Condylectomy and "surgery first" approach: An expedited treatment for condylar hyperplasia in a patient with facial asymmetry

Post-condylectomy orthodontic treatment for a severe asymmetrical open bite in a condylar hyperplasia patient

A satisfactory treatment of an 18-year-old lady was reported with right combination-type condylar hyperplasia (CH) in active phase. The chin severely deviated to the left, with the right gonial angle locating at a lower level. Intraorally, the lower centre line shifted to the left, the scale of which reached the width of one lower incisor. The right molar relation was mesial. Right maxillary second molar over-erupted without contact to lower teeth. There had been 2.5-mm anterior open bite (AOB) before surgery (T1) due to the tongue-spitting habit. After judging the benefits and disadvantages of all treatment alternatives, the decision was made to perform a right condylectomy and post-surgery orthodontics. Before orthodontics (T2) when the chin was positioned centred, an asymmetrical open bite occurred, caused by pre-contact between the right maxillary and mandibular second molars. Meanwhile, the AOB at T2 became 11.5mm. Orthodontic-related treatment included four premolars extraction and intrusion of bilateral maxillary molars using four miniscrews. Finally, this treatment achieved a clinically centred chin with two gonial angles at the same level. Post-condylectomy, the large AOB was resolved, together with a bilateral neutral molar relationship and alignment of the incisor midlines. Besides, the resected right condyle was covered by a continuous cortex bone and returned to the glenoid fossa. In sum, a high-challenging combined-type CH case was accomplished with impressive improvement in facial and occlusal symmetry, thanks to condylectomy and post-surgery miniscrew-assisted orthodontics.

Can Condylectomy Alone Achieve Facial Symmetry in Patients With Hemimandibular Hyperplasia (Condylar Hyperplasia Type 2)?

The purpose of the present study was to evaluate the 3-dimensional orofacial changes occurring after proportional condylectomy in patients with unilateral condylar hyperplasia type 2 (hemimandibular hyperplasia). Eight patients underwent proportional condylectomy that was not followed by orthognathic surgery or orthodontic treatment for at least 1 year. The precondylectomy and postcondylectomy photographs and radiographs were analyzed cephalometrically and compared. The average length of the condylar segment removed was 13 mm and this resulted in almost equal heights of the ramus-condyle units of both sides. Evaluations in the vertical plane improved after surgery; however, when the preoperative asymmetry was significant, the residual asymmetry continued to be notable after condylectomy. Transverse plane evaluations improved after condylectomy, and chin position was satisfactorily centralized in all patients. In the horizontal plane, mandibular setback occurred, and this was considered favorable when the preoperative skeletal profile was class III, whereas the opposite was when the patient was class I before surgery. The occlusion improved gradually over the postoperative months by the intrusion on the affected side and extrusion on the unaffected side into a bilaterally balanced posterior contacts with residual anterior open bite. In conclusion, condylar hyperplasia type 2 patients with mild asymmetry and low esthetic demands can benefit from proportional condylectomy as the sole treatment to both stop the hyperplastic condylar growth and improve the asymmetry to some extent. Surgeons should be able to predict the change that is expected to occur after proportional condylectomy and discuss this with the patient before surgery.

Methods of Definitive Correction of Mandibular Deformity in Hemimandibular Hyperplasia Based on Radiological, Anatomical, and Topographical Measurements-Proposition of Author's Own Protocol

In order to fully evaluate and establish the degree of bone overgrowth, various radiological studies are essential in the careful planning of the amount of surgical excision. In the presented paper, the authors use self-designed anatomo-topographical reference points for planning the surgeries. Routine panoramic radiographs and low-dose computed tomography based on anatomical landmarks help in measuring the proportions of mandibular bone overgrowth with the following preoperative anatomical landmarks: (Go-Go), (Go(Right)-Gn), (Go(Left)-Gn), and (Me−Gn). Measurements taken at selected points and landmarks (gonion-gnathion/gnathion-menton) are easy to conduct. In the authors’ proposal, the main key factor is total chin correction, which is necessary in cases of severe overgrowth; when F0 > C and Go-Gn>, there is >7 mm of vertical bone overgrowth, and the mandibular canal is positioned <5 mm from the inferior mandibular border—MIB. Larger overgrowths (>7 mm) have a greater outcome on the final symmetry than smaller overgrowths. As no guidelines are known, the authors present their own proposal.

What Features on Routine Panoramic Radiographs Could Help Orthodontists to Estimate the Occurrence of Condylar Hyperplasia from Other Mandibular Asymmetries—Retrospective Analysis Study

Hemimandibular hyperplasia (HH) and elongation (HE) are the most common pathologies present in the mandible. Presented condylar hyperplasias have their own radiological and clinical features. In most cases, patients suffer from various forms of malocclusion. From a total of 150 asymmetrical jaw radiographs evaluated, 46 were evaluated and included in this study. A retrospective study on the data of 46 selected patients treated, diagnosed, and consulted from various forms of mandibular and skeletal asymmetry based on routine diagnostic panoramic radiographs evaluated typical and atypical radiological and anatomical symptoms of condylar hyperplasia. The presented evaluation focused on mandibular, maxillary, and other bones, in order to distinguish condylar hyperplasia from other forms of mandibular asymmetry. The degree of maxillary downward growth followed by the occurrence of an open bite on the affected side estimate the degree/presence or cessation of growth in the affected condyle. Mandibular asymmetry with incisor teeth inclination remains the most typical characteristic of condylar hyperplasia. Increased height of mandibular ramus differentiates between condylar hyperplasia and elongation, which also influences the position of the inferior alveolar nerve. Mentioned symptoms, described as the acronym “Go Moira!”, are useful in a quick and simple “glimpse of an eye” differential diagnostic approach. It is possible to quickly and accurately establish the first diagnosis simply by a careful evaluation of patients’ panoramic radiographs.

Standard orthodontic treatment after condylectomy for patients with active unilateral condylar hyperplasia

INTRODUCTION

Unilateral condylar hyperplasia (UCH) is a progressive, nonneoplastic overgrowth of the condyle of the temporomandibular joint. For treating active UCH, a popular method combines orthognathic surgery with high condylectomy and orthodontic treatment. The goal of this study was to introduce a new method to correct asymmetry for active UCH.

METHODS

Retrospectively, 47 patients with active UCH were divided into horizontal-type, vertical-type, and combined-type. All patients were treated with condylectomy plus postsurgery standard orthodontics (CPSO) with applied miniscrews implanted in infrazygomatic crest and hard palate to intrude affected side of maxillary molars and apply intermaxillary traction for contralateral molars. Cone-beam computed tomography was taken at presurgery, postsurgery, and the end of orthodontics (T3).

RESULTS

In the vertical (n = 10) and combined (n = 28) types, deviation of the chin and the canting of the mandible and maxillary occlusal plane were significantly reduced at T3. A difference in the torque of bilateral maxillary first molar (U6) and bilateral mandibular first molar (L6) was significantly reduced at T3. The anterior, superior, and posterior joint spaces in the vertical-type and combined-type were significantly decreased at T3 compared with postsurgery. In contrast, in the horizontal-type group (n = 9), the deviation of the chin was corrected; however, the canting of the mandible and maxillary occlusal plane was significantly increased at T3 compared with presurgery.

CONCLUSIONS

CPSO restored facial and occlusal symmetry for vertical-type and combined-type active UCH and returned affected-side condyle to the glenoid fossa. However, CPSO was not suitable for treating the horizontal-type UCH.

[Diagnostic and treatment alternatives for the correction of facial asymmetries: a literature review]

Facial symmetry refers to a complete coincidence of each facial component on the sagittal plane, while asymmetry refers to the bilateral difference between these components. The presence of perfect bilateral symmetry is almost never present in human, so it is more common for individuals to predominate facial asymmetry. However, this condition can result from functional and esthetic problems. This research seeks to determine the alternatives, diagnosis and ideal treatment plan for the correction of each type of facial asymmetry through orthognathic surgery. For this purpose, a review of articles published between 2015 to date was carried out. Selecting those that were focused on describing or evaluating facial and dentofacial symmetry and asymmetry, type of diagnosis or treatment plan, including clinical cases. The Google search engine, SciELO and databases of medical interest, such as PubMed, PMC and Medigraphic were used. According to the research and treatments carried out during the last few years in the dental clinic, it has been proven that orthognathic treatment accompanied by previous planning is the best option for the management of skeletal facial asymmetries.

An overview of surgery-first orthognathic approach: History, indications and limitations, protocols, and dentoskeletal stability

The most common orthognathic surgery approach consists of three steps: presurgical orthodontic treatment, surgery, and postsurgical orthodontic treatment. Despite its advantages, this technique has some disadvantages, too, including a long treatment period, problems in mastication and articulation, temporary worsening of the patient's appearance, and psychological problems for the patient. The introduction of the surgery-first orthognathic approach has been an attempt to overcome these problems. In this article, we wish to provide a comprehensive overview on this approach. In this approach, which consists of surgery without orthodontic preparation and a short period of orthodontic treatment after it, the overall duration of treatment decreases and the patient's appearance improves. The skeletal anchorage, placed at the time of surgery, can be used to facilitate tooth movements after surgery. Despite the advantages of this technique, it is associated with some limitations; in particular, occlusion cannot have a guiding role during surgery. Therefore, correct diagnosis, prediction of the outcomes, and simulating correction with the model setup are of crucial importance. The surgeon's knowledge and expertise have a significant role in this respect.

Concurrent High Condylectomy and Orthognathic Surgery for Treatment of Patients With Unilateral Condylar Hyperplasia

BACKGROUND

Facial asymmetry from unilateral condylar hyperplasia (UCH) may be definitively treated in the presence of active disease (with high condylectomy and concurrent orthognathic surgery) or after waiting for disease inactivity (orthognathic surgery alone). There is currently no consensus on the standard of care. In this study, we sought to compare functional and esthetic outcomes, as well as treatment duration, between these 2 management options.

METHODS

Patients who underwent treatment for UCH were identified through retrospective review. Pre- and postoperative 3-dimensional (3D) images were obtained. Short- and long-term operative outcomes of those treated during the active (group 1) were compared to those treated in the inactive phase (group 2). Total treatment time, operative time, and length of hospital stay were evaluated. Facial asymmetry was also assessed by laypersons using a Likert scale.

RESULTS

Fifteen patients (mean 25.6 years, range 14-56) were included: 6 in group 1 and 9 in group 2. All surgical outcomes were statistically independent of procedure type. Treatment time was significantly longer in the group 2 (P = 0.03). Both groups demonstrated significant improvement in facial asymmetry scores postoperatively with no significant difference in pre- or postoperative asymmetry between groups (P = 0.64).

CONCLUSIONS

In patients with active UCH, high condylectomy and orthognathic surgery is a procedure that restores facial symmetry and improves jaw function while halting mandibular growth. Good esthetic and functional outcomes, as well as reduced treatment time and disease burden, support the use of this treatment option for this population.

Differences in dental arch characteristics between genders in patients with suspected condylar hyperplasia in a North Sumatra subpopulation: a cross-sectional study

Background: Condylar Hyperplasia (CH) is a self-limiting mandibular condyle disorder that shows asymmetry progress in conjunction with associated occlusal changes as long as condylar growth is still active and leads to facial asymmetry. This study aimed to analysis the difference of dental arch characteristics  based on genders in orthodontic patients with suspected CH in a North Sumatra subpopulation.

Methods: This is a retrospective study of suspected CH patient’s clinical records who sought for the initial orthodontic treatment between January 2015 to March 2019. Patient with facial asymmetry (based on photography, posterior crossbite and midline deviation), the positive temporomandibular joint disorder in functional analysis, and no history of facial trauma were included in the study. Dental arch asymmetry was based on the measurement of dental midline deviation, canine tip in the dental arch, the distance of the upper canines from the palatal suture, and inter canine distance. The evaluation of dental arch was achieved by comparing arch width and length.

Results: There was a significant difference (p<0.05) of upper canine distance from the palatal suture in female patients when evaluating upper dental arch asymmetry. There was a moderate correlation (r=0.379) in midline deviation between upper and lower dental arch. The dimension and dental arch form were mid and flat, and there was moderate correlation (r=0.448) between the upper and lower dental arch form in these suspected CH patients.

Conclusion: Indeed skeletal asymmetry, the evaluation of the dental arch characteristic symmetry and arch form showed asymmetric occlusal characteristics in orthodontics patient with suspected  CH in the North Sumatera subpopulation. In treating these patients, we recommend the plaster cast evaluation as essential and routine procedure in order to understand the complexity of occlusal change due to active growth of condylar and limitation in radiography evaluation.

Facial asymmetry correction: From conventional orthognathic treatment to surgery-first approach

The surgery-first approach (SFA), which proceeds without presurgical orthodontic treatment, is assumed to shorten the treatment course because the direction of post-surgical orthodontic tooth movement conforms to the normal muscular forces. Moreover, the regional acceleratory phenomenon (RAP), evoked by surgery, helps in tooth alignment and compensation in a faster way. Although SFA has definite advantages, especially in class III individuals, there is a lack of data about its indications in patients with facial asymmetry. In this article, we reviewed recently published articles on the treatment of asymmetric patients using the SFA. Different aspects, including the three-dimensional assessment of stability in different planes, approaches for fabrication of a surgical splint, predictability of the results, skills needed for bimaxillary surgery, indications as the treatment of choice for condylar hyperplasia, and combination with distraction osteogenesis in candidates with severe asymmetries were found to be the main topics discussed for patients presenting with facial asymmetry

Anatomical and Clinical Implications in Neocondyle Stability After a Condylectomy

: A condylectomy of the mandibular condyle is considered to be the treatment of choice in most cases of condylar head hyperactivity. The aim of the procedure is to remove the growth center of the mandible which is responsible for the mandibular enlargement and asymmetry. This surgical procedure has an impact on the condyle shape and position, but the restoration of mandibular movement and a stable joint position (namely, the proper alignment of the newly shaped condylar head within the condyle fossa) should also be considered important surgical outcomes. In this article, the authors present their own experience in performing condylectomies with an arthroplasty procedure and a special forced suturing technique (FST) in terms of achieving early, accurate mandibular movement and maintaining a stable condyle position in early and late outcomes.

MATERIALS AND METHODS

A modified high condylectomy with arthroplasty and FST results had been studied in anatomical, radiological, and clinical model.

RESULTS

Early findings after FST are promising. A slight improvement in lateral jaw movement was noted after condylectomy with arthroplasty (P < 0.05) both in early and late follow-up. Incisal opening, mandibular protrusion, and lateral movement were sustained. A stable condyle position within the fossa was achieved in each case of condylectomy with arthroplasty (P < 0.05).

CONCLUSIONS

The FST condylectomy and reattachment of the lateral pterygoid muscle in a new, wider position provided an improvement in lateral jaw movement as well as in incisal opening and mandibular protrusion in early follow-up examination compared to the presurgical values. It seems that the FST enabled a better new condylar head position in the glenoid fossa and improved early functional mandibular movement.

Correction of unilateral condylar hyperplasia and posterior open bite with proportional condylectomy and fixed orthodontic treatment

A 29-year-old female patient with unilateral condylar hyperplasia (UCH) of the left side presented with facial asymmetry, maxillary transverse occlusal plane (MXTOP) cant, posterior open bite, and Class III relationship. Treatment consisted of proportional condylectomy of the left condyle for management of UCH, and fixed orthodontic treatment with intrusion of the left maxillary molars to correct the MXTOP cant and remaining chin point deviation (CPD). Proportional condylectomy with a 14-mm resection of the left condylar head improved the CPD from 11.5 mm to 7.8 mm and resolved the posterior open bite on the left side. However, it produced a Class II relationship on the right and left sides, posterior open bite on the right side, and anterior open bite. Fixed orthodontic treatment with 1.8-mm intrusion of the left maxillary molars using miniscrews corrected the MXTOP cant from 3.5 mm to 1.7 mm, reduced the remaining CPD from 7.8 mm to 3.7 mm, produced counterclockwise rotation of the mandible, and resolved the posterior open bite on the right side and the anterior open bite. After 16 months of total treatment, normal overbite/overjet and Class I relationship were obtained. Treatment results were well maintained after 5 years of retention. For the correction of UCH, it is important to determine the amount of condylar head resection and accurately simulate the correction of CPD and MXTOP cant through intrusion of the maxillary molars.

Condilectomia alta associada à discopexia, com mini-âncoras, no tratamento da hiperplasia condilar: relato de caso

Introdução: A hiperplasia condilar (HC) é uma patologia rara caracterizada por crescimento não neoplásico que afeta a morfologia do côndilo mandibular com deformação progressiva. Dentre os sinais mais comuns se encontram a assimetria facial e mandibular, além de possíveisalterações oclusais como mordida aberta ipsilateral e transversal contralateral. Objetivo: O objetivo do estudo foi demonstrar a eficácia terapêutica da condilectomia alta associada à discopexia, com mini-âncoras, no tratamento da hiperplasia condilar. Relato de caso: Paciente de 24 anos de idade, apresentando assimetria facial, déficit e incompetência funcional mastigatória, mordida aberta posterior ipsilateral e mordida cruzada posterior contralateral. A proposta terapêutica escolhida foi o tratamento cirúrgico com condilectomia alta e discopexia com âncora para estabilização do disco articular, através de acesso endaural para o côndilo afetado com tamponamento auricular. Foi realizado infiltração com ácido hialurônico intra-articular após sutura da cápsula articular e sutura por planos para sutura da pele. Conclusão: A condilectomia alta preveniu a progressão da deformidade facial, minimizando as sequelas funcionais e estéticas, o que visa a favorecer o tratamento das deformidades faciais através de correção ortognática em segundo momento cirúrgico.

Three-Dimensional Orofacial Changes Occurring After Proportional Condylectomy in Patients With Condylar Hyperplasia Type 1B (Unilateral Hemimandibular Elongation)

PURPOSE

To evaluate 3-dimensional orofacial changes that occurred after proportional condylectomy that was not followed by orthognathic surgery in patients with condylar hyperplasia type 1B (unilateral hemimandibular elongation).

MATERIALS AND METHODS

This retrospective analysis used the medical records of 14 skeletally mature patients. Transverse, vertical, and horizontal cephalometric analyses of photographs and radiographs were undertaken. A comparison of preoperative and postoperative measurements was conducted.

RESULTS

After proportional condylectomy, transverse chin position and vertical lip cant improved to various degrees, whereas ramus and condyle height and mandibular lower border discrepancy worsened to different extents. The prominence of the gonial angle of the affected (operated) side increased in all patients after surgery, and this contributed to better symmetry only when the preoperative prominence was small (flat), whereas the opposite occurred when the preoperative prominence was large (bulky). After condylectomy, there was posterior displacement of the pogonion point (setback), which was favorable in cases with a preoperative concave profile and unfavorable in cases with a preoperative convex profile.

CONCLUSION

Proportional condylectomy can successfully arrest the hyperplastic growth of the affected condyle; however, it rarely achieves perfect symmetry of the face. Although it improves some facial features, other facial traits are worsened. Surgeons should have a full understanding of the 3-dimensional changes occurring after proportional condylectomy and should be able to predict, based on preoperative findings, the anticipated improvement or worsening of different facial features.