of type Frankel IV.
;*«•>
Results The facial asymmetry was corrected, a unilateral open bite was created and the reverse overjet in the region 21 was corrected (Fig. 5a,b). Figure 5c shows the occlusion after finished Frankel therapy. The biopsy taken from the condyle indicated a hyperplastic process without any signs of malignancy (Fig. 6a,b).
Figure 4 Tecnetium scintigraphy showing increased growth activity of the enlarged condyle.
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Figure 3 Frontal radiograph showing asymmetric and deviated mandible with a right-sided enlargement of the condylar process.
146
G. FELDMANN ET AL.
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Figure 5 (a) Facial appearance post-operatively after orthodontic treatment, (b) Unilateral open bite post-operativelj and corrected reverse overjet at 21. (c) The occlusion aftei finished orthodontic treatment by Frankel therapy.
Discussion
(b) Figure 6 (a, b) Orthopantogram immediately post-operatively and 15 months later showing the condyle head and condyle-regeneration respectively on the right side.
Mandibular asymmetry is often caused by unilateral condylar hyperplasia. Should this occur during the later stages of growth or after the termination of growth this can lead to a lateral open bite on the hyperplastic side and mandibular deviation causing a cross-bite, on the opposite side. In the present case the hyperplastic process began several years before the end of growth. Consequently, on the hyperplastic side, compensatory growth mechanisms have led to an adaptation in the upper and lower jaws. Thus, occlusal contact was achieved instead of a lateral open bite. On the deviated side compensation has led to an underdevelopment of the alveolar process in both jaws. Due to the large growth potential in a young patient it is not necessary to achieve optimal occlusion immediately post-operatively. Instead,
147
UNILATERAL CONDYKLAR HYPERPLASIA
(bf % Figure 7
(a, b) En face photos before and 11 years post-operatively. The result is stable after completion of growth.
Conclusion Surgical and orthodontic treatment at the age of puberty of cases with unilateral condylar hyperplasia can offer satisfactory aesthetic and social rehabilitation. Address for correspondence Professor Sten Linder-Aronson Department of Orthodontics School of Dentistry Box 4064 S-141 (MHuddinge, Sweden References Bruce R, Hayward J 1968 Condylar hyperplasia and mandibular asymmetry. A review. Journal of Oral Surgery 26: 281-290 Gruca A, Meisela E 1926 Asymmetry of the mandible from unilateral hypertrophy. Annals of Surgery 83: 755-767 Oberg T, Fajers C, Lysell G, Friberg U 1962 Unilateral hyperplasia of the mandibular condylar process. A histological microradiographic and autoradiographic examination of one case. Acta Odontologica Scandinavica 20: 485-504 Obwegeser H L, Makek M S 1986 Hemimandibular hyperplasia—hemimandibular elongation. Journal of Maxillofacial Surgery 14: 183-208 Promt W 1986 Condylar hyperplasia. In: Promt W (ed.)
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establishing facial symmetry was given highest priority during the planning phase. Occlusal adjustments were expected when functional appliances were used. Surgical treatment of condylar hyperplasia and the accompanying facial asymmetry can be achieved by removal of the condyle and/or various different osteotomies to the ramus or mandibular corpus. Removal of the condyle is indicated in cases where joint function is disturbed, where accurate pathological and anatomical diagnosis is required, or as in this case where an abnormally high growth activity can still be demonstrated. In such a case removal should be carried out as early as possible in order to avoid further deterioration in the facial asymmetry. A combination of condylar removal on the one side and ramus osteotomy on the other may be necessary if full correction of the asymmetry is to be achieved. During orthodontic treatment the vertical growth of the upper and lower alveolar processes normalized following the successful elimination of unfavourable muscle function in the area of the lateral open bite. This was achieved as a result of the shielding effect of the functional regulator. A follow-up 11 years post-operatively, after finished growth, the result was still stable. Figure 7a,b show, respectively, en face photos before and 11 years post-operatively.
148 Contemporary orthodontics. The C.V. Mosby Company, St Louis, Toronto, London Rushton M A 1946 Unilateral hyperplasia of the mandibular condyle. Proceedings of the Royal Society of Medicine 39: 431-438 Smeets H J L 1975 Unilateral condylar hyperplasia. In: Cook J T (ed.) Transactions of the Third International Orthodontic Congress. Crosby Lockwood, Staples, London, 141-147
G. FELDMANN ET AL. Walker R 1967 Condylar abnormalities. In: Husted E, Hansen E H (eds) Oral surgery, 2nd International Conference in Oral Surgery. Munksgaard, Copenhagen 81-96 Wang-Norderud R, Ragab R R 1977 Unilateral condylar hyperplasia and the associated deformity of facial asymmetry. Scandinavian Journal of Plastic and Reconstructive Surgery 11:91-96
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© 1991 European Orthodontic Society
Orthodontic and surgical treatment of unilateral condylar hyperplasia during growth—a case report Giinter Feldmann,* Sten Linder-Aronson," Arne Rindler,* and Ulf Soderstrom* * Public Dental Health Service, Orebro, and "Departments of Orthodontics, Karolinska Institutet, Sweden
Introduction
Hyperplasia of the mandibular condyle is an anomaly which usually occurs unilaterally and with equal frequency in both men and women. The term 'condylar hyperplasia' refers to hyperplasia of the condyle alone and should not be used to mean hemimandibular hyperplasia or hemimandibular elongation (Obwegeser and Makek, 1986). Condylar hyperplasia occurs between 10 and 25 years of age (Rushton, 1946), although the majority of cases have been recorded between 15 and 19 years of age. In all probability there is a certain delay before the anomaly is diagnosed. The extent and nature of the deformity is largely dependent on when the increase in growth takes place. Should this occur unilaterally during early childhood one half of the mandible will become enlarged. At the same time, in order to maintain the occlusion, the maxillary teeth and alveolar process tend to compensate for the change in jaw relationships. A growth increase during the teens usually leads to a lateral open bite since alveolar adaptive potential in both the maxilla and mandible is no longer capable of
achieving adequate compensation (Bruce and Hay ward, 1968). Aetiology The cause of unilateral condylar hyperplasia is unknown. Hereditary factors, inflammation, hormonal disturbances and trauma have all been suggested (Rushton, 1946). Oberg el al. (1962) carried out a histological, micro-radiographical, and auto-radiographical examination of one such case. They found an increase in the number of blood vessels penetrating the upper posterior part of the condyle and concluded that the enhanced blood supply could explain the increase in growth. Walker (1967) noted during surgery that the para-condylar soft tissues were more vascular in cases with hyperplasia. WangNorderud and Ragab (1977) believe that condylar hyperplasia is more likely to be due to an intra-uterine moulding rather than to genetic disturbances. Surgical intervention Early surgical intervention and removal of the enlarged mandibular condyle is recommended, in particular in those cases where continued
Downloaded from by guest on February 18, 2015
SUMMARY A 9-year-old boy was diagnosed as having an unilateral cross-bite with mandibular deviation. This was later found to be due to unilateral hyperplasia of the right condyle. The increased growth activity subsequently led to an extreme facial asymmetry and a serious psychological condition began to develop. Consequently, surgery was performed at the age of 11 years 8 months when removal of the enlarged condyle and an oblique ramus osteotomy on the opposite side was performed. I n this way the facial asymmetry was eliminated. No effort during the surgery was made, however, to restore normal occlusion. The post-operative orthodontic treatment was successful in allowing growth to bring about a normalization of the occlusal relationships. Two years after surgery, complete aesthetic and function rehabilitation has been achieved. This has also led to an improvement in the patient's psychological condition. The result was still stable 11 years post-operatively. The case illustrates the value of early treatment and cooperation between orthodontists and oral surgeons.
144 excess condylar growth is suspected. Such i measure is also necessary if the pathology anc anatomical characteristics of the condyle are tc be satisfactorily diagnosed (Gruca and Meisels 1926; Rushton, 1946). In cases where growth ha: normalized and joint function is acceptable intervention in the ramus or mandibular corpus may instead be indicated. Surgical correction of jaw discrepancies is normally performed after termination of growth There are few reports in the literature (Smeets 1975; Promt, 1986) on such measures performec during the active growth period and observed until the end of the growth. Case report
1. Skeletal scintigraphy showed that the mandibular condyle was undergoing a period of increased growth activity. Consequently, further deformation of the mandible could be expected with the added risk of maxillary distortion resulting from compensatory growth. Should this be allowed to occur, surgical correction at a later date would probably have to include maxillary osteotomy also. 2. The present anomaly had led to serious psychological and social problems for the patient. It was feared that these would become irreversible if surgery were delayed until the end of the growth period (for about 10 years). 3. Early surgical intervention would allow maximum advantage to be taken of the remaining vertical growth potential of the alveolar process during post-operative orthodontics. A physically healthy 9-year-old boy (JJ) was referred to the orthodontic clinic in Orebro. He was psychologically withdrawn and unobstrusive. The orthodontic diagnosis was Angle Class I with a Class III tendency and unilateral dentoalveolar cross-bite with mandibular deviation. The initial occlusal relations are presented in Fig. 1 a. In maximum occlusion (IP) the mandible had a left-side deviation with a reverse overjet involving 21, 22, and 63. In the retruded position
Figure 1 (a) The initial occlusal relations in IP. (b) The initial occlusal relations in RP.
(RP) 21 made edge-to-edge contact with 31 and 32. In this position the midlines of both upper and lower dentitions coincided and lateral relationships were satisfactory (Fig. lb). An upper lingual arch was inserted for transverse expansion and for proclination of 21 and 22. Due to unsatisfactory co-operation and repeated distortion of the appliance this was replaced by a labial arch, but to no avail. During this period of 9 months, the facial morphology and dentition were noted to change considerably so that a distinct asymmetry could be seen (Fig. 2a,b). The patient was now fully aware of his abnormal appearance and serious psychological disturbances were beginning to make themselves manifest. The oral surgeons were consulted and a new analysis was performed. This included lateral skull and frontal radiographs, an orthopantomogram, and skeletal scintigraphy all of which were assessed by the entire team. The radiographic analysis revealed an asymmetric and deviated mandible together with a right-sided enlargement of the condylar process (Fig. 3). Tecnetium scintigraphy showed that increased growth activity also existed in this condyle (Fig. 4). It was decided that the above findings were sufficient to justify a combined surgical and orthodontic treatment plan. A tracing prediction and a plaster model reconstruction indicated that a satisfactory aesthetic and functional result could be achieved using the following measures. 1. Pre-surgical orthodontic correction of the reverse overjet involving 21 and 22. 2. Removal of the right condylar process.
Downloaded from by guest on February 18, 2015
The case presented here is of special interest due to the fact that surgery was performed long before the end of growth. The reasons for such early intervention were as follows.
G. FELDMANN ET AL.
145
UNILATERAL CONDYKLAR HYPERPLASIA
Figure 2
(a, b) Distinct facial asymmetry to the left.
A left-sided oblique ramus osteotomy and osteotomy of the coronoid process. The latter was found to be necessary in order to avoid the adverse influence of the temporal muscle. Biopsy of the condyle. Post-operative orthodontic treatment using growth adaptive appliances of type Frankel IV.
;*«•>
Results The facial asymmetry was corrected, a unilateral open bite was created and the reverse overjet in the region 21 was corrected (Fig. 5a,b). Figure 5c shows the occlusion after finished Frankel therapy. The biopsy taken from the condyle indicated a hyperplastic process without any signs of malignancy (Fig. 6a,b).
Figure 4 Tecnetium scintigraphy showing increased growth activity of the enlarged condyle.
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Figure 3 Frontal radiograph showing asymmetric and deviated mandible with a right-sided enlargement of the condylar process.
146
G. FELDMANN ET AL.
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Figure 5 (a) Facial appearance post-operatively after orthodontic treatment, (b) Unilateral open bite post-operativelj and corrected reverse overjet at 21. (c) The occlusion aftei finished orthodontic treatment by Frankel therapy.
Discussion
(b) Figure 6 (a, b) Orthopantogram immediately post-operatively and 15 months later showing the condyle head and condyle-regeneration respectively on the right side.
Mandibular asymmetry is often caused by unilateral condylar hyperplasia. Should this occur during the later stages of growth or after the termination of growth this can lead to a lateral open bite on the hyperplastic side and mandibular deviation causing a cross-bite, on the opposite side. In the present case the hyperplastic process began several years before the end of growth. Consequently, on the hyperplastic side, compensatory growth mechanisms have led to an adaptation in the upper and lower jaws. Thus, occlusal contact was achieved instead of a lateral open bite. On the deviated side compensation has led to an underdevelopment of the alveolar process in both jaws. Due to the large growth potential in a young patient it is not necessary to achieve optimal occlusion immediately post-operatively. Instead,
147
UNILATERAL CONDYKLAR HYPERPLASIA
(bf % Figure 7
(a, b) En face photos before and 11 years post-operatively. The result is stable after completion of growth.
Conclusion Surgical and orthodontic treatment at the age of puberty of cases with unilateral condylar hyperplasia can offer satisfactory aesthetic and social rehabilitation. Address for correspondence Professor Sten Linder-Aronson Department of Orthodontics School of Dentistry Box 4064 S-141 (MHuddinge, Sweden References Bruce R, Hayward J 1968 Condylar hyperplasia and mandibular asymmetry. A review. Journal of Oral Surgery 26: 281-290 Gruca A, Meisela E 1926 Asymmetry of the mandible from unilateral hypertrophy. Annals of Surgery 83: 755-767 Oberg T, Fajers C, Lysell G, Friberg U 1962 Unilateral hyperplasia of the mandibular condylar process. A histological microradiographic and autoradiographic examination of one case. Acta Odontologica Scandinavica 20: 485-504 Obwegeser H L, Makek M S 1986 Hemimandibular hyperplasia—hemimandibular elongation. Journal of Maxillofacial Surgery 14: 183-208 Promt W 1986 Condylar hyperplasia. In: Promt W (ed.)
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establishing facial symmetry was given highest priority during the planning phase. Occlusal adjustments were expected when functional appliances were used. Surgical treatment of condylar hyperplasia and the accompanying facial asymmetry can be achieved by removal of the condyle and/or various different osteotomies to the ramus or mandibular corpus. Removal of the condyle is indicated in cases where joint function is disturbed, where accurate pathological and anatomical diagnosis is required, or as in this case where an abnormally high growth activity can still be demonstrated. In such a case removal should be carried out as early as possible in order to avoid further deterioration in the facial asymmetry. A combination of condylar removal on the one side and ramus osteotomy on the other may be necessary if full correction of the asymmetry is to be achieved. During orthodontic treatment the vertical growth of the upper and lower alveolar processes normalized following the successful elimination of unfavourable muscle function in the area of the lateral open bite. This was achieved as a result of the shielding effect of the functional regulator. A follow-up 11 years post-operatively, after finished growth, the result was still stable. Figure 7a,b show, respectively, en face photos before and 11 years post-operatively.
148 Contemporary orthodontics. The C.V. Mosby Company, St Louis, Toronto, London Rushton M A 1946 Unilateral hyperplasia of the mandibular condyle. Proceedings of the Royal Society of Medicine 39: 431-438 Smeets H J L 1975 Unilateral condylar hyperplasia. In: Cook J T (ed.) Transactions of the Third International Orthodontic Congress. Crosby Lockwood, Staples, London, 141-147
G. FELDMANN ET AL. Walker R 1967 Condylar abnormalities. In: Husted E, Hansen E H (eds) Oral surgery, 2nd International Conference in Oral Surgery. Munksgaard, Copenhagen 81-96 Wang-Norderud R, Ragab R R 1977 Unilateral condylar hyperplasia and the associated deformity of facial asymmetry. Scandinavian Journal of Plastic and Reconstructive Surgery 11:91-96
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